Health inspection·May 14, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to ensure a resident was not served a food item to which the resident had an allergy. This applies to 1 of 3 residents (R1) reviewed for food concerns in a sample of 9. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including allergy status to unspecified drugs, medications, and biological drugs, irritant contact dermatitis, and disorder of skin subcutaneous tissues, asthma, heart failure, chronic obstructive pulmonary disease, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 04/21/2025 showed R1's cognition was severely impaired and required one to two maximum assistance for activities of daily living. R1's allergy status upon admission dated 04/02/2025 showed R1 was allergic to peach and lactose, and R1's face sheet also listed R1's allergy under other information. On 05/13/2025 at 9:00 AM and on 05/14/2023 at 8:20 AM, V10 (R1's family) said the facility served peach on her lunch tray, and she caught it and reported it to the staff. V10 said R1 gets severe skin irritation and her throat closes, and she would have died. The resident/family concerns report dated 04/04/2025 showed that peaches were on R1's meal tray, and R1 is highly allergic to peaches. On 05/13/2025 at 2:39 PM, V11 (Dietary Manager) said the kitchen staff should set up the meal tray by referring to the meal card where food allergies are documented, and the staff who is delivering the tray also should verify that residents are not receiving any food they are allergic to, so that potentially serious consequences could be avoided. V11 said the staff missed it on 04/04/2025 for R1. On 05/13/2025, at 1:00 PM, V8 and V9 (Dietary Aides) said they set R1's lunch tray on 04/04/2025, and it was a very busy day, and they missed it. On 05/13/2025 at 2:00 PM, V2 DON (Director of Nursing) stated there are clear instructions on the meal card and staff should followed the meal card and verify before setting up and delivering the meal tray to residents to avoid any serious consequences. The facility's policy and procedure titled Dining and Food Preference and dated 10/2022 showed that the diet requisition form will notify the dining services department of food allergies upon (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 05/14/2025 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)