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 (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: 145684 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 145684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aliya of Homewood 940 Maple Avenue Homewood, IL 60430 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)