F0584

F

Failure to Maintain Adequate Linens, Room Readiness, and Lighting for Residents

Forest Park, Illinois Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining an adequate supply of clean bed and bath linens, not ensuring adequate lighting in resident rooms, and not providing a properly made bed with a mattress and linens for a resident who was transferred to a new room. Multiple residents reported and surveyors observed a lack of clean washcloths, towels, and blankets across several floors. One resident with paraplegia and a coccyx wound stated that there were no rags or towels available, causing delays in wound dressing changes and in getting out of bed, and reported that staff sometimes brought stained or cut-up rags that appeared to be used for cleaning toilets or furniture. Another resident with psoriasis and psoriatic arthritis reported that there were not enough washcloths to clean his armpits, abdominal folds, and groin so he could apply ordered topical medications multiple times daily, and stated that a CNA had cut a diaper into pieces to use for cleaning residents.

Surveyors’ observations in the laundry department and on the resident units confirmed that the supply of clean linens was very limited. In the laundry area, only 15 clean towels, 6 clean washcloths, and 4 cut-up towels mixed in with clean rags were found, and the Housekeeping/Laundry Supervisor acknowledged that the cut towels were supposed to be used as dust rags and that the facility had recently started doing its own laundry without having a total inventory of washcloths and towels. On multiple floors, linen carts were found with either no clean washcloths and towels or very small quantities, and there were no additional carts or storage rooms with more linens. Staff, including an LPN and a CNA, reported that the facility frequently ran out of linen several times a week and that there were no blankets available on at least one unit when a family member requested a blanket for a resident. Morning meeting minutes documented that the facility was getting low on washcloths and that more linen was needed.

The deficiency also includes failure to ensure adequate lighting and a properly prepared room for a transferred resident. One resident’s room lacked an overbed or reading light on her side of the room, while her roommate had an overbed light and cabinetry; the Maintenance Director confirmed that when single rooms were converted back to double occupancy, the second side was never remodeled to include an overbed light. Another resident with multiple serious medical conditions, including chronic respiratory failure, ESRD on dialysis, CHF, and moderate cognitive impairment, was transferred to a new room after breakfast and reported that there was initially no mattress on the bed and that, after a mattress was brought, the bed remained unmade without a flat sheet, blanket, or pillows for several hours. Surveyors observed only a stained fitted sheet on the bed and no bed linens on the nearby linen cart. Multiple staff members, including the RN on the receiving unit, the nurse manager, the ADON, and the SSD, gave inconsistent accounts and demonstrated lack of awareness or coordination regarding the transfer, and it was later confirmed that it took from mid-morning until mid-afternoon for the resident’s bed to be fully made with complete bed linen.

Facility records, including resident rights policies, job descriptions for CNAs, laundry aides, and the Administrator, and the state Ombudsman resident rights booklet, describe expectations that residents receive care in a safe, clean, comfortable, and homelike environment and that staff ensure residents’ comfort, hygiene, and adequate laundry services. Despite these written expectations, the documented observations, interviews, and record reviews show that residents experienced shortages of basic linens needed for hygiene, bathing, and comfort, lacked appropriate room lighting on one side of a semi-private room, and that a newly transferred resident was placed in a room without a ready, fully made bed for an extended period of time.