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F0584
E

Failure to Maintain Clean and Safe Shower Rooms

Sandy, Utah Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment in its shower rooms, as evidenced by multiple resident and staff interviews and direct observations. Several residents reported refusing to use the 100-hall shower room due to persistent unpleasant odors described as similar to soiled diapers, sewage, or urine. Staff corroborated these complaints, noting that the odor was strong and that some residents would not use the shower room because of it. Observations confirmed the presence of a strong urine and sewage-like odor, soiled linens in unlabeled garbage cans, a fabric chair with brown and white stains, and shower chairs with brown substances on the seat area. Large garbage cans, one without a liner and half full of briefs and trash, contributed to the odor, and the trash was not being emptied regularly according to staff interviews. In addition to odor issues, the physical condition of the shower rooms was found to be in disrepair. The south 300 hallway shower room had missing and broken tiles at the base of a divider wall, and the Maintenance Director acknowledged that the open gap between tiles could allow humidity to penetrate the wall, potentially causing further damage. Mold was observed around a sprinkler head and in a corner with a large water spot, and the toilet in the 200-hall shower room was out of order due to a broken main pipe and was covered with a plastic sheet. These maintenance issues were confirmed by the Maintenance Director, who stated that repairs were needed but had not been requested until a recent resident complaint. Communication and reporting of these issues were inconsistent. While some CNAs reported entering complaints into the maintenance system, others were unsure if the system was being utilized. The Assistant Director of Nursing was unaware of any complaints regarding the odor, and there was confusion among staff about responsibilities for emptying trash and reporting maintenance needs. Housekeeping staff stated that shower rooms were cleaned daily with disinfectant, odor control, and floor cleaner, but persistent odors and cleanliness issues remained. The Administrator was aware of the ongoing odor problem and noted that a plumber had previously worked on the issue, but the problem persisted intermittently.

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