Other·March 22, 2024

§ 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code and requirements of the State Fire Marshal. (b) Facilities licensed and in operation prior to the effective date of changes in construction regulations shall not be required to institute corrective alterations or construction to comply with such new requirements except where specifically required or where the Department determined in writing that a definite hazard to health and safety exists. Any facility for which preliminary or working drawings and specifications have been approved by the Department prior to the effective date of changes to construction regulations shall not be required to comply with such new requirements provided substantial actual construction is commenced within one year of the effective date of such new requirements. (c) All facilities shall maintain in operating condition all buildings, fixtures and spaces in the numbers and types as specified in the construction requirements under which the facility or unit was first licensed. § 72603. Space Conversion. Spaces approved for specific uses at the time of licensure shall not be converted to other uses without the approval of the Department. § 72605. Notice to Department. The Department shall be notified in writing, by the owner or licensee of the skilled nursing facility, within five days of the commencement of any construction, remodeling or alterations to such facility. On 3/5/2024, at 7:35 AM, an unannounced visit was made to the facility to conduct an annual recertification survey. The facility failed to maintain the facility layout according to the original floor plan by converting one of 54 patient rooms (Room 127) to a facility break room and emergency exit access. The facility also failed to report the room conversion to the centralized application branch (CAB, provides standardization and consistency of state licensing and federal certification through the application process) and Department of Public Health. This deficient practice had the potential for the facility not to have an adequate number of beds available for patients needing Skilled Nursing Facility (SNF, type of in-patient facility required to provide 24-hour skilled nursing care and rehabilitation services) placement or room change. A review of the facility’s Daily Census, dated 3/4/2024, indicated that the facility was housing 93 patients. During concurrent record review of the facility’s floor plan and interview with the Administrator (ADMIN) on 3/6/2024 at 8:45 AM, the floor plan indicated that there were 53 resident rooms with a total bed count for 99 beds. The ADMIN stated, Room 127 which used to have two (2) resident beds was blocked because the room was converted to an emergency exit access. The ADMIN stated due to the conversion of Room 127, the facility currently has a total bed count of 97. During a concurrent observation and interview on 3/7/2024 at 2 PM, the ADMIN stated the following rooms have the following resident count: Room 102 – 2 Room 103 – 2 Room 104 – 1 Room 105 – 2 Room 106 – 2 Room 107 – 2 Room 108 – 2 Room 109 – 2 Room 110 – 2 Room 111 – 2 Room 112 – 2 Room 121 – 2 Room 122 – 2 Room 123 – 2 Room 124 – 2 Room 125 – 2 Room 126 – 2 Room 127 – Vacant Room 128 – 2 Room 129 – 1 Room 130 – 2 Room 131 – 1 Room 201 – 1 Room 202 – 1 Room 203 – 2 Room 204 – 1 Room 205 – 2 Room 206 – 1 Room 207 – 2 Room 208 – 2 Room 209 – 2 Room 210 – 2 Room 211 – 2 Room 212 – 2 Room 213 – 2 Room 214 – 2 Room 215 – 2 Room 216 – 2 Room 217 – 2 Room 218 – 2 Room 219 – 2 Room 220 – 2 Room 221 – 2 Room 222 – 2 Room 223 – 2 Room 224 – 2 Room 225 – 2 Room 226 – 2 Room 227 – 2 Room 228 – 2 Room 229 – 1 Room 230 – 2 Room 231 – 2 Room 232 – 1 During a concurrent observation of Room 127 and interview with the ADMIN on 3/7/2024 at 2:30 PM, three chairs, one table, one refrigerator and one microwave were observed in the room. The ADMIN stated Room 127 was converted to a staff break room to accommodate the facility’s need due to a Coronavirus (Covid 19, a severe infection mainly respiratory disease that could spread from person to person) outbreak. The ADMIN stated he was not sure of the date when the facility had their Covid 19 outbreak. The ADMIN stated the facility’s outbreak was closed on 12/12/2023. The ADMIN stated prior to converting Room 127 to a staff break room, Room 127 was converted to an emergency exit access on 4/29/2023 due to a city construction project. The ADMIN stated part of Room 127’s sliding door was removed and was replaced with a temporary emergency exit door. During an interview with the Infection Prevention Nurse (IPN) on 3/7/2024 at 2:35 PM, the IPN stated the chairs, table, refrigerator and microwave should have been removed from Room 127 when the facility’s Covid 19 outbreak was closed. During an interview with the ADMIN on 3/7/2024 at 2:40 PM, ADMIN stated that he did not and should have reported Resident 127’s room conversion and 2 bed suspension to CAB and Department of Public Health District office. The ADMIN stated that the facility should have reported the plan for room conversion and bed suspension before installing the emergency exit door in Room 127. The ADMIN stated the facility does not have a policy on room conversion or bed suspension. The facility failed to maintain the facility layout according to the original floor plan by converting one of 54 patient rooms (Room 127) to a facility break room and emergency exit access. The facility also failed to report the room conversion to CAB, and Department of Public Health. This deficient practice had the potential for the facility not to have an adequate number of beds available for patients needing SNF placement or room change. The above violations had a direct or immediate relationship to the health, safety, or security of all patients.