Inspection·July 27, 2023

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that two of their dietary employees who handle and prepare food, were current with the food handlers training certificate program and failed to follow their facility policy on food handling. This failure has the potential to affect all 42 residents who reside at the facility, whose meals are prepared by dietary staff. Findings include: Reviewed facility staff roster provided by V1 (Administrator) which listed V10 as a dietary aide and V11 as a housekeeper/cook. Reviewed the dietary department staff schedules provided by V5 (Human Resources/Scheduler) from June 2023 to current which listed both V10 and V11 as current dietary staff. On 07/24/2023, requested food handlers' certificates for all dietary staff from V1 (Administrator). Certificates not provided for V10 (Dietary Aide) and V11 (Housekeeper/Cook). At 2:30 PM, V1 said that he was waiting for V10 and V11 to provide him with a copy. On 07/26/2023 at 11:10 AM, V1 (Administrator) provided food handler certificates for V10 (Dietary Aide) and V11 (Housekeeper/Cook) that both showed issued/completion date of 07/24/2023. On 07/26/2023 at 12:33 PM, V3 (Dietary Manager) verified who all the current employed dietary staff were which included V10 (Dietary Aide) and V11 (Housekeeper/Cook). V3 then said V10 and V11's food handler certificates both expired last week and were both told to retake the course as soon as possible. Requested the expired certificates for V10 and V11 from V3 who said, they threw them away. On 07/26/2023 at 12:38 PM, V5 (Human Resources/Scheduler) said she asked V10 (Dietary Aide) for her food handler certificate on 07/24 but V10 said she couldn't find it. V5 then said that V11 (Housekeeper/Cook) went from housekeeping to the cook position on 05/29/2023 and that V5 had requested V11's food handler certificate multiple times since this date but it was never provided to her. V5 (Human Resources/Scheduler) said she asked V11 for her certificate again on 07/24/2023 and was then told by V11 that her license expired in 2021. At 1:08 PM, V5 said V10 (Dietary Aide) was rehired to the facility on [DATE], then provided a copy of V10's previous food handler certificate with expiration date listed as 03/09/2023. On 07/26/2023 at 1:16 PM, V11 (Housekeeper/Cook) said her previous certificate expired between 2021 and 2022 so she threw it away. She then said she started working in kitchen on 05/29/2023 and both (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 07/27/2023 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)