Lack of Formally Appointed and Consistently Present Administrator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed Administrator (ADM) was formally appointed and serving in the capacity of a Nursing Home Administrator (NHA), and that an ADM was present for sufficient hours to provide adequate oversight and management of operations. During observation and interview, the DON’s license was posted in the lobby identifying the DON as the Abuse Coordinator, but there was no indication of an appointed ADM. The facility’s Department Head Directory did not list an ADM, and staff interviews confirmed that the previous ADM had left on January 10, 2026. Staff reported that since the prior ADM’s departure, an interim or regional ADM had been coming to the facility only approximately three times per week for a few hours per visit, either in the morning or afternoon. The receptionist stated that the temporary ADM had been absent from the facility for the past three days due to attending a corporate conference. The DON confirmed that the regional ADM providing oversight did not have a formal appointment letter designating them as the Administrator and had been assigned by the corporate office. As a result, the facility was operating without a consistently present, formally appointed, and properly licensed ADM responsible for managing and overseeing facility operations.
