F584
(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)
§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.
DEFINITIONS §483.10(i)
“Adequate lighting” means levels of illumination suitable to tasks the resident chooses to perform or the facility staff must perform.
“Comfortable lighting” means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of lighting to meet their needs or enhance independent functioning.
“Comfortable and safe temperature levels” means that the ambient temperature should be in a relatively narrow range that minimizes residents’ susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents.
“Comfortable sound levels” do not interfere with resident’s hearing and enhance privacy when privacy is desired, and encourage interaction when social participation is desired. Of particular concern to comfortable sound levels is the resident’s control over unwanted noise.
“Environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.
A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of “homelike” should include the resident’s opinion of the living environment.
“Orderly” is defined as an uncluttered physical environment that is neat and well-kept.
“Sanitary” includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living.
GUIDANCE §483.10(i)
A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible.
This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some practices that can be eliminated to decrease the institutional character of the environment include, but are not limited to, the following:
• Overhead paging (including frequent announcements) and piped-in music throughout the building.
• Meal service using trays (some residents may wish to eat certain meals on trays).
• Institutional signs labeling work rooms/closets in areas visible to residents and the public.
• Medication or treatment carts (some innovative facilities store medications in locked areas in resident rooms or in secured carts that appear like furniture).
• The widespread and long-term use of audible chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic.
• Furniture that does not reflect a home-like environment or is uncomfortable; the absence of window treatments or drapes; the lack of textures or the absence of bedspreads or personal items in rooms or on walls.
• Large, centrally located nursing/care team stations, including those with barriers (such as Plexiglas) that prevent the staff from interacting with residents.
Many facilities cannot immediately make these types of changes, but it should be a goal for all facilities that have not yet made these types of changes to work toward them. A nursing facility is not considered non-compliant if it still has some of these institutional features, but the facility is expected to do all it can within fiscal constraints to provide an environment that enhances quality of life for residents, in accordance with resident preferences.
A “homelike” environment is not achieved simply through enhancements to the physical environment. It concerns striving for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable. It is the responsibility of all facility staff to create a “homelike” environment and promptly address any cleaning needs.
In a facility in which most residents come for a short-term stay, residents would not typically move his or her bedroom furniture into the room, but may desire to bring a television, chair or other personal belongings to have while staying in the facility.
There needs to be sufficient individual closet space so that resident clothing is kept separate from a roommate’s. Closets must be structured so the resident can get to and reach their hanging clothing whenever they choose. Out-of-season items may be stored in alternate locations outside the resident’s room.
Adequate lighting design has these features:
• Lighting with minimum glare in areas frequented by residents. Elimination of high levels of glare produced by shiny flooring and from unshielded window openings;
• Even light levels in common areas and hallways, avoiding patches of low light caused by too much space between light fixtures, within limits of building design constraints;
• Use of daylight as much as possible;
• Extra lighting, such as table and floor lamps to provide sufficient light to assist residents with tasks such as reading;
• Lighting for residents who need to find their way from bed to bathroom at night (for example, red colored night lights preserve night vision); and
• Dimming switches in resident rooms (where possible and when desired by the resident) so that staff can tend to a resident at night with limited disturbances to them or a roommate. If dimming is not feasible, another option may be for staff to use flashlights/pen lights when they provide night care.
While facilities certified after October 1, 1990, are required to maintain an air temperature range of 71-81°F, there may be brief periods of time where that temperature falls outside of that range only during rare, brief periods of unseasonable weather. This interpretation would apply in cases where it does not adversely affect resident health and safety, and facility staff took appropriate steps to ensure resident comfort. This would enable facilities in areas of the country with relatively cold or hot climates to avoid the expense of installing equipment that would only be needed infrequently.
PROCEDURES §483.10(i)
Verify the air temperature above floor level in resident rooms, dining areas, and common areas. If the temperature is out of the 71-81° F range, then ask staff what actions they take when residents complain of heat or cold, such as, providing extra fluids during heat waves and extra blankets and sweaters in cold.
During interviews, ask residents and families whether they think the facility is as homelike as possible, and whether they have been encouraged to bring in personal property items (within space constraints).
Observe bedrooms of sampled residents for personalization. Does the room tell the survey team anything about the resident’s everyday life and interests? Observe for personal items such as family photographs, books and magazines, etc. that belong to the residents. For residents who have no relatives or friends, or few assets, has facility staff assisted these residents to make their rooms homelike, if they so desire? If potential issues are discovered, ask staff about their efforts to provide a homelike environment. Determine if the resident’s preferences are honored or is the facility’s goal of having a sanitary, safe, and uncluttered environment preventing the resident from having an individualized area?
Observe and question sampled residents throughout the survey and note if they are having difficulty reading or doing tasks due to insufficient lighting, or if they are wearing sunglasses or visors indoors due to glare, if they have difficulty seeing food on their plate, experiencing squinting or shading their eyes from glare or other signs that lighting does not meet their needs.
PROBES §483.10(i)
• Does the resident have any concerns with lighting, noise, temperature, or anything else that may affect their comfort?
• Are resident care areas and equipment kept clean and in good repair?
• Does the resident’s room appear cluttered and disorderly, with a lack of storage for clothing, belongings or personal care equipment?
• Are areas of the facility used by residents designed or organized to ensure the resident can receive care and services safely, without risk of falling or injury, while maximizing resident independence?
• Do window treatments, bed linens, towels, privacy curtains, etc., appear clean and in good condition?
• How does facility staff ensure resident personal property is kept safe from loss or theft?
POTENTIAL TAGS FOR ADDITIONAL CONSIDERATION
Examples of some of the related requirements that may be considered when non-compliance has been identified include, but are not limited to, the following:
• For concerns regarding the resident’s right to have personal possessions, including furnishings, see §483.10(e)(2), F557;
• For concerns related to misappropriation of resident property, see §483.12, F602, Misappropriation of Resident Property;
• For issues of safety of the environment, presence of hazards and hazardous practices, see §483.25(d), F689, Accidents;
• For kitchen sanitation, see §483.60(i), F812, Food Safety Requirements;
• For facility-wide sanitary practices affecting the quality of care, see §483.80, F880, Infection Control.
• For issues of fire danger, see guidance provided for §483.90(a) which states, “For additional guidance on life safety from fire and the survey procedures for these regulatory requirements, reference Appendix I in the SOM. Concerns regarding the above regulatory provisions would be addressed through the Life Safety Code survey (K-Tags).”; or
• For issues of cleanliness of areas of the facility used by staff only (such as the break room, medication room, laundry, kitchen, etc.) or the public only (such as the parking lot), see §483.90(h), F921, Other Environmental Conditions.