Failure to Notify Department of Renovations
Penalty
Summary
The facility failed to notify the Department of renovations made to one of its nursing units, specifically Two North Unit, room 213. During an observation and interview, it was found that the room was empty, with no furniture or bed, and maintenance workers were actively working on replacing the flooring. The maintenance worker confirmed that the renovations began that day, and the resident who previously occupied the room had been relocated to another room during the construction. The Nursing Home Administrator later confirmed that the facility did not notify the Department of these renovations prior to their commencement.
Plan Of Correction
Room 213 carpet was pulling up and posed a safety/tripping hazard. Resident was moved to another room temporarily on January 27, 2025, to prevent injury. New vinyl flooring was installed on January 31, 2025. The resident returned to room 213 on January 31, 2025. Department of Health was emailed on January 29, 2025, and Life Safety was emailed on January 30, 2025, concerning changing the flooring due to safety. Reviewed information with Life Safety via phone call on February 11, 2025. Life Safety suggested using their web request and submit information on the flooring. Information submitted on February 14, 2025. All future flooring changes or other similar necessities of change will be reported to the Department of Health Supervisor and will be routed through the Life Safety portal for approval/notification. Education will be provided to the Director of Maintenance. A QAPI will be initiated to ensure any change is reported to the appropriate authorities of the Department of Health and Life Safety. QA will be completed by the Director of Maintenance or designee on a monthly basis and reported to the QA committee.