§483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.
§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;
§483.10(i)(3) Clean bed and bath linens that are in good condition;
§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);
§483.10(i)(5) Adequate and comfortable lighting levels in all areas;
§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and
§483.10(i)(7) For the maintenance of comfortable sound levels.
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Observations:
Based on observation and resident and staff interview, it was determined that the facility failed to maintain a safe, clean, home-like interior on three of five nursing units observed (100, 200, and 300 units).
Findings include:
Observations on February 7, 2024, revealed the following: - 9:40 AM and at 1:48 PM in the 100 unit visiting lounge: an accumulation of dust and debris on the side frame and rungs of the double seat chair. Additionally, a wheelchair leg and bunched up blanket were present on top of the cabinet. - 9:42 AM and at 1:48 PM in the 100 unit hallway bathroom: the curtain in the 100 unit hallway bathroom had multiple holes present in the top mesh portion of the curtain. - 9:44 AM and 1:48 PM in the 100 unit main dining room: a pile of soiled linens including a hospital gown, blankets, towels, and sheet, as well as a clean incontinence brief were present on the countertop near the sink. The sink was noted to be discolored, and dried streaks of liquid were present on the wall behind the sink and on the cabinet below the sink. The grout to the left side of the sink was cracked and discolored. Multiple chairs in the dining area were noted to have dried drips on the sides as well as soiled rungs. At 11:49 AM, residents were observed eating lunch in the dining room. - 10:00 AM and 1:55 PM: Resident 5's (a Resident on the 200 unit) overbed table had multiple rings and dried blobs/drops of liquid. Additionally, in Resident 5's bathroom, a brown substance was present in the shower chair commode bucket and on the shower chair seat. - 10:23 AM in the 300 unit dining room: the floors were dirty with crumbs and spills and the tabletops were dirty. At 12:45 PM, the floors remained dirty with crumbs and spills, the tabletops remained dirty, and Residents 1, 2, 3, and 4 were observed to be eating in the dining room at that time. - At 10:34 AM and at 2:00 PM in Resident 6's bathroom (on the 200 unit): an accumulation of hair in the shower drain, and multiple areas of a black substance were present on the rubber bathmat in the shower stall. An immediate interview with Resident 6 at 10:34 AM, revealed that she had a concern with the hair in the drain. She also confirmed that she uses the bath mat when she showers.
Following a tour and observation of the aforementioned concerns, starting at 1:48 PM, the Assistant Nursing Home Administrator, Director of Nursing, and Employee 3 (Environmental Services Regional Manager) acknowledged the concerns and confirmed that they would be addressed.
28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management
| | Plan of Correction - To be completed: 03/05/2024
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. After, ANHA was toured by surveyor with environmental regional manager M1 visitor lounge was then cleaned, M1 visitor lounge had linens removed as well as wheelchair leg, M1 hallway bathroom was cleaned and curtain replaced, M1 main dining room had soiled linen and brief removed from countertop, M1 main dining room sink was cleaned as well as the wall behind it. M1 main dining room had grout replaced and cleaned. M1 main dining room chair were clean and free of drips and debris. M1 dining room sink cabinet was cleaned. R5 bedside table was cleaned and in bathroom the shower chair and commode bucket were cleaned. M3 dining room had floors cleaned off crumbs and spills and tabletops were cleaned. R6 hair was removed from the shower drain and black substance removed from the shower mat. To identify other residents that have the potential of being affected, the NHA/designee completed an audit on visitor lounges, unit dining rooms and resident bathrooms. Identified areas were cleaned at the time of the audit. NHA or designee educated the Housekeeping department and nursing department on importance of maintaining a clean and homelike environment for residents throughout the facility. Resident common areas, resident bedside tables and resident bathrooms will be audited 3x a week for 4 weeks then monthly x1 month to ensure resident common areas, resident bathrooms and resident bedside tables maintain a clean homelike environment. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
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