The urinal had visible drops of urine on the handle and bottom when inspectors arrived at the facility on September 16. The resident's family member, who was visiting at bedside, pointed out the obvious infection control problem.
"He used the urinal, they don't rinse it and they put in the table," the family member told inspectors. "That is where he eats because he prefers to eat here. Look there is the urinal with urine in the handle. Is not that an infection control issues?"
The resident, identified as Resident 2 in the inspection report, had been living at the facility since his admission date. His cognitive assessment scored 13 out of 15 points, indicating intact mental function. He was lying in bed during the 2:35 p.m. inspection, with the contaminated bedside table positioned on his right side.
The plastic bag of chocolate candies and cookies sat directly next to the soiled urinal. A roll of paper towels completed the unsanitary collection on the table surface where the resident preferred to take his meals.
Licensed Nurse 2, when shown the bedside table setup during a joint observation at 2:53 p.m., immediately recognized the violation. "The used urinal should not be on top of the table for infection control," the nurse told inspectors.
The facility's Director of Nursing echoed that assessment during an interview later that afternoon. The DON stated the urinal should not be on the bedside table due to possible cross contamination for infection control, according to the inspection report.
Federal inspectors determined the facility failed to ensure safe and sanitary measures were met, violating infection prevention and control requirements. The failure had the potential for contamination of food and cleaning supplies and spread of infection to the resident and his visitors, inspectors wrote.
The violation occurred despite the facility's own infection control policy, revised in June 2025, which explicitly requires implementing infection control measures to prevent the spread of communicable diseases and conditions.
That policy outlines standard precautions that apply to the care of all residents, based on the principle that all blood, body fluids, secretions and excretions except sweat may contain transmissible infectious agents. Environmental cleaning and disinfection are specifically included among required standard precautions.
The inspection was conducted in response to a complaint. Inspectors reviewed four residents for infection control compliance and found this violation affecting one resident.
The contaminated urinal placement represented what inspectors classified as minimal harm or potential for actual harm. However, the setup created obvious risks in a healthcare environment where vulnerable residents depend on staff to maintain basic sanitary conditions around food preparation and consumption areas.
The resident's family member clearly understood the health risks, questioning inspectors about whether the urinal placement constituted an infection control issue. The fact that staff had repeatedly placed the used, unwashed urinal on the eating surface suggested a pattern of poor infection control practices rather than an isolated incident.
The facility's nursing leadership acknowledged the violation when confronted by inspectors, indicating awareness of proper infection control protocols. Yet the contaminated urinal remained on the bedside table with food items during the inspection, suggesting inadequate oversight of basic sanitary practices in resident rooms.
For Resident 2, who preferred eating at his bedside table, the contaminated surface posed direct exposure risks. His intact cognitive function meant he was likely aware of the unsanitary conditions but dependent on staff to maintain proper infection control measures in his living space.
The violation highlighted fundamental gaps between the facility's written infection control policies and actual implementation in resident care areas. While the facility's June 2025 policy revision demonstrated awareness of federal requirements, the contaminated bedside table showed those standards were not being followed in practice.
The inspection found the facility failed to prevent potential contamination and infection spread through basic environmental controls, putting both the resident and his visitors at unnecessary risk in what should have been a safe healthcare environment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Mountain Rehabilitation & Healthcare Center from 2025-09-16 including all violations, facility responses, and corrective action plans.
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