Failure to Maintain Clean and Odor-Free Resident Room
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in the shared room of three residents, all of whom had significant medical conditions including urostomy, overactive bladder, and mobility issues. On multiple occasions, a strong odor of urine was noted both inside and outside the residents' room. Direct observation revealed one resident with urine leaking from a urostomy site and a puddle of yellow fluid on the floor next to the bed. Despite staff acknowledging the presence of urine and the odor, the issue persisted over several days, with repeated observations of urine on the floor and ongoing odor. Interviews with staff confirmed that both nursing and housekeeping were aware of the urine spills and the associated odor, but the spills were not consistently or promptly addressed. The Housekeeping Director stated that cleaning urine spills is a shared responsibility between housekeeping and nursing staff, depending on availability. The Director of Nursing and Administrator acknowledged the ongoing problem, noting the resident's behaviors and the difficulty in maintaining cleanliness. Facility policies and job descriptions require maintaining a clean and safe environment, but these standards were not met in this instance.