§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 interview, it was determined that the facility failed to maintain a safe, comfortable, home-like environment for one of two resident shower rooms (C-Wing shower room).
Findings include:
Review of facility policy "Clean, Safe and Orderly Environment," last reviewed 1/17/23, indicated the facility will be maintained in clean, safe, and orderly manner. Housekeeping, Laundry, and Maintenance services will be provided properly with precautions taken to prevent infection and cross contamination.
During an observation on 3/1/24, at 1:00 p.m. the following was noted in the C-Wing shower room: -First shower area: Numerous partially used, resident specific hygiene items (shampoo, body wash, deodorant) on the shower floor, nail clippers on the floor, and a plastic caddy with hygiene items in it. A plastic cover for a curtain rod was on the floor of the shower. Numerous adhesive stickers from the tops of baby powder containers adhered to the shower wall. A brown substance that appeared to be feces was on the shower floor. -Second shower area: A large wheelchair cleaning machine was in the shower area. On top of the wheelchair cleaning machine were (2) disposable briefs, resident clothing, towels, (12) containers of various hygiene items, a box of gloves, and (2) disposable razors. -Third shower area: The waste receptacle for a bedside commode with feces. -Fourth shower area: (3) bottles partially used body wash, (2) cans of shaving cream, (1) partially used bottle of shampoo on the handrail, (1) used razor, and a waste receptacle for a bedside commode filled with water.
During an interview on 3/1/24, at 12:20 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to maintain a safe, comfortable, home-like environment for one of two resident shower rooms. 28 Pa. Code 207.2(a) Administrator's responsibility.
28 Pa. Code 201.18(b)(1) Management.
| | Plan of Correction - To be completed: 03/19/2024
1. Hygiene items were removed from the floor, nail clippers were removed from the floor, plastic caddy was removed, plastic cover for curtain rod was removed, adhesive stickers were removed from wall and the shower room floor was cleaned in the first shower area in the C-Wing shower room. The items were removed on top of the large wheelchair cleaning machine in the second floor shower area in the C-Wing shower room. The waste receptacle for the bedside commode was removed and cleaned in the third shower area in the C-Wing shower room. The bottles of body wash, cans of shaving cream, the used razor and the shampoo was removed from the fourth shower room in the C-Wing shower room. The waste receptacle for the bedside commode was removed and cleaned from the fourth shower room in the C-Wing shower room. 2. The facility will maintain a clean, homelike environment for the residents. The Maintenance Director, Housekeeping Director and Nursing Home Administrator will complete walking environmental rounds to identify any other areas of concern. 3. The maintenance and housekeeping staff will be re-educated on the policy for Clean, Safe and Orderly Environment by the Nursing Home Administrator/designee. The nursing staff will be educated on the facility policy for Clean, Safe and Orderly Environment by the Director of Nursing/designee. Guardian Angel rounds will be modified to include the shower rooms. 4. The Maintenance Director, the Housekeeping Director, Director of Nursing and the Nursing Home Administrator will complete walking environmental rounds weekly to ensure a clean, homelike environment is being maintained. These rounds will be ongoing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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