§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 review of facility policy, facility documentation, observations, resident and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident bathrooms) for one of four nursing units observed (3 South).
Findings include:
A review of the facility policy "Resident Rights" dated 3/4/25, indicated " federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: A dignified existence; Safe home like environment. "
Review of the grievance logs for the months of August, September and October 2025, revealed four grievances filed (8/18/25, two reports on 8/25/25 and 9/4/25) regarding resident rooms and/or bathrooms being dirty.
Review of the resident council minutes dated 10/23/25 revealed residents stated issues related to housekeeping services.
During an interview on 10/29/25, at 9:30 a.m., Employee E5 Housekeeping Manager, stated resident rooms and bathrooms are cleaned daily. The housekeeping department has been attempting to fill vacant positions.
During an interview on 10/29/25, at 9:45 a.m., Housekeeping Employee E1 stated all resident rooms and bathrooms are cleaned daily.
During an interview on 10/29/25, at 9:55 a.m., Housekeeping Employee E2 stated all resident rooms and bathrooms are cleaned daily.
During an observation of the facility on 10/29/25, at 10:00 a.m., the following was revealed:
Wing 3 South resident bathrooms 303, 311, 313 323, 328, 330, and 332 were visibly soiled with debris and/or stains on the floor. The toilets had stains of an unknown origin both internally and externally. The ventilation unit in the bathrooms had visible dust blocking the vent.
During an interview with Resident R1 on 10/29/25, at approximately 10:15 a.m., stated the bathroom is never cleaned. Resident R1 stated it's a shared bathroom with the next room and none of the occupants who share this bathroom use it. Upon inspection of Resident R1 bathroom, room 330 there were feces and urine in the toilet.
During an interview with Resident R2 on 10/29/25, at approximately 10:40 a.m., stated they don't always clean the bathroom. Upon inspection of Resident R2's bathroom, was unclean.
During an observation and an interview with the Director of Nursing (DON) on 10/29/25, at 11:00 a.m., confirmed the residents who share the bathroom of between room 330 and 329 do not independently utilize the bathroom and the conditions of the resident bathrooms for rooms 303, 311, 313, 328, 330, and 321.
During an interview on 10/29/25, at 1:30 p.m., the DON confirmed that the facility failed to maintain the facility in a homelike environment on three of four observed nursing units.
Pa Code: 207.2 (a) Administrator's responsibility.
28 Pa. Code: 201.29(k) Resident rights.
| | Plan of Correction - To be completed: 12/17/2025
-On 10/29/2025, during the complaint survey, the housekeeping supervisor cleaned the 3 south bathrooms (303, 311, 313, 323, 328, 330 and 332) that were identified and all identified stained tiles were cleaned and/or replaced.
The bathroom vents identified were also cleaned during the complaint survey.
The housekeeping manager in services all housekeeping staff on daily room checks and deep cleans.
-ANHA performed a whole house audit to identify and correct any cleanliness issues on 10/30/2025. All identified issues were addressed with housekeeping and corrected.
-ANHA educated housekeeping supervisor on the Residents Rights policy, as it pertains to "a dignified existence; safe home like environment" on 11/10/2025.
-Housekeeping supervisor will in-service at housekeeping staff on the facility Resident Rights policy, as it pertains to "a dignified existence; safe home like environment".
-ANHA to educate housekeeping supervisor on the facility Grievance policy and addressing all grievances in the allotted time frame on 11/10/2025.
-ANHA will monitor varying floors 3x per 2 weeks to ensure cleanliness and homelike environment, specifically resident bathrooms and ventilation systems within bathroom, then weekly x 2 weeks and monthly thereafter. Any identified issue will immediately be addressed with the housekeeping department.
-ANHA will monitor the grievance log facility for completion of housekeeping grievances 2 x per week for 2 weeks, then weekly x 2 weeks and monthly thereafter. Any grievances identified as not completed will immediately be addressed with the housekeeping supervisor.
-All results of audits, monitoring and education will be presented at the next scheduled QAPI meeting for review.
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