Unauthorized Addition of Beds in Resident Rooms
Penalty
Summary
The facility failed to obtain the Department of Health's approval before adding beds to resident bedrooms, resulting in a violation of the regulation that limits the number of beds in a room to the maximum number approved by the Department. During observations conducted on all nursing units from February 10 to February 13, 2025, it was noted that several rooms across different floors had more beds than they were licensed for. Specifically, on the Grove Third Floor, Room 318, which was not on the bed readout, had two beds. On the Main Second Floor, Room 210, licensed for three beds, had four beds. On the Main Third Floor, multiple rooms had more beds than licensed, including Room 303, Room 316, Room 317, Room 318, Room 323, Room 324, Room 326, and Room 327. Similar discrepancies were observed on the Main Fourth and Fifth Floors. The Nursing Home Administrator confirmed the facility's failure to obtain the necessary approval for these additional beds during an interview on February 13, 2025.
Plan Of Correction
1. Bed read out was reviewed and corrected and sent to the Department to ensure the Department roster was and facility layout matched. Beds that were available were placed in active room locations. In the event a bed was identified in a location that it shouldn't be, it was removed. Beds that require repair are removed from resident rooms and returned on either repair or replacement. Grove 318 corrected doh bed read out with active room. Main 210 corrected doh bed read out - 4 active beds remain. Main 303, 316, 317, 318, 323 corrected doh bed read out - 4 active beds remain. Main 326, 327 corrected doh bed read out - 2 active beds remain. Main 324 made a bed inactive in electronic medical record to comply with having the correct number of licensed beds available. 2. Plant ops director was in serviced by NHA to ensure to replace or repair beds or items to return to empty rooms as soon as practicable to ensure availability and use to meet the number of licensed beds. 3. The NHA will review the roster quarterly to ensure resident rooms are fitted with the proper number of resident beds to meet the number of licensed beds.