§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, review of facility policy, and staff interview it was determined that the facility failed to maintain a clean, homelike environment for two of 12 residents reviewed (Residents R1 and R2).
Findings include:
Review of a facility policy entitled "Daily Resident Room and Bathroom Cleaning" dated 10/10/23, indicated, "Check privacy curtains and spot clean as needed."
Observations of Resident R1's room on 8/8/24, at approximately 12:50 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance.
Observations of Resident R2's room on 8/8/24, at approximately 12:55 p.m. revealed the privacy curtain was heavily soiled with a brown colored substance.
During an interview on 8/8/24, at 1:25 p.m. the Assistant Director of Nursing confirmed that the privacy curtains in Resident R1's and R2's rooms were heavily soiled with a brown colored substance and that the privacy curtains should have been cleaned or replaced.
28 Pa. Code 201.18 5(e)(2.1) Management
28 Pa. Code 201.14(a) Responsibility of licensee
| | Plan of Correction - To be completed: 09/20/2024
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
- R1 and R2 privacy curtains were replaced on 8/8/24.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
- All resident privacy curtains will be inspected for cleanliness. Soiled privacy curtains will be replaced with a clean privacy curtain.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
- Environmental Services staff will be educated on the Resident Room cleaning policies and procedures. All staff will be educated on Federal Regulation 483.10 (i)(1)-(7).
How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
- The Environmental Services Director/Designee will inspect the cleanliness of all privacy curtains weekly for 4 weeks, then monthly for 3 months.
- The leadership team will conduct weekly "Culture of Caring", non-clinical rounds, to monitor cleanliness of privacy curtains.
- The Environmental Services Director inspections will be reviewed at monthly QAPI for 4 months.
Dates of when the corrective action will be completed.
- 9/20/24
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