Health inspection·July 14, 2023

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. 22 CCR § 72501. Licensee--General Duties. (b) The licensee, if an administrator, may act as the administrator or shall appoint an administrator, to carry out the policies of the licensee. A responsible adult who is knowledgeable in the policies and procedures of the licensee shall be appointed, in writing, to carry out the policies of the licensee in the absence of the administrator. If the administrator is to be absent for more than 30 consecutive days, the licensee shall appoint an acting administrator to carry out the day-to-day functions of the facility. (c) The licensee shall delegate to the designated administrator, in writing, authority to organize and carry out the day-to-day functions of the facility. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 6/6/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident abuse. The facility failed to ensure the licensee appointed an administrator to carry out the policies of the licensee and the day-to-day functions of the facility, as per its policy on Administrator. The licensee failed to ensure the facility was 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. By 6/7/2023 the facility did not have an administrator since 2/16/2023. As a result, for all residents in the facility there was an increased risk that their needs were not met while residing in an unsafe environment. On 6/6/2023 a review of the facility's Daily Census Report dated 5/30/2023 indicated a total of 70 residents in-house.   During an interview, on 6/6/2023 at 10:01 AM, the Registered Nurse Supervisor 2 (RNS 2) stated, “We do not have an Administrator in the facility and the Chief Operational Officer (COO) is the facility’s Acting Administrator." On 6/6/2023 at 10:23 AM, during an interview, the Director of Nursing (DON) stated the licensed Administrator was responsible for the facility to ensure the implementation of policies and procedures. On 6/6/2023 at 2:32 PM, during an interview, the DON stated that currently she served as the abuse coordinator because of the lack of administrator. The DON stated it was not safe for the facility to not have an Administrator. During an interview, on 6/6/2023 at 2:40 PM, the Chief Operating Officer (COO) stated the facility currently did not have a licensed Administrator and the corporation placed advertisement seeking an Administrator on multiple websites and, “We have received applications from candidates; however, they were newly licensed, and the owners did not accept their applications. The owners have access to review and download the applicants’ applications. I have been following up with the owners lately because I know we are required to replace the Administrator position not later than 30 days after the previous Administrator resigned. The previous Administrator resigned on 2/16/2023." During an interview and concurrent record review on 6/7/2023 at 12:13 PM, the COO stated the previous Administrator was responsible for documenting the Quality Assurance and Performance Improvement (QAPI) meeting minutes and overseeing the QAPI program. The COO was not able to provide any documentation to show the current QAPI measures, meeting minutes for the 4/2023 QAPI Committee Quarterly Meeting. A review of the facility's policy titled, "Administrator," reviewed 1/2023, indicated a licensed Administrator was responsible for the day-to-day functions of the facility and responsible for implementing established resident care, personnel, safety and security, and other operational policies and procedures necessary to remain in compliance with current laws, regulations and guidelines governing long term care facilities. A review of facility undated document titled, “Job Description -Administrator,” indicated the facility Administrator must be licensed, and was responsible for directing the performance improvement committee to ensure quality care throughout the facility. The Administrator directs The facility failed to ensure the licensee appointed an administrator to carry out the policies of the licensee and the day-to-day functions of the facility, as per its policy on Administrator. The licensee failed to ensure the facility was 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. By 6/7/2023 the facility did not have an administrator since 2/16/2023. As a result, for all residents in the facility there was an increased risk that their needs were not met while residing in an unsafe environment. The above violations had a direct or immediate relationship to the health, safety, and security of all residents.