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.
Based on observations, interviews, and record review the facility failed to maintain current Food Protection
Manager Certification for Director of Food and Nutrition Services and provide services of a
person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the
potential to affect all 44 residents residing in the facility.
Findings include:
On 05/20/2024 at 11:10 AM V1 (Administrator) provided facility census listing 44 residents residing in the
facility during course of the survey.
On 05/20/2024 at 11:00 AM during initial kitchen tour, surveyor observed V9 (Dietary Aid) cooking lunch.
Surveyor asked V9 what she is making today, V9 responded, I'm making pulled pork and bean burrito,
Mexican rice, and zucchini. Normally, it's me, another dietary aid, and our cook who's also a dietary
manager in the kitchen, but she is not here today.
On 05/20/24 at 2:12 PM surveyor interviewed V1 (Administrator) who stated in summary: V14 (Dietary
Manager/Cook) is not here today, she had loss in the family, is on bereavement leave, and we don't know
when she'll be coming back. V9 (Dietary Aid) is covering for V14. V14 arranged for V13 (Former Cook) to
cover for her during her absence, but I don't know why he's not here today, he was supposed to be here at
7:00 AM this morning.
On 05/20/24 at 3:36 PM surveyor interviewed V13 (Former Cook) who stated in summary: I work in another
facility, I'm a cook there. V14 (Dietary Manager/Cook) notified me this morning (05/20/2024), that she might
need me to cover for her, but I didn't hear anything else from her, so I didn't come this morning. V1
(Administrator) called me later today and asked what time I was coming over; I didn't know they still needed
me, but I confirmed that I'll be coming shortly. I'll stay to cover for V14 until she's back.
On 05/21/2024 at 11:08 AM surveyor observed V13 (Former Cook) sitting in the nook outside of the
kitchen.
On 05/21/24 at 11:27 AM during kitchen tour surveyor observed V9 (Dietary Aid) cooking lunch. Surveyor
clarified with V9 what she cooked since yesterday during abscess of person-in-charge (PIC) with the
required Food Protection Manager Certification, V9 stated I'm cooking chicken teriyaki, rice, and cabbage
today. I cooked all three meals yesterday, breakfast, lunch, and dinner, and breakfast today. I started
cooking lunch today as well, and that's when V13 took over.
(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
05/23/2024
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)
F 0801
On 05/21/24 at 1:13 PM surveyor interviewed V15 (Dietician) who stated in summary:
Level of Harm - Minimal harm
or potential for actual harm
The cook's (V14) license (Food Protection Manager Certification) has been expired for about two months
now. V9 (Dietary Aid) would have to have the Food Protection Manager Certification in order to cook the
food; otherwise, she is not qualified to cook the food.
Residents Affected - Many
On 05/22/2024 at 11:02 AM V1 (Administrator) provided, after multiple requests, V14's (Dietary
Manager/Cook) Food Protection Manager Certification search result which showed V14's certification has
expired on 03/05/2024 and is invalid.
V9's (Dietary Aid) Food Handler Certification issued on 01/22/2023, valid through 3 years from issue date
reviewed. No additional certificates available for V9.
The facility Person-in-charge (PIC) with the required Food Protection Manager Certification policy
unavailable upon multiple requests.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146078
If continuation sheet
Page 2 of 2
