Deficiency in Resident Room Furnishings on West Wing
Summary
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms, resulting in a lack of beds, mattresses, and functional furniture in 17 out of 17 rooms on the West Wing's third floor. Observations revealed that multiple rooms, including dual and quad occupancy rooms, were missing essential items such as bed frames, mattresses, and furniture. This deficiency was identified during a survey conducted on April 10, 2025, where it was noted that the West Wing third floor was not equipped for resident occupancy. Interviews with facility staff, including the Nursing Home Administrator and the Maintenance Director, confirmed that the third floor of the West Wing had been used for storage and was not ready for immediate resident use. The Maintenance Director mentioned that equipment to furnish the area had been ordered, but only a portion of the unit could be made resident-ready within 24 hours. The Director of Nursing stated that the floor had not been in use since September 24, 2023, and the Nursing Home Administrator confirmed that there were no plans to decertify any beds in the facility.
Plan Of Correction
1. The rooms are confirmed to be clean and equipped with the regulatory requirements. 2. The NHA initially audited this unit with the director of plant ops and environmental services and confirmed it was available for operation in the event of an emergency. 3. The NHA or designee re-inserviced the director of plant operations and environmental services to ensure all units, even units without residents on them, are prepared for use in the event of an emergency. 4. The NHA will audit weekly to ensure the unit continues to be properly available for use in the event of an emergency.
Penalty
The facility failed to include all required members in Infection Control meetings and did not obtain approval before removing beds from resident rooms. Key members like the Medical Director and Infection Preventionist were absent from meetings, and numerous rooms had fewer beds than licensed, with some lacking complete beds. This was confirmed by staff interviews and observations.
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms. Rooms on One North were converted into offices, and many other rooms were turned into private rooms with fewer beds than licensed. The Nursing Home Administrator confirmed these changes were made without the required approval.
Infection Control Meeting and Bed Removal Deficiencies
Penalty
Summary
The facility failed to ensure that Infection Control meetings included all the required nine multidisciplinary members, such as the Medical Director, Infection Preventionist, lab, and pharmacy, for all four quarters. This was confirmed during an interview with the Infection Preventionist, Employee E15, on February 11, 2025. The absence of these key members in the meetings indicates a lack of compliance with the required infection control protocols, which are essential for maintaining a safe and healthy environment for residents and staff. Additionally, the facility did not obtain the Department of Health's approval before removing beds from resident bedrooms, as observed during a survey conducted from February 10 to February 13, 2025. Numerous rooms across various wings and floors were found to have fewer beds than they were licensed for, with some rooms containing only bed frames without mattresses or furniture. This was confirmed by the Nursing Home Administrator, who acknowledged the failure to secure the necessary approvals for these changes, potentially impacting the facility's ability to provide adequate accommodations for residents.
Plan Of Correction
1. A correct Roster was sent to the department to ensure the Department roster was accurate. Beds that were available were placed in proper locations. In the event a bed was identified in a location that it shouldn't be, it was removed. Beds were removed in the event they required repair to be re-placed upon repair or replacement. East 3340, 342, 343, 347, 357 will have one bed returned upon repair or replacement. East 4-442, 450 will have one bed returned upon repair or replacement. Grove 1104, 105, 106, 117 will have one bed returned upon repair or replacement. Grove 2 - 202, 203, 205, 209, 215 will have one bed returned upon repair or replacement. Grove 306, 307, 309, 314, 315, 316, 317 will have one bed returned upon repair or replacement. West 103, 107 will have one bed returned upon repair or replacement. West 270 will have one bed returned upon repair or replacement. West 3rd floor was/is used as an isolation unit in the event of a mass population requiring isolation. All rooms have correct number of beds in rooms, unless beds require repair and will be replaced upon repair. Main 306, 312 will have one bed returned upon repair or replacement. Main 405, 411, 416, 428, 430 will have one bed returned upon repair or replacement. Main 504, 523, 527, 530 will have one bed returned upon repair or replacement. 2. The NHA reviewed the bed roster to ensure resident rooms were fitted to the proper number of resident beds. 3. The NHA will review the roster quarterly to ensure resident rooms are fitted to the proper number of resident beds.
Failure to Obtain Approval for Bed Removal
Penalty
Summary
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms, as observed during a survey on various nursing units. On One North, rooms licensed for multiple beds were found to have no beds present, as they had been converted into offices. Similarly, on One South, Two North, and Two South, rooms licensed for two to four beds were observed to have fewer beds than licensed, with many rooms converted into private rooms with only one bed. During an interview, the Nursing Home Administrator confirmed that the facility had converted rooms on One North into offices and most other rooms into private rooms without the intention of reverting them to their original licensed capacity. The administrator acknowledged that the facility did not seek or obtain the necessary approval from the Department of Health before making these changes, leading to the deficiency noted in the report.
Plan Of Correction
There are rooms that are not immediately able to be set up as a patient room. A request to delicense beds will be submitted to the Department of Health. Education to the administrative staff, nursing and maintenance managers concerning what is needed for a functioning room and if we do not have a functioning room a bed may need delicensed. A QAPI will be completed monthly to ensure that the delicensing of beds was approved and all licensed beds are immediately available for a resident. Results will be reported to the QA committee.
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