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.