Failure to Appoint Licensed Administrator Resulting in Oversight Lapses
Penalty
Summary
The facility failed to ensure that its governing body appointed a licensed administrator, as required by Guam Code Annotated (GCA) Chapter 15, to manage and oversee the facility. Interviews with the Director of Nursing (DON), Medical Director (MD), and Compliance Officer (CO) confirmed that the facility had been without an administrator since April 2024. The Medical Director clarified that he only oversaw clinical work and had no administrative oversight, while the hospital CEO, who was overseeing the Skilled Nursing Unit (SNU), acknowledged she did not possess a Nursing Home Administrator license as required by law. The CO further confirmed that the position had been vacant for some time, with ongoing but unsuccessful recruitment efforts due to salary expectations. As a result of not having a licensed administrator, the facility experienced lapses in oversight and accountability. This led to inconsistent availability of essential supplies for residents, such as linens and colostomy bags, as noted in the findings. The absence of a licensed administrator was verified through interviews and record review, and it was acknowledged by multiple members of the facility's leadership and governing body.