§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 policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in seven out of 12 sampled resident rooms (Residents R1, R2, R3, R4, R5, R6, and Resident R7).
Findings include:
The facility "Resident environment" policy last reviewed 2/1/24, indicated that the facility will provide an environment that is safe, clean, comfortable and homelike.
During a tour with of the facility on 2/26/24, starting at 10:08 a.m. with Environmental services/housekeeping supervisor Employee E1, the following was observed:
At 10:08 a.m. Resident R1's room was observed with white chips and gauges along the wall behind his bed.
At 10:10 a.m. Resident R2's room was observed with white chips and gauges along the wall behind his bed.
staining around the bathroom commode, and brown stains on the corners of the floor.
At 10:14 a.m. Resident R3's room was observed with a white dresser. At the bottom of white dresser was frayed and sharp edges with the potential to lacerate oneself.
At 10:16 a.m. Resident R4's room was observed with her catheter bag leaking on the floor onto the fall mat near her door.
At 10:21 a.m. Resident R5's room was observed with the night light panel glass removed from the night light.
At 10:24 a.m. Resident R6's room was observed with gauges along the wall behind his bed.
At 10:25 a.m. Resident R7's room was observed. His bathroom was observed with black substance lining around the commode and gauges on the wall behind the commode.
During an interview on 2/26/24, at 10:28 a.m. the Environmental services/housekeeping supervisor Employee E1 confirmed that the facility failed to maintain a clean, comfortable, homelike environment in Residents R1, R2, R3, R4, R5, R6, and Resident R7's rooms as required.
28 Pa Code: 207.2(a) Administrator's Responsibility.
28 Pa Code: 201.29(k) Resident Rights.
| | Plan of Correction - To be completed: 03/29/2024
The dresser in R3's room was immediately removed and replaced. The rooms identified with gauges/chips in the wall were immediately worked on by the maintenance department. R4's catheter bag was immediately emptied. The soiled fall matt was immediately cleaned.
Maintenance will conduct a whole house audit to ensure that the issues identified are not affecting any other resident in the facility.
The regional operations consultant will educate the Nursing Home Administrator and the maintenance department on creating and maintaining a homelike environment for residents.
The Nursing Home Administrator or designee will conduct a whole house audit weekly for four weeks and then monthly for three months.
The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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