Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator to manage the facility, as required by policy and regulation. Record review showed that the previous administrator was terminated on 09/02/25 for not having a current license, and since then, the facility had not had a full-time administrator. Interviews with multiple staff members, including the Corporate RN, CNA, LVN, BOM, and DON, confirmed that there was no full-time administrator in place. An interim administrator was present for about two weeks in October, but no permanent replacement had started as of the time of the survey. The Corporate RN, who is not the administrator, was acting on behalf of the facility to hire a new administrator, with a new hire expected to start in January, but no documentation or background checks had been completed for this individual at the time of the review. Facility policy and job descriptions require the administrator to be duly licensed and responsible for the day-to-day operations of the facility. Staff interviews highlighted concerns about the lack of leadership, oversight, and clear reporting lines due to the absence of a full-time administrator. The deficiency was identified through both record review and staff interviews, which consistently indicated that the facility had not maintained compliance with the requirement to have a licensed administrator appointed by the governing body.