Facility Fails to Maintain Homelike Environment
Penalty
Summary
Transitions Healthcare North Huntingdon was found to be non-compliant with the requirements for maintaining a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During an observation conducted on February 5, 2025, several deficiencies were noted throughout the facility. In resident rooms 123 W, 126 W, 119 W, and 203 D and W, there were issues such as peeling and scuffed paint, deep gashes in the walls, and peeling wallpaper. Additionally, the doors to the dietary department and the hallway wall underneath the dining room bulletin boards exhibited scuff marks, peeling paint, and broken plaster. Further observations revealed that the dining room had peeling paint on the walls, and the door jam leading to the outside courtyard had peeling plaster and lacked proper baseboard covering. The wooden handrails throughout the facility, particularly outside the dietary department and conference room, were found to have gashes with splintering wood and unfinished surfaces. These findings were confirmed during an interview with the Nursing Home Administrator and Maintenance Director, who acknowledged the facility's failure to maintain a homelike environment.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Areas identified during the survey have been repaired by placing InPro wall protection behind the headboards, painting and plastering as indicated, and sanding and staining as indicated. Areas repaired are as follows: - Resident room 123 W (window) the area behind the resident's bed headboard contained peeling and scuffed paint. - Resident room 126 W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint. - Resident room 119 W the area behind the resident's bed headboard contained peeling paint. - Resident room 203 D (door) and W the area behind the resident's bed headboard contained peeling wall paper. - The doors to the dietary department contained scuff marks and peeling paint. - The hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster. - The wall in the dining room contained peeling paint. - The door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering. - The wooden handrails contained gashes that contained splintering wood and non-smooth unfinished surfaces, located in the following hallways: outside the dietary department and outside the conference room. A schedule has been implemented to resurface and paint the remaining handrails in the facility. Project will be completed by July 31, 2025. A schedule has been implemented to place InPro wall protection behind an additional 33 beds. Project will be completed by July 31, 2025. The Maintenance Director will complete a facility walk thru audit. Any other areas identified will be repaired. The Administrator/designee will complete staff training on utilizing the TELS electronic maintenance system when environmental concerns are identified so the work can be completed in a timely manner. Environmental audits will be conducted by the NHA or designee weekly x 2, then monthly thereafter prior to the safety committee meetings. The Administrator will complete weekly audits of the progress of handrail resurfacing project and InPro wall protection project to ensure completion as scheduled. The Administrator/designee will complete a comparison audit of work needing completed against work completed to maintain a clean, comfortable and home-like environment. Audit will be completed weekly for two weeks. Results will be taken to the QAPI committee for review of findings and further interventions if indicated.