§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 observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on three of four active resident units (B2 unit, C2 unit and D unit)
Findings included:
An observation on February 6, 2024, at 7:00 PM of resident room B267 revealed a red substance buildup along the assist rail attached to the resident's bed.
An observation of the resident's bathroom revealed an unlabeled urine collection graduate containing a small amount of a yellow urine like liquid resting on the back of the resident's toilet. Brown paper towels, a shampoo bottle, and a bed urinal were observed on the resident's bathroom floor. Black dirt, debris, and dead bugs were observed in the translucent bathroom ceiling light.
An observation on February 7, 2024, at 9:00 AM in the bathroom of resident room B223 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture.
An observation on February 7, 2024, at 9:05 AM in resident room B219 revealed a urinary catheter drainage leg bag containing a urine-like yellow liquid hanging over the resident's bathroom hand assist bar.
An observation on February 7, 2024, at 9:15 AM in resident room B217 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture.
An observation on February 7, 2024, at 9:23 AM in resident room B214 revealed an area of brown and tan stains under the resident's sink measuring approximately 14 inches by 12 inches.
An observation on February 7, 2024, at 9:31 AM in resident room B211 revealed that the sink in the resident's room would not drain water. Water was visible in the sink basin. Gray and tan debris was adhered to the inside of the sink along the water line.
An observation on February 7, 2024, at 9:33 AM in resident room B213 revealed that the sink in the resident's room would not drain water. Water was visible in the sink basin.
An observation on February 7, 2024, at 9:45 AM in resident room B256 revealed black dirt, debris, and dead bugs in the bathroom ceiling light fixture
An observation on February 7, 2024, at 9:50 AM in resident room B259, revealed a green tube with a gray cap was found on the floor. At the time of the observation, Employee 17, a Licensed Practical Nurse (LPN), identified the object as a multi drawing needle (a needle used for the collection of blood). Employee 17, LPN, removed the needle from the resident's room and indicated that the item should not be on the floor in the resident's room. Employee 17, LPN, explained that the cap had an unbroken paper seal. A white paper seal was observed covering the gray cap and green tube and the seal did not appear to be broken.
An observation on February 7, 2024, at 10:00 AM in resident room C224 revealed an unknown brown substance on the middle bed privacy curtain.
An observation on February 7, 2024, at 10:03 AM in resident room C226 revealed an unknown dark red substance on the middle bed privacy curtain.
An observation on February 7, 2024, at 10:10 AM in resident room C210 revealed brown stains on both privacy curtains. On the wall, to the right of the sink, there was evidence of water damage and water stains, extending horizontally approximately four feet behind and beyond the resident's dresser.
Observation of the D-unit large shower room on February 8, 2024, at 7:30 AM revealed a broken stationary shower chair. Multiple cracks were observed on the front edge of the shower chair seat and a bottom part of the seat ledge was broken, exposing sharp edges.
A dark brown substance was observed on the back of toilet seat in the large shower room.
The shower curtains were worn and frayed.
The wheels on a mobile shower chair did not function properly, when the surveyor attempted to move it out of the way. The wheels were not locked, but the chair would not move without increased pushing force.
Interview with the Director of Nursing on February 9, 2024, at approximately 8:45 AM confirmed the facility is to be maintained daily to provide a clean, functional, orderly and sanitary environment for the residents.
28 Pa. Code 201.18 (e)(2.1) Management
| | Plan of Correction - To be completed: 04/09/2024
Room 267 substance on resident's assist rail was cleaned upon surveyor's notification by the housekeeper on that unit. Resident bathroom light fixtures in identified rooms; B223, 217, 256, & 267 were taken down and cleaned. Housekeeping director/designee will check each resident bathroom light fixture for non-compliance regarding debris in the light fixture, and preform the necessary cleaning if needed. The housekeeping director will educate the housekeeping staff regarding identifying and complete daily objectives to include bathroom light fixtures and to correct it as soon as possible. Housekeeping director/designee will audit 5 resident rooms daily, 5 days a week to ensure compliance is achieved for bathroom light fixtures. Audit results form bathroom light fixtures will be reported by housekeeping director/designee at QAPI meetings.
Resident room B219 bag identified was discarded at the time of surveyor's identification. The DON quickly educated the direct care staff, that the identified urinary catheter bags, the facility purchases, were not reusable.
The DON/designee will audit weekly, for one month residents that use disposable urinary catheter drainage bags, to ensure reuse of bags is not being practiced.
Results of the audit will be reported by the DON/designee at QAPI meetings.
Room B259 needle was identified as a blood collection needle, it was also identified that the facility does not use that type of needle, and that the resident recently has a blood draw from a contracted lab collection company. the needle was immediately disposed of in a sharps container, staff searched the resident room for any other collection equipment that may have fallen out of the phlebotomist carry case.
The DON will implement a new process and educate all direct care staff to check, and document resident rooms after phlebotomist leaves, to ensure no equipment is left behind by mistake.
Room check audits will be reviewed by DON/designee and reported at QAPI meetings. The identified sink in room B211 & B213 as not draining, was unclogged, by the maintenance department, day of survey. The maintenance department checked all sinks that day for any clogged or slow draining, and made necessary maintenance if needed.
The maintenance department will check all resident sinks every other month to ensure sinks remain unclogged.
Rooms C224,C210 privacy curtains identified at the time of the survey, were taken down immediately and replaced. In addition the identified will area was addressed that same day. The director of Housekeeping and designee at the time of survey audit each resident room to identify any non compliance regarding privacy curtains. any privacy curtains in non-compliance were taken changed. The Director of Housekeeping will educate all housekeeping staff to identify during daily assignments to check privacy curtains for stains and replace them immediately.
The director of Housekeeping will randomly audit five resident rooms a day , five days a week for one month to ensure compliance is met regarding clean and in good shape. results of audits will be reported by
Director of Housekeeping at QAPI meeting. The shower chair identified was discarded upon notification. The identified toilet seat was cleaned by housekeeping.
The DON will educated direct care staff that toilets must be disinfected between use of residents.
The Director of Maintenance will audit facility wide of all shower chair in use and stored to identify no cracks, sharp edges are present, any identified will be discarded, and replaced with acceptable chairs. The shower curtain identified was replaced at the time of survey. The Director of Housekeeping /designee will audit facility wide all shower rooms for curtains that appear worn or frayed condition and replace them with acceptable ones. The Director of housekeeping will educated his staff to identify worn and frayed shower curtains on their daily assignments and to replace them as needed. The Director of Housekeeping/designee will audit room room curtains weekly for two months to ensure curtain are in acceptable condition.
Results of audits will be reported at QAPI meetings. The mobile shower chair identified wheels were checked by maintenance and identified that the surveyor had one wheel locked. The maintenance department did preform some minor preventative measures by applying some lubricant to the bearing of the wheels of the chair.
The Director of maintenance will add shower chairs to the facility's monthly preventative measures. The director of Maintenance will audit 5 shower chairs weekly for one month for function.
Results of the audits will be reported by Director of maintenance at QAPI meetings.
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