Failure to Notify Department of Kitchen Renovations
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.
Penalty
The facility did not notify the Department about renovations in Two North Unit, room 213, where maintenance workers were replacing flooring. The room was empty, and the resident was relocated during the construction. The Nursing Home Administrator confirmed the lack of notification.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
