Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by persistent foul odors and unsanitary conditions in resident rooms, hallways, and common shower areas. Observations revealed strong urine and feces smells in the 300 hallways and the common shower room. Housekeeping staff were unaware of the source of the odors and had not yet addressed the issue at the time of observation. Multiple residents were found in their beds with intense urine and feces odors, and incontinent briefs and linens were observed to be soiled and discolored with urine and feces. These conditions were directly observed by surveyors and confirmed by staff interviews. Several residents with varying degrees of cognitive impairment and dependence on toileting hygiene were affected. One resident with mild cognitive impairment was found with urine and feces-soaked briefs and soiled linens, while another with severe cognitive impairment was similarly found with feces-soaked briefs and linens. A third resident with moderate cognitive impairment was observed with soiled briefs and linens, and the hallway near her room also had a strong odor. Additionally, a resident with intact cognition reported that her room and the hallways were smelly, particularly after a roommate change. The facility's own housekeeping policy requires a clean, odor-free, and comfortable environment, but this standard was not met during the survey.