Health inspection·September 10, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident rooms were clean. This failure affects six (R1, R2, R4, R5, R9, R10) of ten residents reviewed for housekeeping in the sample of ten. Findings include: 1.) On 9/10/24 at 9:36 AM, R10's garbage can was full. R10 stated R10's garbage can has not been emptied since yesterday. At 11:22 AM and 1:12 PM R10's garbage can remained full. At 1:12 PM, V6 Housekeeper stated V6 has not cleaned R10's room yet today. V6 stated V6 will empty the garbage can when V6 cleans the room. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has a Brief Interview for Mental Status score of 12, the higher end of moderate cognitive impairment. 2.) On 9/10/24 at 9:40 AM, there was a medical glove on the floor behind the door and a pile of wet/used paper towels on the floor near the sink in R4's/R5's room. There were food particles, dirt, and two hairbrushes on the floor under R5's bed. R4 stated the paper towels have been there since last night and there is only one garbage can in R4's/R5's room, which is located in the bathroom. R4 stated housekeepers used to sweep and mop the floors daily, but now R4 rarely sees them do that. At 1:09 PM, V6 Housekeeper had cleaned R4's/R5's room and moved onto the next room. The floor was wet and there was a wet floor sign in the doorway. The food particles, dirt, and hairbrushes were still underneath of R5's bed. At 1:12 PM, V6 entered R4's/R5's room and confirmed she had cleaned the room. V6 stated, V6 only got partway underneath R5's bed. V6 looked underneath the bed and confirmed there was food particles, dirt, and hairbrushes on the floor. V6 stated I will clean that right now. R4's MDS dated [DATE] documents R4 is cognitively intact. 3.) On 9/10/24 at 9:57 AM, there was dirt/dust on the floor behind R9's headboard and underneath R9's enteral feeding pole. R9 stated no staff had been in to clean R9's room yet today. At 10:39 AM, V6 was cleaning R9's room. At 11:28 AM there was dirt/debris behind R9's bed and under the enteral feeding pole. There was a wet floor sign in R9's doorway. At 12:09 PM, V5 Housekeeping Supervisor entered R9's room. The wet floor sign was in the doorway and R9's floor still had dirt/debris behind the bed and underneath the feeding pole confirmed by V5. V5 stated it should have been cleaned when R9's room was cleaned, V5 will clean the area and follow up with V6. R9's MDS dated [DATE] documents R9 is cognitively intact. Page 1 of 3 145965 145965 09/10/2024 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0584 Level of Harm - Minimal harm or potential for actual harm 4.) On 9/10/24 at 10:58 AM, V14 (R1's Family) stated R1 passed away on 9/2/24 at 9:20 PM and R1's room had not been cleaned when V14 came to pick up R1's belongings the following day at 1:20 PM. V14 stated there were pillows and a fall mat rolled up in the corner of R1's room, a box of supplies and razors in R1's windowsill, gloves and used cups on the overbed table, and soiled incontinence wipes on the floor. V14 stated the room had a strong death smell and R2 (R1's room mate) was in the room asleep. Residents Affected - Some R1's undated census and R2's undated census document R1 and R2 shared a room from 4/6/24 until R1 expired on 9/2/24. R1's Nursing Note dated 9/2/2024 at 9:20 PM, recorded by V4 Licensed Practical Nurse (LPN) documents R1 passed at 9:20 PM. On 9/10/24 at 10:47 AM, V4 LPN stated V4 was R1's nurse when R1 passed during the evening shift. V4 stated the only housekeeping complaint is that they leave at 2:00 PM and then it falls to the nurses and Certified Nursing Assistants (CNAs) for housekeeping needs. V4 stated, R2 tries to do her own care at times and makes a mess of things leaving soiled briefs and wipes out, and then staff have to go in and clean up after R2. At 11:52 AM, V4 stated if a resident passes away in the evening, the CNAs/Nurses are suppose to clean up the room and then housekeeping does a deep clean the next day, including picking up fall mats and linens. On 9/10/24 at 11:54 AM, V11 CNA stated it takes the housekeepers a long time to clean resident rooms each day. V11 stated the problem is, housekeepers leave at 2:00 PM each day and then the CNAs/nurses are suppose to cover housekeeping needs. V11 stated, we are already busy with our own work. On 9/10/24 at 11:57 AM, V5 Housekeeping Supervisor stated resident rooms are cleaned daily including sweeping and mopping floors. V5 stated, the housekeepers are suppose to start cleaning resident rooms at 7:00 AM and are usually done by 1:00 PM. V5 confirmed after 2:00 PM the nursing staff are responsible for housekeeping duties including emptying garbage cans and picking up garbage off the floor. V5 stated, when a resident passes away we wait to see what the family wants to do with their belongings, but the housekeeper should go in and pick up garbage and clean. V5 stated walkers, wheelchairs, floor mats, and other equipment stay in the room until after the family comes in. V5 stated, staff leave linens on the resident room floors for long periods causing V5 to pick up the items. V5 stated, staff at times miss the garbage can and leave gloves or wipes on the floor that V5 has to pick up. V5 stated, garbage cans should be emptied every day and checked again at the end of the shift. At 1:18 PM, V5 stated if a resident passes when housekeeping staff are not on duty, nursing staff should empty the trash, especially anything that could cause odor, and remove linens and pillows from the room. V5 stated, V5 will have to follow up with V6 on cleaning resident rooms. On 9/10/24 at 1:26 PM, V9 Housekeeper stated V9 swept R1's/R2's floor on the morning of 9/3/24, but did not do a deep clean until after R1's family visited that day. The facility's Room Change and Cleaning Disinfection policy dated 6/30/24 documents It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. 11. Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned: 145965 Page 2 of 3 145965 09/10/2024 Loft Rehab of Decatur 500 West McKinley Avenue Decatur, IL 62526

F 0584 a. Level of Harm - Minimal harm or potential for actual harm On a regular basis b. Residents Affected - Some When soiling and spills occur c. When a resident is discharged from the facility . 145965 Page 3 of 3