Failure to Timely Notify State Agency of DON Change
Summary
The facility failed to notify the State Agency within five working days following a change in the Director of Nursing (DON), as required by licensure regulations. Record review showed that the DON was changed on 9/13/25, but the notification form was not faxed to the Department of Health and Human Services (DHHS) until 9/29/25, exceeding the required timeframe. During an interview, the Administrator confirmed that the notification was not submitted within the mandated five working days. This deficiency had the potential to affect all 68 residents residing in the facility at the time.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not submit required written notice to the State Agency when a new ADM and a new DON assumed their positions. The DON reported starting in the role recently and confirmed she had not filed the Centralized Applications Branch (CAB) application and had not been informed of CAB expectations, while the ADM believed the DON was responsible for the application. The ADM also stated he had been in his role for several months and believed the corporate office should have submitted the change-in-ADM application. State Agency database review showed no applications received for either position, delaying verification of the ADM and DON qualifications for oversight of clinical services for 109 residents.
The facility failed to comply with disclosure of ownership and administrative change requirements by not notifying the State Agency when its NHA left and by not ensuring a qualified NHA was assigned for a two-day period. Written communications showed that the outgoing NHA informed the State Agency of his last day after the fact, and the State Agency then sought clarification from the facility’s VPO about who was acting as NHA. The VPO indicated he was acting as NHA but had been out ill, and review of the timeline confirmed there was no assigned NHA for two days. The DON later confirmed that the facility did not notify the State Agency at the time of the NHA change and did not have an NHA assigned during that period, constituting noncompliance with state requirements for licensee responsibility.
The facility failed to timely notify the State Agency (SA) of a change in the DON position for a census of 85 residents. The DON began the role but the required change-of-DON application and written notice were not completed and mailed until weeks later, as confirmed by the DON’s and acting ADM’s interviews and the dated documents. The ADM reported being unaware of the required timeframe for notification, and SA records showed the DON application was received several days after it was mailed, delaying SA verification of the DON’s qualifications.
The facility did not update the state survey agency regarding changes in its administrative leadership, including an interim Administrator who served for several months and the current Administrator. A review of the EIDC website showed that these administrators were not listed as required, and the current Administrator acknowledged that the facility had failed to report these changes. This non-compliance affected all residents and was identified during a complaint investigation.
The facility did not provide written notice to the State Agency about a change in administrator, as the name listed in the TULIP system did not match the current ADM. Staff interviews confirmed the ADM had been in the role for several months, but the state records were not updated to reflect this change.
The facility did not inform the State agency when a new Medical Director replaced the previous one, as confirmed by the Nursing Home Administrator during an interview.
Failure to Notify State Agency of Changes in ADM and DON
Penalty
Summary
The facility failed to provide required written notice to the State Agency (SA) regarding changes in key administrative personnel, specifically the Administrator (ADM) and the Director of Nursing (DON). The current DON began working in the DON position on 4/21/26, but the facility did not submit the necessary application to the Centralized Applications Branch (CAB), the SA unit responsible for reviewing licensure and certification-related transactions. In an interview, the ADM stated he did not think the CAB application for the new DON had been completed and indicated that the DON was responsible for completing it. In a separate interview, the DON confirmed she had started working at the facility eight days prior, had not filed the CAB application, and stated she was not informed about CAB expectations, indicating a lack of clarity about responsibility for regulatory notification. The facility also failed to notify the SA of the change in the ADM position. During an interview, the ADM reported he had been working at the facility since August 2025 and stated that the change-in-ADM application should have been completed and sent to CAB by the facility’s corporate office at that time. A review of the SA database showed no record of receiving an application for either the DON or the ADM from the facility. These failures delayed the SA from verifying that the ADM and DON were qualified to lead clinical services for a census of 109 residents and from confirming compliance with federal and state regulations.
Failure to Timely Report NHA Change and Maintain Assigned Administrator
Penalty
Summary
The facility failed to notify the State Agency (SA) of a change in the Nursing Home Administrator (NHA) at the time of the change and failed to ensure that a qualified NHA was assigned to the facility for two days. Written communication dated 3/29/26 showed that NHA Employee E3 informed the SA that his last day as NHA at the facility was 3/27/26. A subsequent written communication dated 3/30/26 from the SA to the facility’s President of Operations (VPO) Employee E4 requested clarification regarding who was acting as NHA, as the SA had been made aware of Employee E3’s departure. VPO Employee E4 responded that he was acting as NHA “for now” and noted he had been out with an illness and would provide the requested information as soon as possible. Review of this information revealed that no NHA was assigned to the facility from 3/28/26 through 3/29/26. In an interview on 4/1/26 at 9:00 a.m., the Director of Nursing confirmed that the facility did not notify the SA of the NHA change at the time it occurred and did not have an NHA assigned during that two-day period, in violation of PA Code 201.14(a) regarding responsibility of the licensee. No residents or specific clinical conditions were mentioned in the report, and the deficiency pertains solely to administrative oversight and regulatory noncompliance related to NHA assignment and notification requirements.
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.
Failure to Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's administrator. Record review of the TULIP system showed that the administrator listed did not match the current administrator (ADM) of the facility. Observations confirmed that the name posted in the facility as the administrator and abuse coordinator was not the same as the one recorded in TULIP. Interviews with the ADM revealed she had been serving as administrator since March 2023, but her name was not updated in the state system. Staff interviews further confirmed that the ADM was recognized as the administrator and abuse coordinator by employees, and the DON stated that the ADM had been the only administrator during her tenure. The ADM reported that she had completed the necessary form for the change and provided it to the previous owners, but the update was not made in TULIP. Review of the Facility Summary Report also showed a mismatch between the administrator's name and the ADM. No information about residents or their medical conditions was included in the report, and the deficiency centers solely on the failure to notify the State Agency of the change in facility administrator.
Failure to Notify State Agency of Medical Director Change
Penalty
Summary
The facility failed to notify the State agency of a change in its Medical Director at the time the change occurred. Review of facility data showed that Doctor Employee E1 was the Medical Director as of 1/1/20, but during an interview, the Nursing Home Administrator stated that Doctor Employee E1 was no longer employed and that Doctor Employee E2 became the new Medical Director effective 7/24/25. The Nursing Home Administrator confirmed during the interview that the State agency had not been informed of this change in Medical Director as required by regulations.
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