Failure to Notify Department of Kitchen Renovations
Penalty
Summary
The facility failed to notify the Department of renovations made to the Main Kitchen, as required by regulations. Observations and staff interviews revealed that the facility had been experiencing plumbing issues in the Main Kitchen, with corroded sewer pipes causing sewage to leak back into the ground. As a result, the floor was removed, and plumbing repairs were initiated, which were still ongoing at the time of the survey. Despite these significant alterations, the facility did not inform the Department prior to commencing the renovations. During the renovation period, the Dietary Staff utilized the kitchen in the adjacent Personal Care Home (PCH) to prepare food for the facility's residents. The food was then transported back to the facility's Main Dining Room for tray line service. Due to limited freezer space in the PCH kitchen, a freezer truck was rented and placed in the facility's parking lot to accommodate the food supply. The Director of Nursing confirmed that the facility did not report these renovations to the Department, as required.
Plan Of Correction
2590 - Facility Administrator, or designee shall notify the Department of Health of replacement of sewer line and removed flooring above sewer lines in kitchen. The facility Administrator will be educated by the corporate manager, or designee, on proper notifications to the Department of Health. The facility Administrator will audit the nursing facility operations for possible notification requirements to the Department of Health for one month then weekly for two months. Results of audits will be reviewed at the month QAPI meeting for tracking and trending purposes. The facility Administrator shall ensure compliance.