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F0921
E

Unsanitary Hot Water Heaters in Resident Closets

Shelbyville, Illinois Survey Completed on 11-16-2025

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 sanitary conditions for hot water heaters located in resident closets, affecting six residents reviewed for physical environment. Observations revealed that several hot water heaters in resident closets had visible lime build-up, rust, and black mold on the units, surrounding floors, and walls. Residents reported that their clothes, which hung directly above or touched the water heaters, became very warm, and some expressed concerns about potential health risks due to the presence of mold and lime build-up. One resident's family member had previously reported concerns about mold and lime build-up to facility staff, but there was no documentation of this concern in the resident's electronic medical record, nor evidence that the issue was addressed. Interviews with staff, including the DON, Maintenance Director, and Custodian, confirmed awareness of the unsanitary conditions and the presence of water heaters in multiple resident closets. Staff acknowledged that some water heaters were in poor condition, with visible mold, rust, and lime build-up, and that resident clothing was in direct contact with the units. Despite these concerns being reported by residents and family members, and staff being aware of the issues, the unsanitary conditions persisted at the time of the survey.

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