Health inspection·April 25, 2025

F837 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is— (i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. §483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with §483.75(f). [§483.70(d)(3) Governing body responsibility of QAPI program will be implemented beginning November 28, 2019 (Phase 3).] On 3/13/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Administration / Personnel. The facility failed to: 1. Ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA). 2. Ensure an ADM was present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT)/Operations Manager (OM) was performing administrative tasks without the presence of the ADM at the facility. As a result, the facility was operating without a licensed ADM that had the potential to negatively affect the facility’s functions. During an observation and concurrent interview on 3/13/2025 at 9 a.m., observed ADM 1’s license was posted at the facility’s lobby. The Assistant Operation Manager (AOM) stated ADM 2 was attending a corporate conference and had not been in the facility since 3/10/2025. A record review of the Department Head Directory on 3/13/2025 at 9:15 a.m. indicated ADM 2 was the facility’s ADM. During an interview on 3/13/2025 at 9:49 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated ADM 2 was the facility’s ADM since 12/2024. LVN 1 stated ADM 2 conducts the stand-up meetings and introduced himself as the facility’s new ADM since 1/2025. LVN 1 stated ADM 2 and the social services staff visited the residents and addressed their concerns. LVN 1 state ADM 1 was last seen in the facility on 12/2024. During an interview on 3/13/2025 at 10:14 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated ADM 2 was the facility’s ADM. CNA 1 stated during an in-service or staff meeting a few months ago (CNA 1 was unable to state the exact date), ADM 2 introduced himself as the new ADM of the facility. CNA 1 stated she had not seen ADM 1 since 12/2024. CNA 1 stated ADM 2 talked to residents and introduced himself as the facility’s ADM. During an interview on 3/13/2025 at 10:35 a.m. with Resident 3, Resident 3, who was cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) intact, stated ADM 2 was new to the facility. During an interview on 3/13/2025 at 10:50 a.m. with the Assistant Director of Nursing (ADON), the ADON stated she worked in the facility five days a week. The ADON stated ADM 2 was the facility’s ADM. The ADON stated ADM 2 introduced himself to the residents as the facility’s ADM since 1/2025. The ADON stated ADM 2 conducts investigations, handled facility and resident concerns, and approved facility supply orders. The ADON stated she never met or seen ADM 1. During an interview on 3/13/2025 at 11:01 a.m. with the Medical Records Director (MRD), the MRD stated on 1/2025 facility staff meeting, ADM 2 introduced himself as the facility’s new ADM. The MRD stated ADM 1 was last seen in the facility on 1/2025. The MRD stated ADM 2 participated in stand-up meetings, interacted with staff and residents, and gave directives and guidance to the facility staff since he came on 1/2025. During an interview on 3/13/2025 at 11:36 a.m. with the Social Services Director (SSD), the SSD stated she worked in the facility five days a week. The SSD stated a copy of the grievance forms were given to the department head involved and to the ADM. The SSD stated the facility ADM since 1/2025 was ADM 2. The SSD stated ADM 2 and the SSD discussed and resolved nursing staff and resident concerns. During an interview on 3/13/2025 at 12:51 p.m. with the AOM and concurrent record review of the Department Head Directory, dated 1/12/2024, the Department Head Directory indicated ADM 2 was listed as Administrator in Training/Operations Manager and ADM 1 was the ADM. The Department Head Directory, dated 3/11/2025, indicated ADM 2 was the Administrator. A record review of the facility-provided job descriptions of an Operations Manager (OM), dated 1/3/2025, and the job description on an ADM, dated 3/7/2025, the Job Description Essential Duties indicated the OM, and the ADM was responsible for the overall operational functioning of the facility. The Qualification section of the Job Descriptions for both the OM and ADM indicated the OM and ADM must maintain licensing credentials for an ADM. The AOM stated ADM 2 was officially the OM on 1/3/2025. The AOM stated the California Department of Public Health (CDPH) License and Certification Verification Page indicated ADM 2’s NHA license was effective 3/7/2025. The AOM stated ADM 1 showed ADM 2 the facility operations through phone calls, Zoom or Microsoft teams calls. The AOM stated ADM 2 performed the essential duties of an ADM listed in the ADM and OM job descriptions since 1/2025. During a record review of the Concern and Grievance Report, dated 1/31/2025, 2/4/2025, 2/5/2025, 2/15/2025, 2/20/2025, and 2/28/2025, the AOM stated ADM 2 signed the Concern and Grievance Report as an ADM. During a record review of the CDPH NHA Program letter, dated 3/7/2025, the CDPH NHA Program letter indicated the letter must be posted as proof of licensure as a NHA until the wall license arrive. The letter was not posted at the facility. During a telephone interview on 3/13/2025 at 1:06 p.m. with ADM 2, ADM 2 stated he performed the essential duties and day-to day operations of the facility as indicated on the ADM and OM job descriptions. ADM 2 stated he did not have an ADM license when he started as the facility’s OM on 1/3/2025. ADM 2 stated he had weekly Zoom or Microsoft Teams meeting with ADM 1 and discussed documentation review and other facility concerns. ADM 2 stated ADM 1 was in the facility on the first half of 1/2025. During a follow up interview on 3/13/2025 at 3:02 p.m. with the AOM, the AOM stated an ADM without an active license had the potential to risk the safety of the facility’s operation, employees, and residents. The AOM stated the facility failed to ensure there was a licensed ADM in the facility to perform the facility’s day-to day operations. A record review of the facility’s Policy and Procedure (PnP) titled, “Administrator,” last reviewed on 2/28/2025, indicated a licensed ADM was responsible for the day-to-day functions of the facility. The PnP indicated the governing body of the facility had appointed an ADM who was duly licensed in accordance with current federal and State requirements. The ADM was responsible for… maintaining his license on a status as required by law and maintaining a copy of such license or registration on premises. ADM 2 signed the Patient Care Policy Committee Meeting Minutes, dated 2/28/2025, as an ADM. The facility failed to: 1. Ensure a licensed ADM held a current and active license from the State to serve in the capacity of an NHA. 2. Ensure an ADM was present at the premises enough hours to permit adequate attention to the facility. The AIT/OM was performing administrative tasks without the presence of the ADM at the facility. As a result, the facility was operating without a licensed ADM that had the potential to negatively affect the facility’s functions. The above violations had a direct relationship to the health, safety, or security of the residents in the facility.