§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 safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). Findings include: Review of the facility policy "Resident Rights - Quality of Life - Homelike Environment" dated August 2024, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment.
Review of Title 42 Code of Federal Regulations 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. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of the admission record indicated Resident R3 was admitted to the facility on 10/24/19.
Observation on 11/18/24, at 10:30 a.m. of Resident R3's room indicated gouges in the wall behind the head of the bed.
Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R3 had gouges in the wall behind the head of the bed.
Review of the admission record indicated Resident R5 was admitted to the facility on 4/7/23.
Observation on 11/18/24, at 11:33 a.m. Resident R5 was seated in a wheelchair at the dining table. The frame and undercarriage of the wheelchair was covered with dust and dried debris.
Interview on 11/18/24, at 11:34 a.m. Nurse Aide (NA) Employee E1 confirmed the wheelchair was covered with dust and dried debris.
Review of the admission record indicated Resident R70 was admitted to the facility on 11/6/20.
Observation on 11/18/24, at 11:40 a.m. of Resident R70's room indicated gouges in the wall behind the head of the bed.
Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R70 had gouges in the wall behind the head of the bed.
Review of the admission record indicated Resident R73 was admitted to the facility on 11/19/18.
Observation on 11/18/24, at 11:43 a.m. Resident R73 was seated in a wheelchair visiting with family. The frame and undercarriage of the wheelchair was covered with dust and dried debris.
Interview on 11/18/24, at 11:44 a.m. Environmental Aide Employee E3 confirmed R73's wheelchair was covered with dust and dried debris.
Review of the admission record indicated Resident R76 was admitted to the facility on 9/20/24.
Observation on 11/18/24, at 11:44 a.m. of Resident R76's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing.
Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R76's transition strip from bedroom to bathroom was missing.
Review of the admission record indicated Resident R93 was admitted to the facility on 1/5/21.
Observation on 11/18/24, at 10:39 a.m. Resident R93 was seated in a wheelchair. The frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris.
Interview on 11/18/24, at 10:39 a.m. NA Employee E6 confirmed R93's frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris.
Review of the admission record indicated Resident R113 was admitted to the facility on 3/10/22.
Observation on 11/18/24, at 10:16 a.m. Resident R113 was seated in a wheelchair with a right lateral support (positioning device) corroded in dried grime and debris. The wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris.
Interview on 11/18/24, at 10:16 a.m. NA Employee E6 confirmed R113's right lateral support, wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris.
Review of the admission record indicated Resident R361 was admitted to the facility on 11/14/24.
Observation on 11/18/24, at 9:54 a.m. of Resident R361's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing.
Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R361's transition strip from bedroom to bathroom was missing.
Interview on 11/19/24, at 9:50 a.m. the Unit Manager Employee E2 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361).
28 Pa. Code 201.1(i)Resident rights. 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management
| | Plan of Correction - To be completed: 01/02/2025
R3, R5, R70, R73, R76, R93, R113, R361 were not affected by the deficient practice of not providing a "Homelike Environment". All residents have the potential to be affected. Cited areas were immediately corrected by maintenance and EVS staff. Team members educated by DON/designee on providing the residents with a safe, clean, comfortable and homelike environment. The Administrator or designee will conduct a whole community audit on transition strips and gouges in walls. The wheelchairs are on a cleaning schedule weekly and as needed. Director of EVS or designee will conduct audits of 10 wheelchairs per day, five days a week for 6 weeks to ensure compliance. Areas cited will be specifically added to monthly environmental safety rounds completed by the Administrator so ongoing checks will be completed. The results of these audits will be shared with the Administrator and reviewed with our QAPI team.
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