§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, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of three nursing units. (Central, North, and South)
Findings include:
Observations on February 12, 2024, from 10:00 a.m. to 11:00 a.m., revealed dirty floors in rooms 306, 307, and 402, cracked/broken floor tiles in room 402, trash on the floor in room 302, and a stained privacy curtain in room 308.
On February 11, 2024, at 9:30 a.m., and February 12, 2024, at 9:40 a.m., brown stains were observed on the wall adjacent to the sink in room 610.
On February 11, 2024, from 11:01 a.m. to 2:18 p.m., the following was observed:
Window curtains were in poor condition, disrepair, and/or falling from the rods in rooms 103, 104, 105, 106, 108, 109, 117, 205, 211, 213, and 215.
There were cracked floor tiles, a bent threshold plate, an unattached television cable, a leaking faucet, and a continuously running toilet in room 104.
The bedside cabinet for 205A had a broken drawer.
Multiple cigarette butts were on the ground adjacent to the residents' smoking area.
Observations on February 11, 2024, from 9:49 a.m. to 12:17 p.m., and on February 12, 2024, from 1:03 p.m. to 1:50 p.m., revealed the following:
Small winged insects were observed in rooms 510, 508, 515, and 609, and in the corridor.
Floors were dirty with debris in rooms 502 and 515, and there was a brown stain under the bedside table in 500A (present both days).
The surface of the wall was peeling behind the bed in 503A.
In room 504, the baseboard molding was loose and a corner of the wall was broken.
CFR: 483.10(i) Safe, Clean, Comfortable, and Homelike Environment Previously cited 3/17/23.
28 Pa. Code 201.18(b)(1)(e)(2.1) Management.
| | Plan of Correction - To be completed: 03/05/2024
1. The maintenance repairs including cracked floor tiles, unattached TV cable, leaking faucet, continuously running toilet, broken cabinet drawer, wall repair, baseboard molding that is loose, and cracked in the corner are scheduled to be completed. The pest control company has been contacted to exterminate the drain flies on the south unit.
Housekeeping is cleaning the floors noted to be dirty with debris and a brown stain under the bedside table. Any trash noted has been removed from the floor, the stained privacy curtain has been removed and washed. The curtains in poor condition or in disrepair are being replaced. 2. To identify other like areas of environmental concern, room audits will be completed, and any new findings will be corrected and added as a prioritized phased plan.
3. To prevent recurrence, housekeeping and maintenance staff will be educated on the regulation to provide and maintain a safe, clean, comfortable, and homelike environment.
4. To monitor the corrective action and ensure that the deficient practice does not recur, the Admin or designee will complete weekly audits on the facility environment and maintaining cleanliness and keeping in good repair. Audits will be completed 1X/week X 4 weeks; 1X/ bi-weekly X 1 month; 1X/month X 1 month. Results will be reviewed at the monthly QAPI meeting.
5. Date of compliance: March 5, 2024
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