F0921

C

Unsanitary, Damaged, and Non-Private Shower Rooms Affecting All Residents

Hazel Crest, Illinois Survey Completed on 01-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in the common shower rooms on both the first and second floors, affecting all residents. A resident, a 67-year-old female with multiple diagnoses including thyroid disorder, essential hypertension, paranoid schizophrenia, unspecified psychosis, thyrotoxicosis, mild dementia, mental disorder NOS, vitamin D deficiency, constipation, and spasmodic torticollis, was identified as the complainant through her Maximus case manager, but she was unavailable for interview. The case manager reported that during a visit in the fall, he observed the first-floor shower room next to the conference room and described it as horrible, with broken floor tiles, no privacy curtains, and mold throughout the bathroom.

Surveyor observations on the first floor showed that the 400 hall shower room was locked and required the Maintenance Director to open it, as nursing and housekeeping staff did not have a key. Inside, the toilet bowl had dark brown stains and, when flushed, spewed dark brown water. Floor and wall tiles were chipped, some shower areas lacked curtains, assistive devices were stored in the room, and there were varying degrees of dark substance on the grout of walls and floors. The 200 hall shower room contained bath blankets on the floor, unflushed urine in the toilet, chipped 1x1 floor tiles and broken wall tiles, dark substances on floors and walls, and was also used for storage of assistive devices. There was no privacy curtain for the toilet, which was visible from the hallway when the door was open, and there was no lock on the door. The DON stated that most first-floor residents are more independent and shower without assistance, and the identified resident’s care plan indicated she requires assistance with ADLs.

On the first floor, another shower room on the 500 hallway was entirely used for storage and not available for shower use. On the second floor, all shower rooms were observed to have crumbling tile, lack of privacy curtains, and varying levels of dark substances on floors and walls. A housekeeper reported that bathrooms are cleaned once per shift and upon request, while the Housekeeping Manager stated that she and housekeepers make rounds and clean when they determine it is needed. The Infection Preventionist stated she is mainly involved with antibiotics and not housekeeping and did not provide a policy for shower cleaning or remediation of the dark substance. There was no facility policy on housekeeping protocol for shower cleaning, no logs or scheduled cleaning records available for review, and resident council minutes documented at least three complaints about the shower rooms being filthy. Based on these observations, interviews, and record reviews, the facility did not provide a clean, safe, comfortable, and sanitary area for residents to shower, and a deficiency was cited.