Failure to Maintain a Designated Full-Time DON
Penalty
Summary
The facility failed to designate a full-time DON as required, leaving the position vacant for 37 days. During interviews, staff members B and C reported that the facility had been without a DON for a little over a month and that DON tasks were divided among the IDT during this period. An email from staff member A dated 9/8/25 showed an advertisement posting for the DON position and indicated that the IDT took over DON tasks after the previous DON left, but there was no documentation that the prior DON’s duties were specifically reassigned to an RN or multiple RNs. Another email from staff member A on 9/8/25 confirmed that the previous DON no longer worked at the facility, and a subsequent email dated 10/16/25 documented that staff member B started as the new DON on that date, confirming the facility was without a designated DON from 9/8/25 through 10/16/25. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of a designated full-time DON and the absence of documented reassignment of DON responsibilities to an RN during the vacancy period.
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