F0584

F

Failure to Maintain Adequate Housekeeping, Laundry, and Maintenance Resulting in Unsanitary Environment and Equipment Issues

Havana, Illinois Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to maintain a safe, clean, comfortable, and homelike environment for all 58 residents. The facility assessment referenced support staff such as plant operations, custodians, housekeeping, and maintenance, but did not include an addendum specifying the staffing plan or number of staff needed for maintenance, housekeeping, and laundry services. Housekeeping/laundry schedules showed that only one laundry aide worked eight hours on 12 of 15 days reviewed, and only one housekeeper worked eight hours on 7 of 15 days, leaving large portions of time and shifts without coverage. Staff interviews consistently reported that there were not enough housekeepers or laundry staff, especially on second and third shifts, and that CNAs did not have time to perform laundry duties.

As a result of this inadequate staffing and scheduling, the facility was not kept clean and free of odors, and there were persistent shortages of clean linens and mechanical lift slings. Multiple clean linen storage rooms were observed to be dirty, with floors covered in brown staining, trash, and debris, sinks with rust or white buildup, missing floor tiles, and overflowing trash cans. Linens stored in these rooms, including towels and sheets, were stained a light brown color and smelled of feces, and there were no clean washcloths or bed pads available in some areas. Staff and residents reported that linens frequently arrived stained, dirty, or smelling of feces, and that clean washcloths, bed pads, towels, and slings were routinely unavailable in the mornings. CNAs and nurses stated they often had to use towels instead of washcloths to clean residents, dig through dirty laundry to find the “least dirty” sling, or encountered “clean” washcloths with feces still on them.

The lack of adequate housekeeping and maintenance also led to resident rooms and bathrooms not being cleaned daily and to physical plant disrepair. Observations showed resident rooms with scattered debris, overflowing trash cans, stained cubicle curtains, missing chunks of drywall, exposed unpainted drywall patches, cracked and bulging drywall above heating/cooling units, and a flickering over‑bed light that had been ongoing for weeks. Residents reported that their rooms and floors were always dirty, that their trash was always full, and that housekeepers were not able to clean their rooms every day. Several residents described toilets that overflowed into their rooms for weeks before being fixed, resulting in water and feces (“turds”) on their floors. One resident stated their sheets always smelled like feces, that they had purchased their own washcloths because they refused to use the facility’s, and that they had not had a housekeeper clean their room since early in the month.

In addition, the facility failed to ensure that mechanical lifts and related equipment were adequately maintained and available. The manufacturer’s manual specified that the emergency red button is used when the control unit is not functioning and that a person can be lowered by pulling the red quick release lever in a power failure. During demonstration, the mechanical lift’s emergency button was found to be missing, and the lift’s legs were covered in debris and brown stains. The maintenance supervisor acknowledged not realizing the emergency button was missing and was unsure who was responsible for cleaning the lift, while a CNA reported that residents had been stuck in the air when batteries died and that there were not enough batteries to keep the lift functioning. Staff also reported that one of two full mechanical lifts had been broken for about a month, leaving only one working lift for multiple residents who required mechanical lift transfers, and that showers and transfers were missed when slings and clean linens were unavailable.

Environmental observations further showed that the facility did not provide a homelike environment. On the memory care unit, two dining room windows lacked blinds or curtains and instead had see‑through bed sheets tacked up unevenly, covering only part of the windows. A concern form from a visitor described sheets hanging on dining room windows as “very tacky” and noted the absence of pictures on the walls. Another resident reported never having curtains and therefore hanging a bedspread over the window to block the sun. These conditions, combined with the dirty linen rooms, stained and foul‑smelling linens, unclean resident rooms, and unrepaired fixtures, demonstrate that the facility did not honor residents’ rights to a safe, clean, comfortable, and homelike environment and did not provide treatment and supports for daily living in a safe and sanitary manner.