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F0677
E

Failure to Provide Required Showers and ADL Assistance Due to Linen and Staffing Shortages

Decatur, Illinois Survey Completed on 06-04-2025

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 provide showers and adequate assistance with activities of daily living (ADLs) for five residents who were unable to perform these tasks independently. During a Resident Council meeting, multiple residents reported not having received showers in the past week, despite facility policy requiring showers twice weekly. Observations confirmed that these residents had visible signs of poor hygiene, including food on their clothing, oily hair, and dirt under their nails. Medical records corroborated that the last documented showers for these residents were well beyond the required frequency, with some not having received a shower for up to two weeks. Interviews with staff revealed that a shortage of linens and housekeeping staff contributed to the failure to provide showers. Certified Nursing Assistants (CNAs) reported running out of linens, particularly on weekends, and the Director of Nursing confirmed that staff shortages led to CNAs being unable to locate necessary supplies. Additionally, it was noted that towels and linens were sometimes stored in residents' drawers, further complicating access. Despite grievances being filed by residents after each monthly council meeting, there was no reported improvement in the provision of showers or ADL assistance.

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