Health inspection·March 21, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to follow their policy to ensure housekeeping staff inspected the privacy curtains in resident rooms and removed visibly soiled privacy curtains. This failure has the potential to affect 5 (R2, R3, R4, R5, and R6) residents reviewed for a clean, comfortable, homelike environment. Findings include: On 03/19/24 at 12:40 PM, R2 was asked of her concern with housekeeping. R2 said, The housekeeper comes in everyday and cleans my room. Me and my daughter have told them about this curtain. See it has stains that look like stool on it. The staff said they could take it down and wash it, but they haven't done anything. We noticed the curtain was filthy when I came to this room. Surveyor observed the privacy curtain with multiple large brown and tan stains on both sides. On 3/19/24 at 1:00 PM, surveyor observed the privacy curtains in R5 and R6's room. The privacy curtains were visibly stained and dirty. V9 CNA (Certified Nurse Assistant) was in the room at this time assisting the residents with lunch. V9 was asked regarding the privacy curtain appearance. V9 said, The curtain is dirty, it has food or something on it. On 3/19/24 at 1:05 PM, V3 LPN (Licensed Practical Nurse) was asked of the privacy curtain appearance. V3 looked at the privacy curtain and said, It's dirty, I see stains on it. I'll ask the housekeeping director to look at this. I think housekeeping is supposed to check these. R5 and R6 were in bed. They were unable to answer questions related to the cleanliness of the privacy curtains at this time due to their cognition. On 3/19/24 at 1:09 PM, the privacy curtains in R4's room were noted to be visibly stained and dirty. R4 was asked of the cleanliness of the privacy curtains. R4 said, They're dirty. On 3/19/24 at 1:11 PM V8 Housekeeping Supervisor and surveyor reviewed the resident rooms privacy curtains for cleanliness. V8 reviewed R4's privacy curtain. V8 said, The privacy curtains and floor aren't clean in here. V8 reviewed R3's privacy curtain. V8 said, The privacy curtains are dirty in here. V8 reviewed R2's privacy curtain. V8 said, Oh it has stains and its dirty. V8 reviewed R5 and R6's privacy curtain. V8 said, I'll get these taken down and cleaned now. I'll take a look at this whole unit. On 3/19/24 at 1:13 PM, V8 Housekeeping Supervisor was inquired of the cleanliness of the privacy curtains in resident rooms. V8 said, I'm the housekeeping supervisor. The housekeepers should be noticing this every time they go into the rooms. The managers when they round should also be telling us Page 1 of 2 145684 145684 03/21/2024 Aliya of Homewood 940 Maple Avenue Homewood, IL 60430

F 0584 Level of Harm - Minimal harm or potential for actual harm if they see something. The housekeepers should be checking the curtains daily and letting me know so they can be taken down and washed. On 3/19/24 at 1:20 PM, V1 Administrator is speaking with R2 in her room regarding concerns with housekeeping. Residents Affected - Some On 3/19/24 at 1:22 PM, R3 was inquired of the cleanliness of his room. Do you have any concerns with housekeeping? How long have these privacy curtains been dirty? R3 said, No, the housekeepers come in and clean every day. Different people come in and I may have told someone about the curtains, but they've been dirty for quite some time. It's got stains. On 3/19/24 at 1:26 PM, V8 returned to the unit with three other housekeeping staff to address the privacy curtain concerns. On 3/21/24 at 10:34 AM, housekeeping staff were on the unit replacing privacy curtains in resident rooms. On 3/21/24 at 10:35 AM, R2 was asked regarding the privacy curtains. R2 said, They changed this in 2 hours, they got it done. It looks so much better now. The revised 11/2019 Housekeeper job description states in part: Primary duty- Performs housekeeping and cleaning activities within well established guidelines and assigned areas and shift (s) to ensure that quality standards, safety guidelines and customer service expectations are met. The housekeeper is responsible for satisfactory and timely completion of assigned cleaning area according to schedule. The housekeeper is responsible for the daily cleaning and sanitizing of patient room furniture, as well as sitting room and dining room furniture. Removes and disposes of trash and relieves laundry staff as needed. The Daily Cleaning Procedures policy states in part: 6) Spot clean walls and inspect privacy curtains. Work your way clockwise around the room (starting at the door and finishing at the door) spot cleaning walls and vertical surfaces that are visibly soiled. Inspect all privacy curtains in room. If dirty, notify your supervisor which curtains need to be changed. The revised 11/2019 Environmental Services Director job description states in part: Manages and supervises the housekeeping, laundry, and floor care staff at a single site according to policies and procedures, and federal/state requirements. Provides leadership, support, coordination, and guidance to ensure that quality standards, inventory levels, safety guidelines and customer service expectations are met. Essential job functions include the following supervises, coordinates, and evaluates work of all housekeeping employees, delegating work equally among employees. 145684 Page 2 of 2