§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 as well as resident and staff interviews, it was determined that the facility failed to provide sufficient maintenance services necessary to maintain a safe, sanitary, comfortable, and home-like interior on three of five nursing units (Heritage, A, and Medbridge units).
Findings include:
During a tour with Employee 1 (Director of Maintenance) on February 29, 2024, at approximately 2:30 PM to 3:30 PM, Employee 1 revealed that the ceiling water damage in Heritage Hall continued to be in disrepair. Employee 1 said that the facility will have to hire a contractor to repair the ceiling. When Employee 1 was asked if the facility had made any attempts to have a contractor review the ceiling damage or to obtain an estimate for the cost of the repair, he replied, "not yet."
Observation on A unit on February 29, 2024, at approximately 2:45 PM, revealed the ceiling in the hallway in front of the nursing station continued to have light brown stains and was bubbled.
An interview with Resident 1 on February 29, 2024, at approximately 3:00 PM, revealed that the grab bars on both sides of the toilet were repaired, but Resident 1 was upset that his towel bar was removed and hadn't been replaced. Employee 1 informed Resident 1 the towel bar was ordered and delivered a week ago, and was going to be replaced.
Observation in Resident 2's room on February 29, 2024, at approximately 3:15 PM, revealed the drywall was patched, but remained unpainted.
Observation of what was previously designated as Resident 5's room on February 29, 2024, at approximately 3:30 PM, revealed the wallpaper needed replaced and the towel bar had not been replaced. The cove base remained loose on the wall to the rear of the bed, closest to the window.
Observation of what was previously designated as Resident 6's room on February 29, 2024, at approximately 3:30 PM, revealed the walls remained patched, but not painted, and there was no towel bar in the bathroom.
Observation of what was previously designated as Resident 7's room on February 29, 2024, at approximately 3:35 PM, revealed the wall behind Resident's bed remains patched, but not painted.
An interview with the Nursing Home Administrator on February 29, 2024, at approximately 3:45 PM, revealed the maintenance repairs are important and the facility has attempted to hire additional maintenance staff without any success.
28 Pa. Code 201.14(a)Responsibility of licensee
28 Pa. Code 201.18(b)(3)(e)(2.1)Management
| | Plan of Correction - To be completed: 03/08/2024
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the center has taken, and will take, the actions set forth in the following plan of correction. The following Plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The center is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
1. Residents 1,2,5,6 and 7 have not had any ill effects from the center not finishing/completing repairs within the building. Mentioned residents rooms have been painted, wallpaper repaired and towel bars installed.
2. The Maintenance Director or designee will audit and complete a full center sweep of resident rooms. Identified needs will be prioritized. Needs that are identified will be completed at a minimum of 2 rooms per week, until identified work is completed.
3. NHA or Designee will educate department heads on providing a safe/clean/comfortable/homelike environment while rounding in the rooms.
4. The Maintenance director or designee will audit 2 rooms per week x 4 weeks to ensure the ability to correct noted areas of improvement. Results/progress will be reviewed at the center's QAPI meeting.
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