Failure to Notify State Agency of Change in DON
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to provide written notification to the State Agency (SA) regarding a change in the Director of Nursing (DON), as required by both regulation and facility policy. Document review showed that the DON was hired on 10/07/2024, but the Administrator confirmed during interview that no written notice was sent to the SA at the time of the change. The Administrator stated unawareness of the requirement to notify the SA. A letter formally notifying the SA of the DON change was only prepared and dated on 07/01/2025, well after the DON's start date. Facility policy specifies that written notice must be provided to the SA in advance or at the time of such changes, including the identity of the new individual and the effective date.