Lack of Full-Time Licensed Administrator Onsite
Penalty
Summary
The facility failed to have a full-time licensed Administrator overseeing its day-to-day operations, as required by its own policy and regulatory standards. Review of facility policy indicated that a licensed Administrator is responsible for managing daily functions, but observation revealed that the Administrator license displayed belonged to a sister facility. Surveyor notes confirmed a gap in Administrator coverage, with the current Administrator's start date immediately following the previous Administrator's end date. Interviews with the DON revealed that there was no Administrator present in the building on the day of the survey, and that the Administrator primarily works at a sister facility, only visiting about once a week. During the Administrator's absence, the DON, who is not a licensed Administrator, assumes responsibility for the facility.