Failure to Maintain Clean and Homelike Environment in Shared Room
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents sharing a room, resulting in persistent foul urine odors and unclean living conditions. One resident, who was severely cognitively impaired and had a history of refusing care, was observed with a half-full, uncapped urinal and an open bedside commode containing urine and splatters across the seat. Multiple observations over several days documented a strong foul urine odor emanating from the room and into the hallway. Staff interviews confirmed that the resident's behaviors often prevented timely cleaning, and staff would only clean the area when the resident was not present. The other resident in the shared room, who was cognitively intact but had a history of major depressive disorder and occasional refusal of care, expressed dissatisfaction with the persistent odor but felt unable to address the issue. Staff acknowledged that both residents' refusals of care contributed to the unclean environment and that relocating the affected resident had not been considered. The ongoing odor and lack of cleanliness were directly observed and corroborated by staff and resident interviews.