Health inspection·January 27, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, sanitary, and comfortable environment by failing to prevent ongoing water leakage through the roof and mold-like growth in the shower rooms and on ceiling tiles. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: On [DATE] at 9:35 AM there was black mold-like substance on the East Hall shower room ceiling vent grate. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath. On [DATE] at 9:40 AM one 2'x2' ceiling tile in front of room [ROOM NUMBER] and 106 was missing and the tile next to that spot appeared to have been saturate with water at one point, was bulging downward towards the floor and was discolored and brown. On [DATE] at 9:46 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] and 108 were missing and four ceiling tiles around that spot had brown water-like spots on them. On [DATE] at 9:54 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] were completely missing. On [DATE] at 9:57 AM there was black mold-like substance on both of the [NAME] Hall shower room ceiling vent grates. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath. On [DATE] at 10:01 AM one 2'x2' ceiling tile was missing by the [NAME] Hall nurses station. On [DATE] at 10:03 AM one 2'x2' ceiling tile was missing in front of room [ROOM NUMBER] and 213 and the surrounding tiles had brown water-like spots on them. On [DATE] at 10:06 AM one 2'x2' ceiling tiles at the end of the [NAME] Hall by the exit door had brown water-like spots on them and one corner had black and pink mold-like substance growing on it. The facility Resident Council Minutes for the month of [DATE] document resident complaints of the roof leaking and needs fixed. Page 1 of 3 145862 145862 01/27/2024 Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On [DATE] at 10:10 AM both R2 and R3 stated the roof had been leaking in the facility for a couple months. Both R2 and R3 stated they think V7 Maintenance was trying to patch it but it was not working and only getting worse. Both R2 and R3 stated they had used their own trash can once the week before when it was leaking to help catch the water so it didn't get all over the floor and create a hazard. Both R2 and R3 stated they had seen mold-like substances growing in the shower rooms. Both R2 and R3 agreed that these issues needed to be addressed in a more thorough fashion. On [DATE] at 8:05 AM V3 Licensed Practical Nurse stated the roof has been leaking for a couple of months but has gotten worse. V3 stated the leaking is happening down the East and [NAME] Hallways and is not getting fixed properly. V3 stated staff put out buckets to catch the water when it leaks. On [DATE] at 8:15 AM V4 [NAME] stated the roof has been leaking for a few months. V4 stated the maintenance department tries to repair it but it is not working and they need a professional roofing company. On [DATE] at 8:30 AM V5 Licensed Practical Nurse stated the roof is leaking but she does not know for how long. R5 stated the staff set out buckets to catch the water. On [DATE] at 8:47 AM V6 Certified Nurses Assistant stated the roof has been leaking for a couple of months but has gotten worse. Staff put out buckets to catch the water. On [DATE] at 9:30 AM V8 Housekeeper stated the roof has been leaking for a few months on East and [NAME] halls. V8 confirmed she has seen a mold-like substance in the [NAME] Hall shower room stall and has tried to clean it but it does not get rid of it for good. On [DATE] at 9:43 AM V9 Activities Assistant stated the roof has been leaking and staff use trash cans to catch the water. On [DATE] at 10:01 AM V10 Licensed Practical Nurse and V11 Certified Nurses Assistant stated the roof has been leaking pretty badly down [NAME] Hall and on East Hall. Staff use buckets to catch water and try to prevent water hazards. On [DATE] at 8:50 AM V1 Administrator confirmed the roof has been leaking. V1 was not sure about a time frame but felt a couple months sounded accurate. V1 stated the roof leaks down the East and [NAME] Halls. V1 Administrator confirmed the facility census was 62. On [DATE] at 8:58 AM V7 Maintenance Director stated the roof has been leaking for about a year. V7 stated it has gotten worse in the last few months. V7 stated he has patched it several times however it is not working. V7 confirmed the leaking occurs down the East and [NAME] hallways and is a steady drip when it is raining. V7 confirmed the removed ceiling tiles in the building are areas where water has been leaking through. V7 confirmed some tiles have water spots from getting wet. V7 confirmed the shower room stalls need to be cleaned more thoroughly and currently have a black and orange mold-like substance growing on them. V7 confirmed the shower room vent grates also have a black mold-like substance on them. V7 stated the facility does have a plan to have a roofing company come and do professional repairs but is not sure when that will be exactly. On [DATE] at 10:57 AM V12 Corporate Maintenance Director stated the facility has been struggling with it's roof leaking for quite some time and the issues is ongoing. V12 confirmed the issues has gotten worse as of recently with all of the rain and snow. V12 stated the facility just had a 145862 Page 2 of 3 145862 01/27/2024 Hilltop Skilled Nsg & Rehab 910 West Polk Street Charleston, IL 61920

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many professional roofing company come out to do an estimate for repairs or replacement. V12 stated the plan is to get the roof repaired or replaced by this Spring. V12 stated the facility's housekeepers have the right products to properly clean the showers and if done correctly the facility should not have any mold-like substances growing in the shower stalls. V12 confirmed he would be talking with facility maintenance and housekeeping in order to get the items cleaned or replaced if needed. V12 confirmed the staff should have remedied these issues. 145862 Page 3 of 3