Failure to Maintain Sanitary and Comfortable Resident Room Environment
Penalty
Summary
A deficiency was identified when a pervasive urine odor was present in a resident's room, compromising the sanitary and comfortable environment required for residents, staff, and the public. Observations on multiple occasions revealed a strong urine odor upon entering the room, with staff interviews confirming that this was a persistent issue. The resident involved had severely impaired cognition, as indicated by a low BIMS score, and was frequently incontinent of urine. The care plan noted the resident's non-compliance with hygiene needs, specifically a refusal to wear incontinence products despite frequent incontinence. Housekeeping staff reported that the resident's bedding was changed daily and the mattress was sprayed, but acknowledged that the odor remained, particularly due to the resident missing the toilet frequently. Wet areas were observed on the bathroom floor, and staff confirmed that floors were mopped daily, but interventions only partially addressed the odor. Facility policy required prompt disposal of soiled linens and reporting of lingering odors, but the persistent urine smell indicated these measures were insufficient in this case.