Inspection·January 25, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to provide daily housekeeping cleaning services for one resident (R1) of four residents reviewed for housekeeping in a sample of four. Findings include: The facility's Resident Rights Policy and Procedure, Undated, documents: Purpose: To ensure the preservation of every resident's right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. IX. Safe environment. Each resident has a right to a safe clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. The facility shall provide: A. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. B. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility's Effective Plan for Housekeeping Policy, dated 3/23/23, documents: It is the policy of this facility to provide a clean and sanitary environment. 1. The housekeeping staff will keep the building clean, safe and in orderly condition. This includes all rooms, corridors, attics, basements and storage areas. The facility's Resident Council Minutes, dated 11/14/23, documents: Housekeeping/laundry: All halls say on weekend their hall or rooms don't get cleaned all the time. The facility's Resident Council Minutes, dated 12/12/23, documents: Housekeeping: Rooms are not cleaned on weekends, certain housekeepers. The facility's Resident Council Minutes, dated 1/9/24, documents: Housekeeping: Need toilets to be cleaned, some housekeepers don't even bring cleaner in with them. Would like to see rooms and bathrooms cleaned. R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, documents: (My/R1's) room hasn't been cleaned by Housekeeping since October 17, 2023. They have been outside my room every day, sometimes twice, to clean the rooms adjacent to mine but not mine. R1's Suggestion/Complaint/Grievance Form, Dated 10/20/23, also documents in Section 1 that V17 Housekeeping/Laundry Supervisor spoke with V16 Housekeeping and V9 Housekeeping and both staff admitted to not cleaning (R1's) room. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145604 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henry Rehab and Nursing 1650 Indian Town Road Henry, IL 61537 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)