§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 adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on four of four nursing units (Beaver, Nittany, University, and Heirloom; Residents 5, 6, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 22).
Findings include:
Observation of the University Nursing Unit on May 6, 2025, at 9:30 AM revealed the following:
Resident 15's footboard had peeling veneer on almost half the surface, exposing the board underneath.
Observation of the Heirloom Nursing Unit on May 6, 2025, at 9:45 AM revealed the following:
Resident 5's room revealed missing and ripped wallpaper on the wall by the door, the ripped wallpaper was four feet long and two feet tall. The cove base was also missing from this part of the wall. The conduit covering behind his bed was hanging off the wall and bent. One of the closets bifold doors was missing, and the other one that was present was hanging off its tracks.
The hallway immediately exiting Resident 5's room was missing a piece of handrail three feet long.
Resident 16's room was missing one of his closet bifold doors.
Resident 17's room was missing one of her closet bifold doors. There was wallpaper missing behind the second unoccupied bed in Resident 17's room.
Resident 18's window blind on the right side had broken, bent, and missing slats.
Resident 19's overbed tray table was missing all the veneer off the sides, exposing the particle board. The hallway immediately exiting Resident 19's room was missing a piece of handrail two feet long.
Observation of the Beaver Nursing Unit on May 6, 2025, at 10:15 AM revealed the following:
Resident 6's bed control cord was frayed exposing the wires inside.
The shower room next to Resident 6's room was badly marred and scraped, and there was a hole forming in the wood.
Resident 20's window blinds on the right side had broken, bent, and missing slats.
Resident 21's windows were both open to the outside, with no screens present to protect the room from pests/bugs. There was cove base peeling off the wall in front of the unoccupied first bed of Resident 21's room.
Resident 22's window blind on the left side had broken, bent, and missing slats. The cove base was peeling off the wall in front of Resident 22's bed.
The facility provided this surveyor with a book of auditing in response to questions about the environment. The audits entitled "Embassy Ambassador Rounds" did not target the specific maintenance issues as observed above.
An audit dated April 14, 2025, identified that Resident 5's wallpaper was peeling off his wall and that the cove base was missing. There was no evidence that the facility attempted to correct this environmental issue.
An audit dated April 15, 2025, identified that Resident 16 was missing one of his closet doors. There was no evidence that the facility attempted to correct this environmental issue.
An audit dated April 28, 2025, identified that the shower room door from the above observation on the Beaver Nursing Unit "need some love." There was no evidence that the facility attempted to correct this environmental issue.
Observation of Resident 9 on May 6, 2025, at 10:05 AM revealed he was in bed. An oxygen concentrator was plugged into a free standing outlet box lying on the floor with wires exposed behind it, which appeared to have been pulled off the wall behind the residents bed. A long strip of conduit attached to the box was observed hanging from the wall behind the bed with the wallpaper ripped and holes in the wall to the side of the resident's bed.
Concurrent observation of Resident 9's bathroom revealed the countertop was significantly stained. The flooring was blackened and extremely sticky throughout the bathroom, extending out into the resident's room. Two basins and body wash were stored under the sink.
Observations of the Nittany nursing unit revealed the following:
Resident 11's room on May 6, 2025, at 11:03 AM revealed dirt and debris buildup along the front of the room where the cove base meets the wall, in front to the closet, and collected behind the resident's door to the room.
Observation of Resident 13's room revealed a household air conditioner unit along the wall under the resident's window. The vent of the air conditioner was covered in a black substance. The filter area on the lower portion of the air conditioner unit was covered in dust.
Concurrent observation of Resident 13's bathroom revealed a toilet seat riser tucked behind the toilet on the floor, and a urine/bowel collection hat also on the floor. The trash bin had dried brown spots on the exterior and lid. The ceiling vent in the bathroom was covered in dust.
Observation of Resident 12's room on May 6, 2025, at 11:12 AM revealed dust and debris buildup along the front of the resident's room where the floor meets the cove base, extending in front of the closet, and behind the door to the hallway.
Observation of Resident 12's bathroom revealed the ceiling vent was covered in dust/black substance.
Observation of Resident 14's room on May 6, 2025, at 11:13 AM revealed the flooring was wet (freshly mopped) throughout the room. Dirt/debris and white specks were observed along the front of the room along where the floor meets the wall, and in front of the resident's closet. Significant dirt/debris and cobwebs were observed on the flooring, and the corner behind the resident's door to the hallway. These areas were dry.
The Nursing Home Administrator and Director of Nursing were made aware of above environment concerns on May 6, 2025, at 2:00 PM.
483.10(i) Safe, clean, homelike environment
Previously cited 3/14/25
28 Pa. Code 201.18(b)(3) Management
| | Plan of Correction - To be completed: 06/06/2025
The items identified during the revisit are being addressed.
Whole house audits were done on the concerns to identify additional like areas.
Education will be done with all staff on the areas of concern identified on the revisit, including proactive rounding, ambassador rounds, and the importance of maintaining a clean and dignified environment for the residents.
The NHA or designee will do environmental audits twice weekly for one month and monthly for two months. Audit results will be reported on and reviewed at the monthly quality assurance process improvement meeting for track, trending and additional recommendations.
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