Inspection·August 28, 2023

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. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment. The facility failed to repair broken wall-mounted toilet tissue holders with shared bathroom, missing baseboard exposing bathroom hot water heating system. The facility also failed to repair missing floor and wall tiles in the bathroom resulting in uneven concrete floor for a shared bathroom. This applies to all 40 residents residing in the facility. The findings include: On 8/26/23 at 10:10 PM, observed room AA's bathroom wall tile with two broken and missing ceramic tile pieces behind the toilet. On 8/26/23 at 10:15 AM, the shared bathroom across from room AA was observed with missing floor tiles (6 inches x 12 inches), leaving an uneven, loose, and inch-deep concrete floor close to the bathroom entrance door resulting in potential tripping hazard. Both shared bathrooms on the first floor close to room AA were observed with a broken wall-mounted toilet tissue holder, exposing sharp edges to residents. On 8/26/23 at 11:00 AM, observed the second-floor shared bathroom on the southwest side with a broken wall-mounted toilet tissue holder exposing sharp edges to residents. On 8/26/23 at 11:05 AM, observed the second-floor shared bathroom on the northwest side with a broken wall-mounted toilet tissue holder exposing sharp edges to residents. On 8/26/23 at 11:10 AM, observed two north unit shared bathrooms (close to room B) with a missing baseboard to the hot water heating system, exposing the inside heating element. On 8/26/23 at 12:45 PM, V6 (Maintenance Director) stated, I started three months ago, and we didn't have a maintenance director when I started. I am working on catching up on the maintenance work. The resident should have a clean and hazard-free environment. I ordered tissue holders and will take care of them on Monday. I will replace the missing tiles in the bathrooms. The facility presented a Homelike Environment (revised in August 2011) policy statement states that the residents are provided with a safe, clean, comfortable, and homelike environment . 5. Notify the interdisciplinary team and or anyone in the maintenance department for any concerns related to the resident's environment, such as broken equipment or changes in the room temperature of the resident (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: 146078 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 146078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahva Care of Stickney 3900 South Oak Park Avenue Stickney, IL 60402 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)