Failure to Notify Department of Bed Reduction
Penalty
Summary
The facility failed to provide the required notification to the department regarding the reduction in the number of licensed beds in operation. This deficiency was identified through facility records, observations, and staff interviews. The facility's bed readout document indicated that there were 12 Medicare/Medicaid licensed beds on the second-floor nursing unit in rooms 224, 225, and 226. However, during an observation on December 27, 2024, it was found that these 12 beds were not prepared for resident use. Specifically, room 224 had four bed frames in disrepair with headboards and footboards removed, and air mattresses on the floor. Room 225 had six headboards and bulletin boards on the floor, a stained air mattress, and various debris. Room 226 had three head and footboards resting on a bed, a bed frame without a mattress, air mattresses on the floor, and a PTAC unit with its face removed. The Nursing Home Administrator confirmed that the beds were not prepared for resident use and acknowledged the failure to notify the department of the reduction in licensed beds.
Plan Of Correction
1. Rooms 224, 225 and 226 were cleaned and beds were assembled the same day, 12/27/2024. 2. Residents had no negative outcomes. 3. Temporary Restriction on 12 beds in rooms 224, 225, and 226 has been submitted to Department of Health on 1/13/2025. 4. Rooms 224, 225, and 226 will be audited by Plant Operations Manager/designee 1x/week for 3 weeks. 5. Results reported to QAPI for review and approval.