§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.
|
Observations:
Based on observations, resident and resident family interviews and staff interviews, it was determined that the facility failed to maintain a clean, homelike environment on five of six nursing units (1 South, 1 West, 2 South, 3 South and 3 East nursing units). Failed to provide a clean, comfortable, homelike environment for 33 of 52 residents (R1, R6, R7, R8, R9. R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36 and R37).
Findings include:
During an observation on 6/6/24, from 8:35 a.m., through 9:50 a.m., the following was identified:
- The main entrance hallways of the facility leading to 1 West and 1 South nursing units and to the main dining room was spoiled with splotches of black substances and debris.
-The main resident lounge(s) located on 1 South, 1 West, 2 South, 3 South and 3 West nursing units with wheelchairs, staff equipment of computers, etc and pieces of paper, food debris and sticky substances on all of the floors. Tables in need of cleaning with sticky substances and food debris.
- The main hallways of all of the nursing units identified had debris and splotches on them.
-The main dining room floor had debris.
Nursing Unit 3 East:
-Residents R6, R7, R8 and R9's shared bathroom had soiled bathroom floor with brown substance and personal debris on it.
- Residents R6 and R7's room floor had debris and sticky substances and soiled linens and a full garbage can under the sink.
-Residents R8 and R9's room floor had debris and sticky substances, the sink had broken sharp edges and Resident R9's wheelchair was heavily soiled with white substances on the seat and leg rests.
-Residents R10, R11 and R12's room floors was soiled with debris and the sink had broken sharp edges.
-Resident R13 had a broken sink with sharp edges.
- Residents R14 and R15 has a broken sink with sharp edges.
-Residents R16, R17, R18 and R19's shared bathroom floor is soiled with debris and black substance.
-Residents R20 and R21's room floor and bathroom floor had areas of a black substance and a basin with a soiled dried wash cloth under the sink and two foot rests in the corner.
-Residents R1 and R22's room had a soiled floor with dried food debris, black marks and spider webs in the window corners.
Nursing Units 3 South:
- Residents R23, R24, R25, R26, R27, R28, R29 and R30 rooms had broken sinks with sharp edges and soiled floors.
-Residents R31 and R32's area under the sink was soiled and sticky.
-Residents R33, R34, R35 and R36's bathroom toilet was black inside and room floors were soiled with debris.
Resident R37's fall mat was stuck underneath the clothes cabinet with heavily soiled debris around the mat and a brown substance dried puddle at the head of the bed area under the dresser and mat.
Nursing Units 2 South, 1 South, 1 West resident rooms all had debris throughout the rooms on the floors.
During an interview on 6/6/24, at 11:15 a.m., the Housekeeping/ Laundry Supervisor Employee E1 confirmed that the facility failed to maintain a clean, comfortable, homelike environment on five of six nursing units (1 South, 1 West, 2 South, 3 South and 3 East nursing units). Failed to provide a clean, comfortable, homelike environment for 33 of 52 residents (R1, R6, R7, R8, R9. R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36 and R37).
28 Pa. code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c)(d) Resident rights.
| | Plan of Correction - To be completed: 06/28/2024
1.On June 6th the areas noted by surveyor on 1 West, 1 South, 2 South, 3 South, 3 East, main hallways to entrances and the main dining room were corrected as it related to cleanliness to provide a home like environment. All chairs, clutter and employee equipment removed from resident lounges. Other areas related to sinks being repaired were reviewed by NHA and maintenance staff and the sinks that were identified during the survey needing repaired will be repaired. All other areas cited have been or will be adressed.
2.NHA/designee, housekeeping manager, and maintenance director of the center will conduct a whole house inspection of resident rooms, bathrooms, main hallway entrances, main dining room, resident wheelchairs and common areas to identify any other potential sanitary, homelike environment concerns. Areas of concern identified will be corrected.
3.Housekeeping staff will be re-educated on "Daily Procedures for Cleaning a Resident Room / Bathroom". Education with housekeeping staff on cleaning resident rooms, bathrooms, wheelchairs and common areas will be completed by housekeeping manager or designee. Maintenance and housekeeping will be educated on residents' right to a safe, clean, comfortable and homelike environment.
4.Audits of resident rooms, bathrooms, wheelchairs, main hallway entrances, resident sinks and common areas will be completed by the NHA/designee 3x weekly for 4 weeks, then monthly x's 2. Findings of the audits will be reported to Quality Assurance and Performance Improvement Committee for monitoring and need for continued audit plan based on compliance.
|
|
