F0727

E

Failure to Maintain a Full-Time DON

Kittanning, Pennsylvania Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the consistent services of a full-time Director of Nursing (DON), defined as 35 or more hours per week, as required by regulation. The DON job description indicated that the position was responsible for planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with applicable standards, regulations, and facility policies, and required a current unrestricted RN license. The DON began employment on 1/15/26, but review of facility “Stand-Up” sheets from early February through late March showed that the DON was either documented as not present, had not signed the sheets (making presence unknown), or there were no sheets available for multiple business days. Specifically, the DON was documented as not present in the building on numerous listed dates, and several additional undated Stand-Up sheets also documented that the DON was not present.

Further review showed that the Assistant DON’s employment ended on 2/16/26, and after that date no other RN was placed in an interim DON role. The Nursing Home Administrator confirmed on 3/23/26 that the DON was not in the building and was using paid time off through her last day of employment on 3/24/26. In a subsequent interview on 3/25/26, the Administrator confirmed there was no documented evidence that the DON worked 35 or more hours per week in the facility in the capacity of DON. The cited deficiency references 28 Pa Code 201.3 (Definitions), 201.14(a) (Responsibility of Licensee), 201.18(e)(6) (Management), and 211.12(b)(c)(d) (Nursing Services).