Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  170 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on January 6, 2020, it was determined that Cheltenham Nursing and Rehab Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

 Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
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 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.

Based on observation and interviews with residents and staff, it was determined that the facility failed to ensure that a comfortable room temperature was provided for one of three residents reviewed (Resident R1).

Findings include:

Resident R1 was admitted to the facility on September 24, 2019. Review of the clinical record revealed a Minimum Data Set (MDS - assessment of resident needs), dated September 24, 219 revealed that his diagnoses included HIV (human immunodeficiency virus - a virus that destroys white blood cells that fight infection), diabetes, one-eye blindness, other eye low vision, and abnormal gait & mobility.

Observation of the resident's room on January 6, 2020 at approximately 10:00 a.m., revealed that the temperature of the room was noticeably warmer than that of both the hallway temperature and nearby rooms. The temperature obtained on the surveyor's thermometer was 78.1 degrees Farenheit.

In an interview with Resident R1 on January 6, 2020 at approximately 11:00 a.m., he stated that his room had been uncomfortably hot for an extended period of time and that it continued to be so at the time of our interview. Resident R1 also stated that he had informed facility staff that the temperature of the room made him uncomfortably hot.

In an interview with the Director of Maintenance on January 6, 2020 at approximately 1:00 p.m., he stated that he had been aware that Resident R1's room has been uncomfortably hot. During this interview, the Director of Maintenace obtained a room temperature of 78.1 on a facility thermometer. In an interview with Employee E8, a nursing assistant, on January 6, 2020 at approximately 2:00 p.m., she stated that Resident R1's room had been hot for a long time.

The facility failed to ensure that one resident had been provided with a room that was maintained at a level that was comfortable Resident R1.

28 Pa Code 207.2(a) Administrator's responsibility
Previously cited 9/20/19

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/20/19

 Plan of Correction - To be completed: 01/27/2020

1. Room temperature was adjusted to Resident R1's satisfaction.
2. Unit manager interviewed R1's three other roommates and none had any complaints about the temperature of the room. Unit manager or designee will meet with R1 regularly to see if temperature of the room is at a comfortable setting for Resident R1.
3. Employee E8 was educated on 1/6/2020 by the Unit Manager in reference to the importance of informing proper personnel of resident complaints immediately. NHA re-educated Department heads and IDT team on 1/6/2020 on the grievance process and following up on resident concerns.
4. Audits will be conducted daily for 4 weeks monthly for 3 months, then quarterly for 2 quarters. Results will be reviewed at the QAPI meeting.

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