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F0584
F

Failure to Maintain Clean and Homelike Environment and Adhere to Deep Cleaning Policy

Naperville, Illinois Survey Completed on 04-22-2025

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, and homelike environment for all 79 residents, as evidenced by persistent urine odors, dirty hallways, and debris in both resident rooms and common areas. Upon entrance and throughout the survey, strong urine odors were noted in the hallways, and multiple areas were observed to have dirty floors with black and brown marks, smudges, and food debris. Trash and soiled linen receptacles were full, and old meal trays were left on top of trash bins. Housekeeping staff were not observed cleaning the hallways during these times, and the facility was unable to provide documentation of regular or deep cleaning as required by their own policy. Several residents with significant cognitive and physical impairments were found in unclean environments. One resident, who is always incontinent and requires assistance with most activities of daily living, was found in a room with broken furniture pieces, plexiglass from a lighting fixture, and food and paper debris scattered on the floor. Another resident, with severe cognitive impairment and frequent incontinence, had a room and hallway cluttered with food debris, trash, and wheelchair parts, and reported that cleaning was only done when she left her room. Additional observations included overflowing garbage cans, medication cups and food wrappers on the floors, and residents having to step over debris to enter their rooms. One resident, who is dependent on staff for mobility and transfers, had a care plan specifically requiring clutter-free and clean environments, yet her room and hallway were not maintained accordingly. Interviews with staff revealed that the facility was not following its own policy for quarterly deep cleaning of resident rooms. The Housekeeping Director and Administrator confirmed that only one room was deep cleaned per week, resulting in each room being deep cleaned only once per year, rather than quarterly. There was no documentation of monthly cleaning schedules or audits to ensure compliance. Staffing shortages and changes were also noted, with key housekeeping staff absent or on leave, further impacting the cleanliness of the facility. Residents and staff both reported a decline in cleanliness and housekeeping services.

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