F0584

E

Persistent Musty Urine Odor on One Hall Undermining Homelike Environment

Mount Pleasant, Texas Survey Completed on 02-23-2026

Penalty

Fine: $17,220

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on Hall C by not ensuring the area was free of offensive, musty urine odors. Over multiple days of observation, surveyors repeatedly noted a musty urine odor on Hall C at various times of day. On several occasions, staff present on the hall, including a CNA, the Social Worker, and the Corporate Compliance Nurse, acknowledged smelling an offensive odor, though some were unable to identify its exact source. At one point, staff were observed transferring soiled laundry with a pungent musty urine odor from a resident’s room into a bag after learning that the resident’s family was not actually washing the resident’s laundry, contrary to what the resident had told staff.

Interviews with facility leadership and staff showed inconsistent awareness of the odor problem. The Housekeeper Supervisor attributed the odor to a possible incontinence episode in the hallway or someone walking by. The ADON and DON both stated they had not noticed any offensive or urine odors on Hall C and reported that residents had not complained to them about odors. They each stated that all staff were responsible for ensuring the facility did not have offensive odors, and the DON described expectations that CNAs change sheets on shower days, clean mattresses when necessary, and keep residents clean and dry to prevent odors. The facility’s undated Resident Rights policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management are to minimize institutional characteristics, including institutional odors, but the persistent musty urine odor on Hall C demonstrated a failure to meet this standard during the survey period.