§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 staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for residents on one of eight nursing units. (Bair 2 Nursing Unit)
Findings include:
During the initial tour of the Bair 2 nursing unit on February 12, 2024, at 11:00 a.m., the following observations were made,
-Next to the nurse's station (lower number resident rooms), there was coffee cups, a cup of water and a clear cup on the on the handrail.
- There was used socks, trash and food like substance throughout the hallway.
-Next to the dining room closet there was trash on the floor appeared like used napkins, sugar packets and food particles on the floor.
-Resident Room 209A had a bed side table next to the bed which had a black substance on the table which appeared like dried food or drink.
-Next to the nurse's station with higher number resident rooms, there was white powder like substance on the floor,
- Resident bathroom in room 212A had water in the floor with 4 wet towels on the floor next to the toilet.
-In Bair 2 nursing unit dining room, there were breakfast trays from the morning,
-Inside the Bair -2 elevator there was trash on the elevator floor.
During a tour with Unit Manager, Employee E12, on February 12, 2024, at 11:00 a.m., confirmed the above findings.
28 Pa. Code: 201.14(a) Responsibility of licensee.
| | Plan of Correction - To be completed: 04/12/2024
Coffee cups, cup of water and clear cup removed from the handrail on February 12, 2024 by housekeeping Trash on the floor; napkins, sugar packets and food particles were cleaned from the floor on February 12, 2024 by housekeeping Next to the nurse's station with higher number resident rooms with white like substance on the floor were cleaned on February 12, 2024 by housekeeping. Room 209 bedside table cleaned on February 12, 2024 Leaking toilet in Room 212 was repaired by Maintenance on February 12, 2024 and towels removed from the floor Left over meal trays removed by Dietary February 12, 2024 Bair 2 elevator trash was cleaned by housekeeper on February 12, 2024 Resident rooms, hallways, dining rooms, elevators audited for cleanliness and leaking toilet on February 19, 2024 Staff development or designee will complete in-service to nursing staff about completing work order for repair, ensuring cleanliness of resident rooms and hallways in order to ensure homelike environment. Housekeeping Director will in-service housekeeping staff about proper cleaning of resident rooms, hallways, kitchen during their shift Housekeeping director will complete hallways and rooms audit of 2 units weekly x4, and monthly x 3 months Dietary Director will complete weekly audits for late trays weekly x4 and monthly x3 months Maintenance director will complete 25% audit of room toilets for leaks and complete repair weekly x4, them monthly x3 months Administrator or designee will complete weekly audit with housekeeping director, maintenance director of 2 units per week x4 weeks and monthly x 3months Result of audits will be presented at monthly QAPI until substantial compliance is achieved
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