Health inspection·November 30, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that staff donned appropriate personal protective equipment (PPE) when entering an isolation room. The facility also failed to post isolation signs on doors of residents who had been diagnosed with Covid 19. Residents Affected - Few This applies to 3 of 4 residents (R4, R6, and R9) reviewed for infection control in the sample of 13. The findings include: Review of R4, R6, and R9 Covid 19 laboratory results on 11/22/23 documents they all tested positive for Covid 19 on 11/21/23. Review of the facility's isolation order summary show that R4, R6, and R9 are to be on strict contact/droplet isolation related to Covid. R4 and R9 are to be on Contact/Droplet isolation until December 2, 2023, and R6 until December 1, 2023. On November 28, 2023, at 10:35 AM, there were contact and droplet isolation signs posted on the door of R6's room. The sign shows that an N95, gown, gloves and a face shield or googles should be donned before entering the room. V8 CNA (Certified Nursing Assistant) went into R6's room and talked to R6 and turned his call light off. V8 did not put on a gown, gloves, or a face shield/goggles before entering R6's room. On November 28, 2023, at 11:59 AM, R9 had no isolation signage on the door or outside of the room that alerted what kind of isolation the resident was on. On November 28, 2023, at 12:04 PM, R4's room door was closed. There was no isolation signage on the door or outside the room that showed what kind of isolation R4 was on. On November 28, 2023, at 1:05 PM, the Surveyor walked to R9's room with V4 (Infection Preventionist). There was no sign on the door. V4 stated R9 is on isolation for Covid 19. V4 stated she did not know why there was no signage outside the room to show what kind of isolation the resident is on. V4 stated there should be signs outside of resident's rooms to show what kind of isolation the residents are on. The next day on November 29, 2023, at 8:35 AM, the Surveyor was with V1 (Administrator) and R9's room still had no signage outside the door to show what kind of isolation the resident was on. The facility's Covid 19 Transmission Based Precautions policy dated June 2023 shows that gloves and (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: 146067 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 146067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Geneva 1101 East State Street Geneva, IL 60134 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)