Failure to Maintain a Clean and Homelike Environment Due to Persistent Urine Odor
Penalty
Summary
Surveyors observed a strong urine odor throughout the facility, including the front of the building and multiple hallways, during their visit. This odor was consistently noted in several areas, such as the 2200 and 2100 halls, and was present during multiple walkthroughs, including one conducted with the Director of Nursing (DON). The persistent foul smell was also reported by residents and staff, who indicated that the issue had been ongoing and that complaints had been made to facility staff. Three residents were specifically identified as being affected by the unsanitary environment. One resident, with diagnoses including Hepatitis A, bipolar disorder, and depression, reported feeling sick due to the odor and confirmed that the facility had been notified of the issue. Another resident, with a history of cerebral infarction, reduced mobility, and muscle weakness, described the odor as rotten and stated that it was a frequent topic of conversation among residents. A third resident, diagnosed with epilepsy, malnutrition, and polyneuropathy, also confirmed the constant presence of the urine smell and stated that they would seek out staff when the odor was noticeable. Interviews with staff, including two CNAs and the DON, confirmed that they had received complaints from residents about the urine odor and that they themselves had noticed the smell throughout the building. The DON attributed the odor on one hall to residents refusing showers and stated that housekeeping was notified when foul odors were present. Facility infection control policies reviewed by surveyors indicated a requirement to maintain a safe, sanitary, and comfortable environment, which was not met as evidenced by the ongoing odor issue.