§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 review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for bathing for six of seven residents sampled (Resident R1, R2, R3, R4, R5, and R6).
Findings Include:
Review of the facility policy "Homelike Environment" dated 10/7/25, indicates the facility will provide an environment that is safe, clean, comfortable, and homelike.
During a facility tour and observation with Maintenance Director Employee E1 on 2/25/26, between 9:00 a.m. and 9:28 a.m. the following resident rooms were observed to have unacceptable water temperatures for bathing:
-The water temperature of the resident room sink registered at 60 degrees Fahrenheit for Resident R1.
-The water temperature of the resident room sink registered at 59 degrees Fahrenheit for Resident R2.
-The water temperature of the resident room sink registered at 77 degrees Fahrenheit for Resident R3.
-The water temperature of the resident room sink registered at 55 degrees Fahrenheit for Resident R4.
-The water temperature of the resident room sink registered at 73 degrees Fahrenheit for Resident R5.
-The water temperature of the resident room sink registered at 79 degrees Fahrenheit for Resident R6.
Interview on 2/25/26, at 9:00 a.m. Resident R1 indicated it's very cold. It's been that way for six months when asked if the water temperature in the room was acceptable for bathing.
Interview on 2/25/26, at 9:03 a.m. Resident R2 indicated it is ice-cold, I wouldn't wash a dog in water that cold, when asked if the water temperature in the room was acceptable for bathing.
Observation on 2/25/26, at 9:25 a.m. Resident R4 sink had water running from the faucet and no staff in the room.
Interview on 2/25/26, at 9:27 a.m. Nurse Aide (NA) Employee E2 indicated staff must let the water run sometimes for up to 30 minutes to get it warm enough for bathing.
Interview on 2/25/26, at 9:30 a.m. NA Employee E3 indicated sometimes we use the sinks in the hallways because they're used more often and tend to have warmer water than the resident rooms.
Interview on 2/25/26, at 9:30 a.m. Maintenance Director Employee E1 confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining an acceptable water temperature for bathing for six of seven residents sampled (Resident R1, R2, R3, R4, R5, and R6).
28 Pa. code: 201.14 (b) Responsibility of licensee.
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c) Resident Rights.
| | Plan of Correction - To be completed: 03/19/2026
1. Maintenance director fixed one of the resident room sinks during survey.
2. A whole house audit of resident room sinks, shower rooms, and hallway sinks was conducted by Maintenance Director. This audit checked for hot water and identified any other areas of the facility that were not providing hot water for resident use. Required parts were ordered and all identified units will be repaired before date of compliance.
3. Education to the maintenance department will be conducted by NHA or designee on providing a safe/clean/homelike environment which includes hot water at an appropriate temperature.
4. Weekly audits of 10 resident area sinks will be conducted by maintenance director or designee. This will continue weekly x 3 weeks, monthly x 2 months.
5. Results of audits will be submitted to QAPI for monitoring.
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