Failure to Maintain a Homelike Environment Due to Urine Odor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the strong odor of urine in Resident #10's room and the hallways of the 2 West Unit. Observations made during the recertification survey revealed that Resident #10's room consistently had a strong smell of urine, and the hallways of the 2 West Unit were similarly affected. Resident #10, who had moderately impaired cognition and was dependent on assistance for toileting, was noted to be incontinent of bladder and bowel. The resident's care plan indicated a self-care deficit related to toileting, requiring extensive assistance. Despite daily housekeeping and laundry services, the odor persisted, suggesting inadequate handling of soiled clothing and linens. Interviews with staff revealed that Resident #10's clothing, which often smelled strongly of urine, was not consistently bagged and tied before being placed in the laundry hamper, contributing to the odor. Housekeeping staff confirmed that laundry was picked up daily, and soiled clothing should be bagged to contain odors. However, observations showed that the laundry hamper in Resident #10's room contained soiled clothing that was not properly bagged, leading to the persistent odor. Additionally, the use of pull-up style disposable briefs, which were prone to leakage, further exacerbated the issue. Staff acknowledged that the odor should not be present and that proper procedures for handling soiled clothing were not consistently followed, resulting in the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified: - Upon notification of this deficiency, resident #10 was removed from his room to allow for terminal cleaning. - Assessment revealed that this resident suffered no ill effects as a result of the deficient practice. - Resident #10 room was terminally cleaned on - Soiled laundry bagged and removed from room down to laundry on - Hallways were mopped and cleaned to eliminate odor on 4/2/2025 and continues to be cleaned daily. - LPN #6, and CNA #12 were all reeducated on the facility’s homelike environment policy with an emphasis on how soiled clothing should be managed to ensure odor control. Residents at Risk: - A facility wide audit will be conducted to ensure a safe, clean, and homelike environment is maintained and no other issues were identified. - Although all residents had the potential to be affected by this deficient practice, no other resident was found to be affected. Systemic Changes: - The Administrator reviewed policy on Homelike Environment and no revision is needed. - All staff will be in-service on Policy and Procedure Homelike environment. - The facility utilizes a complete room schedule to do a thorough cleaning. - An audit tool was developed to ensure safe, clean, and homelike environment is maintained. Monitoring of Corrective Actions: - The Housekeeping Supervisor or designee will conduct environmental Room and hallway audits for urine odors. The audit will be conducted weekly x3 months, then monthly x3 months. Any outstanding issues will be addressed immediately and reported to the administrator. - On a monthly basis the Housekeeping Supervisor will report findings to the administrator. - On a monthly basis the Housekeeping Supervisor or designee will report audit finding to Qapi Committee. - Qapi committee to determine if further action is required based on report. Responsible: Director of Plant Operation/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025