Health inspection·January 17, 2025

F835 42 CFR §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (b) Compliance with Federal, State, and local laws and professional standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. 22 CCR §72007 Administrator Administrator means a person licensed as a nursing home administrator by the California Board of Examiners of Nursing Home Administrators or a person who has a state civil service classification or a state career executive appointment to perform that function in a state facility. 22 CCR §72513. Administrator (a) Each skilled nursing facility shall employ or otherwise provide an administrator to carry out the policies of the licensee. On 12/9/2024, an unannounced visit was conducted at the facility during the annual Recertification survey. The facility failed to ensure adequate administration services as the facility's administrator did not have an Administrator's license and failed to ensure the facility had a designated Administrator. As a result, on 5/1/2024, all residents in the facility were at an increased risk in not having their concerns and needs addressed in a timely manner. A review of the facility's Administrator's Job Description dated 3/20/2023, indicated the facility's Administrator held the title of Chief Nursing Officer (CNO) of the General Acute Care Hospital (GACH) 1. The Job Description indicated the CNO coordinated and directed the operations of the Nursing Departments, ensured quality patient care was given across the continuum with appropriate level of care, and was actively involved, at the executive level, in the leadership of the organization. The CNO organized and administered areas of Patient Care services to attain the hospitals objectives established by the Governing Body, identified and articulated the vision and strategic direction for the discipline of Nursing, collaborated on the implementation of strategies to achieve them and directed performance improvement and continuous quality improvement (CQI) activities. The Job Description indicated a current Registered Nurse (RN) License was required for the CNO position. A review of the organizational chart for GACH 1 dated 11/6/2024, indicated the facility Administrator was the CNO for GACH 1. A review of the undated organizational chart for the facility, indicated the Administrator also held the title of Administrator for the facility, in addition to holding the title as the CNO for GACH 1. During an initial tour observation of the facility on 12/9/2024 at 9 AM, there was no posted Administrator license observed on the facility's bulletin board. During an interview on 12/10/2024 at 12:17 PM, the facility's Director of Nursing (DON) stated and confirmed there was no posted Administrator license on the facility's bulletin board. The DON stated the previous Administrator resigned from the facility in 4/2024 and when the previous Administrator left, the CNO of GACH 1 became the Administrator for the facility. The DON stated she was not sure if the current Administrator (the CNO) had an Administrator's license. During an interview on 12/10/2024 at 12:22 PM, Licensed Vocational Nurse (LVN) 6 stated the facility did not have an Administrator and the DON had been the only one they had seen in the facility. LVN 6 stated they had not seen the CNO for GACH 1 at the facility. During an interview on 12/10/2024 at 12:27 PM, LVN 7 stated the facility had no Administrator. LVN 7 stated the facility solely had a DON and that the CNO for GACH 1 rarely came to the facility. LVN 7 stated sometimes the CNO for GACH 1 did not come at all. On 12/11/2024 at 2:53 PM, during an interview, the Administrator (CNO) stated she was the current CNO for GACH 1 and the Administrator for the facility. The Administrator stated she had been the CNO for GACH 1 for two years and started as the Administrator for the facility in 4/2024. The Administrator (CNO) stated she had a RN license and did not have an Administrator's license. The Administrator (CNO) stated she did not have a set number of hours that she spent at the facility or at GACH 1 but spent time at both. The Administrator (CNO) stated she met with the DON as frequently as she could. The Administrator (CNO) further stated she had no set time to come to the facility but would come as needed and would go back and forth between GACH 1 and the facility. During an interview on 12/12/2024 at 3:52 PM, the Medical Director (MD) 1 stated the facility's previous Administrator left in 4/2024. MD 1 stated the facility did not have a dedicated Administrator and that the CNO for GACH 1 had been the facility's acting Administrator since the previous Administrator resigned. MD 1 stated with the facility not having a dedicated Administrator there was a potential for the facility residents to be impacted when it comes to having the resident and/or family concerns addressed. MD 1 stated he and the DON could not address all administrative concerns because there were too many people. MD 1 stated there was no one to immediately address resident and family concerns. A policy and procedure regarding Administration was requested from the facility but was not provided. The facility failed to ensure adequate administration services as the facility's Administrator did not have an Administrator's license and failed to ensure the facility had a designated Administrator. As a result on 5/1/2024, all residents of the facility had an increased risk in not having their concerns and needs addressed in a timely manner. The above violation had direct or immediate relationship to the health, safety, or security of all the residents in the facility.