Deficiency in Resident Room Furnishings on West Wing
Penalty
Summary
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms, resulting in a lack of beds, mattresses, and functional furniture in 17 out of 17 rooms on the West Wing's third floor. Observations revealed that multiple rooms, including dual and quad occupancy rooms, were missing essential items such as bed frames, mattresses, and furniture. This deficiency was identified during a survey conducted on April 10, 2025, where it was noted that the West Wing third floor was not equipped for resident occupancy. Interviews with facility staff, including the Nursing Home Administrator and the Maintenance Director, confirmed that the third floor of the West Wing had been used for storage and was not ready for immediate resident use. The Maintenance Director mentioned that equipment to furnish the area had been ordered, but only a portion of the unit could be made resident-ready within 24 hours. The Director of Nursing stated that the floor had not been in use since September 24, 2023, and the Nursing Home Administrator confirmed that there were no plans to decertify any beds in the facility.
Plan Of Correction
1. The rooms are confirmed to be clean and equipped with the regulatory requirements. 2. The NHA initially audited this unit with the director of plant ops and environmental services and confirmed it was available for operation in the event of an emergency. 3. The NHA or designee re-inserviced the director of plant operations and environmental services to ensure all units, even units without residents on them, are prepared for use in the event of an emergency. 4. The NHA will audit weekly to ensure the unit continues to be properly available for use in the event of an emergency.