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F0584
E

Failure to Control Persistent Urine Odors in Resident Hallway

Great Falls, Montana Survey Completed on 04-24-2025

Penalty

Fine: $65,800
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a homelike environment and adequately control persistent urine odors in the 400B hallway, affecting two of 39 sampled residents and their visitors. Multiple observations over several days documented a strong, unpleasant urine smell throughout the hallway. Interviews revealed that one resident, who previously maintained a clean home before a dementia diagnosis, would not have tolerated such conditions, and her family expressed concern about the overwhelming odor upon her relocation to the hallway. The family also noted that excessive use of odor-masking spray caused the resident to cough, and they attempted to mitigate the smell with personal air fresheners and a fan. Another resident also commented on the persistent malodor in the area.

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