Inspection·September 23, 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 provide a clean environment in good repair for two of three units in the facility. This failure has the potential to affect all 16 residents residing on the first floor and all 43 residents residing in the facility. Findings include: 9/18/2024 at 9:30AM upon entering the facility for an onsite complaint investigation and walking to the basement with V1 (Administrator), surveyor observed lots of peeling paint on the walls leading to the therapy room and towards the bathroom in the basement. There are also two rusted pipes on the wall with peeling paint and a big hole on the wall leading to the ceiling inside the therapy room. 9/18/2024 at 11:18AM, surveyor conducted observation of the shower room on the first floor with V3 (CNA) and noted a large area with dark materials on the ceiling, the wall was noted to be peeling with holes, and there were patches of peeling paint all over the bathroom wall. V3 stated there is leakage from the second-floor bathroom when they are giving showers, she thinks that is where the dark deposits on the bathroom ceiling is coming from, V3 added that she has not really paid close attention to it, but it does not look good. 9/18/2024 at 12:03PM, V1 (Administrator) stated that the dark area in the ceiling of the first-floor bathroom is not mold, it is caused by leakage from the second-floor bathroom. V1 stated they usually have it (ceiling) painted but have not done so lately. V1 stated the last time fire safety came to the facility, they saw it and gave them verbal instruction to fix it. V1 stated that they are aware of the repairs and paint needed in the facility. V1 stated the owners repaired the roof to prevent leakage all over the facility. V1 stated they are currently dealing with a plumbing problem and the plan is to start with the inside repairs in November. 9/18/2024 at 12:05PM, V6 (Maintenance Director) was showing surveyor the dark deposit area in the first-floor bathroom ceiling, stating that he just scraped it, and it is not mold. V6 stated it is because of leakage from the second-floor bathroom. V6 added that fire safety told him to fix it when they were in the facility in March. V6 stated he has not had a chance to do it. Surveyor asked V6 if they ever tested the deposits for mold, and he (V6) stated no. A document presented by V1 (Administrator), (undated), titled general maintenance policy states as follows: the facility shall maintain the building in good repair, safe and free of hazards. The same document stated in part, 1. The maintenance director shall make physical plant repair as needed. 4. Maintain the interior and exterior finishes of the building as needed to keep it (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 09/23/2024 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)