Failure to Maintain Licensed Administrator and Effective Facility Administration
Penalty
Summary
The facility failed to ensure effective administration to maintain the highest practicable well-being of each resident by operating without a licensed administrator from 08/20/2025 to 09/13/2025. The former administrator was terminated on 08/19/2025, and there was no record of a licensed interim or permanent replacement during the subsequent period. Interviews with the nurse supervisor, DON, and VP of Operations confirmed that no state-licensed nursing home administrator was present on staff, and administrative duties were informally reassigned among department heads, none of whom were licensed administrators. The VP of Operations, who holds a state administrator license, was not physically present at the facility and communicated with department heads remotely. Staff interviews indicated a lack of awareness of a designated acting administrator, and administrative responsibilities were primarily handled by the DON. Residents interviewed during the survey reported not knowing who the administrator was since the previous administrator's departure, though they expressed no immediate safety concerns and stated they would report issues to the DON. The facility was unable to provide documentation of a designated acting administrator or a signed administrator job description when requested. The facility's policy requires a licensed administrator to be responsible for day-to-day operations, including ensuring adequate staffing and compliance with laws and regulations, but this requirement was not met during the period in question.