Persistent Odor and Inadequate Cleaning in Alzheimer's Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the Alzheimer's care unit by not preventing persistent urine odors in the hallway and not ensuring routine cleaning of a resident room. Record review showed that the Alzheimer's unit had 12 occupied beds, and the deep cleaning schedule indicated that one resident's room was deep cleaned only once in January, with no deep cleaning scheduled for February and the next deep cleaning not planned until the second Wednesday in March. On three separate observations on 03/02/2026, 03/04/2026, and 03/05/2026, surveyors noted a strong urine odor in the hallway of the Alzheimer's care unit. The DON/RN, a medication aide, and a nursing assistant each confirmed the presence of the urine odor during interviews on those dates. The facility's Routine Cleaning and Disinfection policy, revised 12/2025, required that horizontal surfaces with infrequent hand contact, such as window sills and hard surface flooring in routine resident-care areas, be cleaned on a regular basis, when soiling and spills occur, and when a resident is discharged. Despite this policy, observations of one resident room on 03/02/2026 and again on 03/03/2025 revealed black, brown, and white particles on the bedside table and a brown spot with white and brown particles on the floor. During the 03/03/2025 observation, a medication aide confirmed the presence of these particles and the brown spot on the floor, indicating that the room had not been cleaned in accordance with the facility’s stated cleaning and disinfection procedures.
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