Failure to Maintain Clean, Homelike Rooms and Safe Bedding
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for multiple residents and lacked any documented system for tracking maintenance requests or completed repairs. Surveyors observed that one resident’s wall next to the closet had a large area of dents and scratches measuring approximately three feet by one foot, and the closet door was missing. Another resident’s closet also lacked a door, and the wall behind that resident’s dresser had five nails protruding approximately one inch from the wall. A third resident’s wall next to the head of the bed had multiple scratches and dents covering an area approximately two feet by one foot, and this resident stated she wanted the wall repaired and liked her room to look neat and well taken care of. A fourth resident’s mattress had a large wet area in the center, and the top layer of the mattress was very worn and thin. Staff interviews confirmed there was no formal process in place for the maintenance department to know what needed repair, as prior written request slips had been discontinued and staff were instead verbally notifying the Administrator, with nothing documented. The Maintenance Assistant reported that this lack of written tracking made it difficult to keep up with repairs. A CNA stated that the resident with the wet mattress had to lie on a wet bed every night because the mattress surface was so worn that urine seeped through and saturated the mattress, causing the resident’s clothes to become wet when sitting on the bed even if the resident was dry and not incontinent at that time. A housekeeper reported that the chemical spray used to clean mattresses degraded their surface, allowing urine to remain on and soak into the mattress. A Regional RN confirmed that the previous paper system for documenting maintenance requests and repairs had been eliminated by the Administrator in favor of verbal reporting. The Illinois Long Term Care Ombudsman Resident Rights pamphlet states that residents have the right to a clean and homelike environment.
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