§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 policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' bathrooms for three of seven residents reviewed (Residents 3, 4, 6).
Findings included:
The facility's policy regarding cleaning and disinfecting, dated September 1, 2024, indicated that the facility was to provide a sanitary and homelike environment.
Observations of Resident 4's bathroom on April 23, 2025, at 11:25 a.m. revealed that the base of the toilet, where the toilet and the floor meet, had a heavy accumulation of dried, yellowish/brown, removable debris. This debris was noted to encompass all sides of the toilet base.
Observations of Resident 3's bathroom on April 23, 2025, at 11:57 a.m. revealed that the entire base of the toilet had an accumulation of dried, crusted, yellowish debris, with pieces of caulking coming off.
Interview with the Maintenance Director on April 23, 2025, at 12:05 p.m. confirmed that the floor around the toilet bases in Residents 3's and 4's bathroom were in need of cleaning. He indicated that housekeeping cleans the bathrooms daily and the toilet bases should have been clean.
Observations of Resident 6's bathroom on April 23, 2025, at 9:58 a.m. and 1:34 p.m. revealed that the floor along the baseboard in the bathroom was scattered with black debris, there was a black stain on the floor under the water shut-off valve that supplied the toilet, as well as a golden/brown stain on the floor beside the toilet on the sink side, and there was an area of the vinyl flooring missing toward the hinge side of the door.
Interview with the Maintenance Director on April 23, 2025, at 1:55 p.m. confirmed that the floor in Residents 6's bathroom was in need of cleaning. He indicated that housekeeping cleans the rooms daily and that the they have a schedule to routinely deep clean the rooms, as well as deep clean the rooms when a resident is discharged from the room.
28 Pa. Code 201.18. Management (b)(3)(2.1)
| | Plan of Correction - To be completed: 05/19/2025
Identified restrooms were addressed on the day of the survey. The area around the base of the toilets in resident 3 and 4's restrooms were inspected and found to have old, dry caulking. The old caulking was removed and new caulking was applied. Resident 6's restroom was addressed. The black substance was removed and the tile has been repaired.
Remaining resident restrooms were inspected to identify any cleaning and/or maintenance related needs.
The housekeeping staff were re-educated by environmental services director on maintaining a homelike environment including cleaning techniques with additional tools to aid in hard to reach areas. Re-education was also provided for submitting maintenance requests for additional repairs and maintenance needs. The reporting procedure housekeeping utilizes is placing work orders through the work order system.
Environmental services director/designee will conduct random resident room audits for cleanliness and homelike environment. Audits will be completed weekly for 4 weeks and then monthly for two months. Findings will be submitted to the Quality Assurance and Performance Improvement Committee for review.
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