The incident at Woodlake Healthcare and Rehabilitation Center was one of several cleanliness failures federal inspectors documented during a September complaint investigation. Persistent urine odors permeated hallways, residents complained about decade-old stained carpeting, and one family member said his father's bathroom "smelled like death" even after cleaning.
The facility's environmental services director acknowledged they currently have no floor technician and are "stretched thin" on cleaning staff.
Family member FM-B described watching the catheter incident unfold during his relative's first days at the facility. R3, a resident with leg fractures and other injuries requiring catheter care, had just arrived when the problems began.
"The first thing he smelled when they got to her unit was urine," according to the inspection report. On R3's first night, a staff member emptied her catheter bag but failed to replace the cap properly, causing urine to leak across the floor.
The second time staff emptied the catheter bag, the employee spilled urine directly onto the carpet. Instead of properly cleaning the mess, the staff member used a brown paper towel to rub the urine into the carpet fibers.
Federal inspectors found the facility failed to maintain clean, odor-free environments for residents across multiple areas. During their September 11 walkthrough at 10:50 a.m., inspectors detected musty odors outside one resident room on the two-east unit. The next morning at 8:23 a.m., the hallway outside another room smelled distinctly of urine, with no trash or linen carts nearby to explain the odor.
R2, a resident with diabetes and muscle weakness who had been at the facility for two weeks, expressed frustration about the conditions. She told inspectors the facility had used the same carpet for 10 years and described being "dumped in this shit hole."
The carpet was stained and musty, R2 said. She criticized housekeeping staff for sweeping rather than vacuuming the carpeted areas. R2 had ordered her own bottle of fungicide to combat the odors and planned to spray a recliner brought up from the basement because "it stunk."
R1's family member reported similar concerns about persistent odors in his father's bathroom. Despite facility cleaning efforts, family member FM-A said it still "smelled like death" when he visited.
A formal grievance filed in August highlighted broader cleanliness issues. The complaint described a resident's room as "a mess" with insufficient garbage cans and dirty floors.
The facility's social service designee acknowledged awareness of R3's family concerns, which included the urine incidents on carpet, missing furniture, and other cleanliness problems. Because of these issues, R3 "did not think the facility was welcoming or clean," the designee said.
Environmental services director acknowledged the staffing challenges affecting cleanliness standards. Without a dedicated floor technician, the facility struggles to maintain proper cleaning schedules. She said she would prefer to clean hallways at least weekly but current staffing limitations prevent consistent maintenance.
The director indicated that when made aware of specific concerns, staff would speak with residents and families and provide additional training if needed. However, the inspection findings suggest systematic problems beyond individual incidents.
R2's mental status assessment showed intact short and long-term memory, meaning her complaints about facility conditions reflected clear observations rather than confusion. Her decision to purchase personal fungicide demonstrated residents taking matters into their own hands when facility cleaning proved inadequate.
R3's medical conditions included fractures of her left fibula and tibia, wrist pain, and dependence on medical devices including the catheter that became central to the cleaning violations. Her injuries required careful medical attention, making the unsanitary conditions particularly concerning for infection control.
The catheter incidents represented multiple failures in basic care protocols. First, staff failed to properly secure the catheter cap, allowing continuous leaking. Then, when directly spilling urine during bag changes, staff chose to rub waste into carpet rather than follow proper cleanup procedures.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting some residents. The citation fell under regulations requiring nursing homes to maintain safe, clean, and comfortable environments for residents, staff, and visitors.
The facility's admission records showed R2 arrived September 3, just over a week before the inspection. Her rapid recognition of cleanliness problems suggested ongoing issues rather than temporary maintenance lapses.
R1's diagnoses included digestive system surgery, chronic pain, and weakness. His family member's specific complaint about bathroom odors persisting despite cleaning efforts indicated problems with deep sanitation rather than surface-level housekeeping.
The August grievance about insufficient garbage cans and dirty floors suggested residents and families had been raising cleanliness concerns for weeks before the federal inspection. The formal complaint process indicated attempts to resolve issues internally before regulatory involvement.
Environmental services staffing shortages affected multiple aspects of facility cleanliness. Without dedicated floor technicians, routine deep cleaning tasks like carpet maintenance fell behind schedule. The director's comment about being "stretched thin" suggested broader staffing challenges beyond environmental services.
R2's observation that housekeepers swept carpeted areas rather than vacuuming indicated improper cleaning techniques that could worsen odor retention in carpet fibers. Her personal purchase of fungicide represented a resident attempting to address facility maintenance failures with her own resources.
The inspection found three residents affected by environmental cleanliness failures, but the scope of odor problems in hallways suggested broader impact on the resident population. Persistent urine smells in common areas would affect all residents, staff, and visitors using those spaces.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodlake Healthcare and Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
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