§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, resident and staff interviews, it was determined that the facility did not provide a safe and homelike environment related to the condition and functionality of resident sinks for four out of nine-bathroom sinks. (First-floor nursing unit).
Findings Include:
On April 27, 2026, at 9:27 a.m., an interview was conducted with the Maintenance Director, Employee R3, and the Director of Nursing, Employee E2, who confirmed the following observations:
Room 116 had a sink with slow water drainage.Room 125 had a hole by the Bed B below the windowOn April 27, 2026, at 10:00 a.m., during an interview, Resident R1 reported that the bathroom sink sometimes does not shut off properly and that both faucet knobs must be aligned in order for the water to be turned off.
On April 27, 2026, at 10:46 a.m. observations were conducted with the Administrator, Employee E1 and revealed the following:
Room 111: No light in the bathroomRoom 116: Sink had slow drainage of waterRoom 124: Broken faucet that would not shut off water; no knob on the left side of the faucetRoom 126: Sink faucet would not shut off water28 Pa. Code 201.18(e)(2.1) Management
| | Plan of Correction - To be completed: 05/20/2026
1. Maintenance repaired work orders for Room 111 bathroom light, Room 116 slow-draining sink, Room 124 broken faucet and missing left faucet knob, Room 125 hole below the window near Bed B was closed, and Room 126 sink faucet that would not shut off properly is functioning.
2. The Maintenance Director or designee completed an random audit of bathroom sinks, lighting, and visible wall conditions on the first-floor nursing unit to identify similar concerns. Any additional issues found were documented, prioritized, and repaired promptly. The facility also expanded the environmental audit to resident rooms on other units to ensure no similar deficient practice existed elsewhere in the building.
3. The maintenance director reeducated nursing leadership, and housekeeping staff on prompt reporting of maintenance concerns to TELS online portal for fast response.
4. The Administrator, Maintenance Director, or designee will complete weekly environmental rounds of random resident rooms and bathrooms for 4 weeks, then monthly for 3 months, to verify that sinks drain properly, faucets shut off correctly, lighting is functional, and room walls remain intact and safe. Findings will be documented and any variances corrected promptly.
6. Education was provided to all residents (with capacity) to report maintenance issues to staff that will be added to TELS portal
5. Results of the audits will be reviewed in the QAPI held monthly.
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