Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide timely written notice to the State Agency (SA) of a change in the Director of Nursing (DON) position for a census of 85 residents. The current DON reported in an interview that she began her role on 12/10/25 and that corporate staff requested her licensing information, but she did not know when the leadership change notification was sent to the SA. During a concurrent interview and record review, the acting Administrator (ADM) confirmed that the change-of-DON documents were dated and mailed on 1/7/26, rather than at the time the change occurred, and stated he was not aware of the time requirement for notification. A facility letter to the SA dated 1/7/26, signed by the DON the same day, referenced a “CHANGE OF DIRECTOR OF NURSING Application,” and SA database records showed the DON application was received on 1/13/26. This delay in notification postponed the SA’s verification that the DON was qualified to lead clinical services, which the report states had the potential to compromise resident safety and regulatory compliance for all 85 residents. The deficiency centers on the facility’s inaction in promptly notifying the SA of the DON change at the time it occurred, as required by rules on disclosure of ownership and administrative personnel changes. The DON’s start date, the later date of the application and mailing, and the ADM’s lack of awareness of the time requirement are specifically documented as the factors leading to the late reporting.
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