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F0561
E

Failure to Maintain Resident Comfort and Provide Requested Personal Care

Metropolis, Illinois Survey Completed on 11-17-2025

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

Surveyors identified that the facility failed to honor and support resident self-determination by not keeping residents warm after showers and not providing nail care upon request for multiple residents. Observations revealed that shower rooms consistently measured around 71 degrees Fahrenheit, and staff were instructed not to adjust the thermostats. Several residents and their families reported that the shower rooms were cold, and residents were often returned to their rooms wet, inadequately dressed, or only covered by a towel, leading to prolonged discomfort. Staff interviews confirmed that residents frequently complained about the cold environment during and after showers, and that the shower chairs were uncomfortable, especially for those with pressure sores. One resident with significant medical issues, including dementia, pressure ulcers, and mobility deficits, reported receiving a cold shower late at night, being left with wet hair, and not being properly covered or dressed, resulting in her feeling cold all night. Family members corroborated these accounts, stating that complaints about the cold showers and improper handling had been communicated to facility administration multiple times. Other residents, including those with cognitive impairments and chronic illnesses, also expressed discomfort with the cold shower rooms and reported refusing showers to avoid being cold. Staff acknowledged that the shower rooms could be cold and that residents often voiced their discomfort. Additionally, the facility failed to provide timely nail care upon resident request. One cognitively intact resident repeatedly asked staff to trim his nails, which were observed to be long and dirty over several days. Despite reminders to both CNAs and LPNs, the resident's request was not fulfilled, and he stated that he avoided showers due to the cold, further impacting his ability to receive nail care. These failures demonstrate a lack of responsiveness to resident preferences and needs regarding personal care and comfort.

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