Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment for a resident, resulting in persistent foul odors and unclean conditions in a shared room. Observations over several days documented a strong odor resembling sweat and urine, particularly on one side of the room. One resident, who was cognitively intact, reported being bothered by the odor and stated they had informed staff multiple times without resolution. The other resident in the room, who had moderate cognitive impairment, was observed with greasy hair and admitted to infrequent showers, with staff confirming that this resident often refused personal care. The room was also noted to have an unclean tray table with old food items and spilled fluids on the floor. Multiple staff interviews confirmed awareness of the foul odor, with some staff noting that the mattress had been replaced several times and that the resident often refused showers. Despite these ongoing issues, there was no evidence that staff had addressed the concerns of the resident who was bothered by the odor, nor had social services or nursing leadership discussed the impact of the environment with them. The failure to address the unsanitary and uncomfortable conditions persisted over several days, as documented by repeated observations.