§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 a review of facility policies, observations and staff interviews it was determined that the facility failed to provide a clean safe homelike environment in one of five shower rooms (Miller's Crossing Nursing Unit Shower room).
Findings include:
A review of facility " Housekeeping Services" policy date 2/9/24. indicated that housekeeping service promote a safe and sanitary environment.
A review of facility "Maintenance Department" policy date 2/9/24, indicated that the department conducts on-going monitoring of the facility for areas needing repair.
During an observation on 7/19/24, at approximately 10:00 am it was revealed that the shower stall in the Miller's Crossing Nursing Unit shower room contained a brown substance on the back wall, the flooring contained a build up of debris and grime along the baseboard and corners and the facility failed to safely secure the baseboard to prevent possible resident injury.
During an interview on 7/19/24, at 10:15 the Nursing Home Administrator confirmed that the shower stall in Miller's Crossing Nursing Unit had a brown substance along the back wall, the flooring contained a build up of debris and grime and that the baseboard needed to be properly secured.
PA Code: 207.2(a) Administrator's responsibility
| | Plan of Correction - To be completed: 08/21/2024
Quality Life Services, Chicora has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services, Chicora's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services, Chicora.
1. The facility maintenance department removed the loose baseboard in the Miller's Crossing shower room on 7/19/24 to prevent possible resident injury. The facility housekeeping department cleaned the shower stall in the Miller's Crossing shower room on 7/19/24 to remove the buildup of grime and debris near the baseboards as well as the brown substance on the back wall.
2. The entire baseboard was replaced within the Miller's Crossing shower stall on 7/22/24 by the facility maintenance department.
3. NHA or designee will educate all staff on reporting maintenance or housekeeping concerns to ensure the facility maintains a clean, safe, homelike environment for all residents.
4. NHA of designee will conduct weekly whole house environmental audits for 4 weeks to ensure the facility maintains a clean, safe, homelike environment. Compliance date is August 21, 2024.
5. Results of these audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes.
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