§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 interview, it was determined that the facility failed to maintain a clean homelike environment in one of three resident rooms observed (Resident R1) and failed to maintain a safe, comfortable, home-like environment for six of twelve units (second floor main unit, third floor main unit, fourth floor main unit, fifth floor main unit, east unit third floor and east unit fourth floor.
Findings Include:
Review of the facility policy "Resident Environment" dated 10/1/23, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike.
Observation 6/12/24, at 1:41 p.m. Resident R1 rooms baseboards appeared with grayish-brown streaks, scuff marks, the tile under sink was very worn and faded. The TV stand belonging to roommate was visible soiled with coffee ground like substance.
During an interview 6/12/24, at 1:50 p.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the baseboards appeared to have grayish brown like streaks and scuff marks, the tile under the sink was faded and worn and the roommate ' s television stand was visibly soiled with coffee ground like substance.
During an interview 6/12/24, at 11:20 a.m. Nurse Aid (NA) Employee E9 stated "the water is hot in the morning and gets colder throughout the day, we try to give our showers early in the morning.
During an interview 6/12/24, at 11:35 a.m. NA Employee E7 stated "it is like this every day, the other floors get cold as well, even the water in the rooms is cold.
During an interview 6/12/24, at 11:10 Resident R7 stated "I would like to get my shower now, however the water was to cold", Resident R7 was taken to the 5th floor to receive her shower.
During an interview 6/12/24, at 11:15 Resident R6 stated " the water is sometimes not as warm as I would like so I take a fast shower".
During an interview 6/12/24, at 11:17 a.m. Resident R8 stated "sometimes the water is too cold".
During an interview 6/12/24, at 11:27 a.m. Resident R5 stated " I got my shower this morning it started out nice and warm but got colder as I continued, it usually is cold".
Interview 6/12/24, at 11:38 a.m. Maintenance Employee E8 stated if the water is cold on this floor, it will be cold on the other floors as well.
Interview 6/12/24, at 11:43 the Director of Nursing stated, "I was unaware of a water temperature issue."
Interview 6/12/24, at 12:00 p.m. NA Employee E10 stated "it gets cooler throughout the day".
Observations of the following temperatures completed by Employee E8 as follows:
6/12/24, 11:40 a.m. second floor main room 210 north hall sink 90 degrees.
6/12/24, 11:44 a.m. second floor main shower room north hall 82 degrees.
6/12/24, 11:50 a.m. third floor main north hall room 310 sink 90 degrees.
6/12/24, 11:56 a.m. third floor main north shower room 90 degrees.
6/12/24, 11:59 a.m. third floor main south room 318 north hall sink 96 degrees.
6/12/24, 12:05 a.m. third floor main south hall shower room 96 degrees.
6/12/24, 12:16 p.m. fourth floor south resident bathroom 100 degrees.
6/12/24, 12:20 p.m. fourth floor main north room 410 sink temperature 89 degrees.
6/12/24, 12:26 p.m. fourth floor main north shower room 92 degrees.
6/12/24, 12:36 p.m. fifth floor main south bathroom sink 100 degrees.
6/12/24, 12:42 p.m. fifth floor main south shower room 100 degrees.
6/12/24, 12:50 p.m. fifth floor north hall room 510 sink temperature 90 degrees
6/12/24, 12:56 p.m. fifth floor north hall shower room 90 degrees.
6/12/22, 1:14 p.m. east unit fourth floor men's shower room 85 degrees.
6/12/24, 1:16 p.m. east unit fourth floor women's shower room 85 degrees.
6/12/24, 1:20 p.m. east unit fourth floor room 440 sink temperature 97 degrees.
6/12/24, 1:18 p.m. third floor east hall men's bathroom sink temperature 97 degrees.
6/12/24, 1:20 p.m. third floor east hall shower room 96 degrees.
6/12/24, 1:22 p.m. third floor women's hall room 340 sink temperature 98 degrees.
6/12/24, 1:24 p.m. third floor women's shower room temperature 96 degrees.
During an interview 6/12/24, at 1:31 p.m. Maintenance Employee E8 confirmed the water temperatures were not in range and cold, then stated "I'm going to check the main tank, you should have enough hot water for the shower."
During an interview 6/12/24, at 1:41 p.m. the Director of Nursing confirmed the facility failed to create a safe, comfortable, homelike environment for six of twelve nursing units.
.28 Pa. Code 207.2(a) Administrator's responsibility.
28 Pa. Code 201.18(b)(1) Management.
| | Plan of Correction - To be completed: 06/25/2024
1. Resident R1's baseboards under the sink and TV stand were cleaned. The water temperature was checked on units to confirm it was within range.
2. An initial audit was completed to confirm resident room on unit main 4 are cleaned per cleaning schedule and water temperatures throughout the campus are within range.
3. The Director of Environmental services was re in-serviced on the regulation to ensure a clean and homelike environment. The Director of Plant Operations was re in-serviced on the regulation to ensure temperatures are within range.
4. The director of environmental services or designee will audit room cleanliness on the unit main 4 daily for 1 week and weekly for 2 weeks to ensure cleanliness. The director of plant operations or designee will audit water temperatures per unit weekly for 4 weeks to ensure water temperatures are within range. Audit findings will be shared with QAPI committee.
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