§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 observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms, dining room and hallways) as required. (resident rooms, dining room, and hallways)
Finding include:
During an observation of the facility on 2/5/25, at 10:30 am the following was revealed:
* Resident room 123 W (window) the area behind the resident's bed headboard contained peeling and scuffed paint.
* Resident room 126 W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint
* Resident room 119 W the area behind the resident's bed headboard contained peeling paint
* Resident room 203 D (door) and W the area behind the resident's bed headboard contained peeling wall paper.
* the doors to the dietary department contained scuff marks and peeling paint
* the hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster
* a wall in the dining room contained peeling paint.
* the door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering.
* the wooden handrails throughout the facility contained gashes that contained splintering wood and non smooth unfinished surfaces, some of which where located in the following hallways: outside the dietary department and outside the conference room.
During an interview on 2/5/25, at 10:45 am the Nursing Home Administrator and Maintenance Director Employee E1 confirmed that the facility failed to maintain the facility in a homelike environment.
Pa Code: 207.2 (a) Administrator's responsibility
| | Plan of Correction - To be completed: 03/11/2025
Preparation and or evaluation of the
following plan of correction set forth
in this document does not constitute
admission or agreement by the
provider of the truth of the facts
alleged or conclusions set forth in
the statement of deficiencies. The
plan of correction is prepared and or
executed solely because it is
required by the provisions of federal
and state law.
Areas identified during the survey have been repaired by placing InPro wall protection behind the headboards, painting and plastering as indicated, and sanding and staining as indicated. Areas repaired are as follows: Resident room 123 W (window) the area behind the resident's bed headboard contained peeling and scuffed paint, Resident room 126 W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint , Resident room 119 W the area behind the resident's bed headboard contained peeling paint , Resident room 203 D (door) and W the area behind the resident's bed headboard contained peeling wall paper, the doors to the dietary department contained scuff marks and peeling paint , the hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster, wall in the dining room contained peeling paint, the door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering, the wooden handrails contained gashes that contained splintering wood, and non-smooth unfinished surfaces, located in the following hallways: outside the dietary department and outside the conference room.
A schedule has been implemented to resurface and paint the remaining handrails in the facility. Project will be completed by July 31, 2025.
A schedule has been implemented to place InPro wall protection behind an additional 33 beds. Project will be completed by July 31, 2025.
The Maintenance Director will complete a facility walk thru audit. Any other areas identified will be repaired.
The Administrator/designee will complete staff training on utilizing the TELS electronic maintenance system when environmental concerns are identified so the work can be completed in a timely manner.
Environmental audits will be conducted by the NHA or designee weekly x 2, then monthly thereafter prior to the safety committee meetings.
The Administrator will complete weekly audits of the progress of handrail resurfacing project ad InPro wall protection project to ensure completion as scheduled.
The Administrator/designee will complete a comparison audit of work needing completed against work completed to maintain a clean, comfortable and home-like environment. Audit will be completed weekly for two weeks.
Results will be taken to the QAPI committee for review of findings and further interventions if indicated.
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