Failure to Appoint Licensed Administrator for Facility Management
Penalty
Summary
The facility's governing body failed to appoint a state-licensed Administrator responsible for the management of the facility from 3/25/2025 through the surveyor's exit on 5/1/2025. During this period, the Director of Nursing (DON) confirmed that there was no full-time Administrator in place, and that the MDS nurse, who had recently obtained her administrator license, was intended to fill the position but had not yet received or accepted an official offer. The MDS nurse was not present at the facility daily, as she had permission to work from home on some days, and staff were reporting to the DON in the absence of an Administrator. Interviews with the MDS nurse, Business Office Manager (BOM), and Regional Director of Operations (RDO) all confirmed that the facility had been without an Administrator since the previous Administrator's departure. The MDS nurse stated she was waiting for an offer letter and had not officially accepted the position. Facility policy requires the governing body to appoint a licensed Administrator responsible for facility management, but this had not occurred during the period reviewed.