Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident with multiple diagnoses, including end stage heart failure, cirrhosis of the liver, and immunodeficiency. The resident's room was repeatedly observed to be cluttered, unclean, and to have a persistent foul urine odor. Staff documented the presence of half-eaten old food items, sticky residue on furniture, sticky floors with visible wheelchair track marks, and a strong urine smell. These conditions were noted on multiple occasions over several days. Staff interviews confirmed the ongoing issue, with a housekeeper reporting that despite increased cleaning frequency, the urine odor and visible uncleanliness persisted. An LPN stated that the odor was due to urine, as the resident sometimes spilled urine on himself, and staff attempted to empty urinals to reduce the smell. The room was located at the end of the hallway and the odor was noticeable upon approach. The deficiency was identified through direct observation and staff interviews.