§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 observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on three of four nursing units ( A, B, and F Wing Nursing Units) and Chapel, (Residents 1, 7, 8, 9, and 10).
Findings include:
Observation on the F Wing Nursing Unit on February 20, 2025, at 12:15 PM revealed the following:
The floor in the main hallway in front of the nurse's station was scuffed with a build-up of dirt. An indentation in the floor that spanned across the hallway contained various debris.
A lidded garbage can in the hallway had an extensive build-up of dried liquid stains on the front.
A dining/sitting area located across from the nurse's station was open and utilized by residents per an interview with Employee 1, licensed practical nurse, on February 20, 2025, at 12:26 PM. Observation of this area revealed the following:
A vent on the wall under the window contained a significant amount of various debris.
The windowsill contained a thermos and three clear, large-sized plastic cups from a fast-food restaurant each partially filled with liquids. A canned energy drink with a clear, plastic cup over the opening was observed on a piece of furniture on the perimeter of the room.
There were multiple backpacks placed on the furniture around the room.
A concurrent interview with Employee 1 revealed it was unclear who the cups or backpacks belonged to. Continued observation revealed several unidentified staff members in the area proceeded to remove the backpacks and drinks from the room.
Three tables placed together in the center of the room had dried stains on the legs. The center table had damage to the edge, and on a corner, with the particle board showing.
The floor under the tables had extensive scuffing, debris, and dried liquid spills spanning the length under the three tables.
Observation on February 20, 2025, at 12:35 PM of the room for Residents 7, 8, 9, and 10, revealed an eight-inch section of the cove base peeling from the wall located under the sink just inside the entrance to the room. The underlying portion of concrete was visible.
The Nursing Home Administrator was notified of the above findings on February 20, 2025, at 1:29 PM.
Observation of the Chapel on February 20, 2025, at 4:30 PM revealed the following:
Four sections of drop ceiling panels had large brown water stains on them.
Three ceiling fans had an extensive build-up of black colored dust on each fan blade.
A large, lidded garbage can had an extensive build-up of dried stains on the front of it.
A dirty linen container had used medical gloves discarded on top of the lid.
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on February 20, 2025, at 4:45 PM.
Observation of Resident's 1's room on February 20, 2025, at 12:01 PM revealed the resident was not in his room, and there was not a roommate residing in the room. A chair placed beside the resident's bed was observed with a green folded pad covering the seat portion of the chair. Brown smears were observed down the center of the pad. A bedside commode was observed pushed alongside the unoccupied bed in the room. The commode was sitting on top of a white folded pad on the floor. The pad had wet marks on it and brown colored debris. The commode had a plastic liner in the basin of it and it was full of feces and toilet paper. A small garbage can on the floor beside the commode contained an incontinence brief.
Follow up observation in Resident 1's room at 12:30 PM on February 20, 2025, revealed the same observation as noted above and the resident was not in the room. Upon concurrent interview with staff members in the hallway as to the location of the resident, the staff indicated the resident had discharged from the facility at approximately 11:30 AM.
An observation of the resident nourishment refrigerator located on the A nursing unit at 12:33 PM revealed soiled shelves on the interior of the refrigerator, debris and dried spills were observed through the clear shelving under the shelf liners. The bottom left interior drawer was broken with a yellow/orange colored sticky substance throughout the interior of the drawer.
An observation of the resident nourishment refrigerator on the B nursing unit at 12:45 PM revealed soiled shelves on the interior of the refrigerator.
In an interview with the Nursing Home Administrator and Director of Nursing on February 20, 2025, at 4:45 PM the findings regarding the refrigerators were reviewed and they indicated staff would have been present with Resident 1 as the resident was preparing for discharge from the facility and the commode should have been emptied.
483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited deficiency 6/7/2024
28 Pa. Code 201.18(b)(3)(e)(2.1) Management
| | Plan of Correction - To be completed: 03/17/2025
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of the federal and state law.
F0584
1. Floor of main hallway in nursing unit F was swept to remove debris and floor scrubber was utilized to clean the area of the floor that spanned across the hallway. Lidded trash can was cleaned and all debris and stains were removed. Solarium was cleaned and all staff belongings were placed in staff designated areas. Vents on the wall in the F wing Solarium was cleaned by maintenance. Tables in the F wing solarium were removed from service and replaced.
Resident 7,8,9 and 10, room cove base was repaired by maintenance and no further cove base was identified to be displaced
2. No other areas in the building contained staff belongings in areas that are designated to residents. All hallways in front of nursing stations were checked, cleaned and scrubbed. No other vents in the building were identified to have debris in them. Tables in other common areas were checked for any damage or debris.
Drop Ceiling Tiles in the chapel were replaced with new tiles.
3. All Employees were educated on the areas that are designated on each wing for staff belongings.
Maintenance was educated on replacement of stained tiles on an urgent bases as they are noticed.
Housekeeping was educated on the importance of clean and homelike environment with the understanding that the regulatory requirements as directed by CMS.
4. Administrator or designee will complete Environmental audits 1 x weekly for 4 weeks and monthly x 2, to ensure cleaning and maintenance needs are addressed timely to ensure homelike environment is being maintained. Results of the audits will be submitted and reviewed by the Quality Assurance Committee.
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