Health inspection·December 14, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify an area of pressure prior to it becoming unstageable in a resident (R27) at high risk for pressure injury. This failure resulted in R27 needing to be hospitalized with osteomyelitis (bone infection) which required antibiotics. This applies to one of three residents reviewed for pressure in the sample of 12. Residents Affected - Few The findings include: The facility face sheet for R27 shows diagnoses to include adult failure to thrive, pressure ulcer of the sacral region and osteomyelitis of the sacral region and was admitted into the facility on 9/15/23 after a hip fracture. The facility assessment dated [DATE] shows R27 to have severe cognitive impairment and requires moderate assistance from staff for all activities of daily living. The facility scale for predicting pressure risks completed on admission, dated 9/15/23 shows R27 to be at high risk. The skin evaluation dated 9/21/23 shows no areas of concern to the sacral area of R27's body. The nursing progress note dated 9/27/23 for R27 shows a note stating R27 [has developed an unstageable pressure injury to her sacrum]. The measurements of the pressure injury were recorded as 4 by 8 CM (Centimeters) with 75% slough (dead cells in the base of a wound) that was yellow and a red perimeter around the wound. On 12/13/23 at 1:10 PM, V3 (Wound Care Nurse) said R27 was admitted to the facility for rehab after a hip fracture. V3 said R27 developed a facility acquired unstageable pressure injury to her sacrum. V3 said R27 was seeing an outside wound clinic for this wound and was sent from the clinic to the hospital when it became infected. On 12/14/23 at 9:00 AM, V3 said she expects the staff to find a pressure injury before it becomes unstageable. On 12/14/23 at 9:15 AM, V2 (Director of Nursing) said a pressure injury should be reported to the nurse before becoming unstageable. On 12/14/23 at 10:03 AM, V9 (R27's Physician) said R27 has a pressure injury to her sacrum and treatment to a wound should begin as soon as it is found. V9 said finding the wound is dependent on the cooperation of the resident and any pre-existing conditions. On 12/14/23 at 10:17 AM, V11 (Certified Nursing Assistant) said R27 is always compliant with her Page 1 of 13 146166 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0686 care. Level of Harm - Actual harm On 12/14/23 at 11:00 AM, V7 (Registered Nurse) said a wound should be found by staff prior to it becoming an unstageable wound. V7 said R27 is compliant with her care. Residents Affected - Few The facility assessment dated [DATE] for R27 shows no rejection of care has been observed. The Physician Progress note dated 11/15/23 shows R27 was seen after her re-admission into the facility after a hospital stay. The note shows she was treated for an infected pressure skin injury and osteomyelitis to her sacral area pressure injury. R27 is to continue with intravenous antibiotics. The facility care plan dated 9/18/23 shows to monitor/document/report any changes in skin status. The facility policy with a revision date of April 2018 for pressure ulcer/skin breakdown shows nursing staff will assess and document a resident's significant risk factors for developing pressure ulcers The nurse will describe and document the following: full assessment of pressure sore, pain assessment, resident's mobility status 146166 Page 2 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was assessed for safety prior to the use of a motorized wheelchair for 1 of 2 residents (R6) reviewed for safety in the sample of 12. This failure resulted in R6 being sent to the emergency room and receiving 30 stitches to the right lower leg. The findings include: R6's face sheet printed on 12/14/23 showed diagnoses including but not limited to dementia, cognitive communication deficit, altered mental status, anxiety, osteomyelitis (bone infection), absence of right toe, foot pain, and history of falls. R6's facility assessment dated [DATE] showed moderate cognitive impairment. The assessment showed substantial/maximal staff assistance needed for toilet transfers and the use of a walker for ambulation. R6's activities of daily living care plan showed an intervention dated 11/17/23 for: TRANSFER-The resident is able to transfer with 1-assist, gait belt, walker. R6's impaired cognitive function care plan showed an intervention dated 11/26/23 for: Cue, reorient and supervise as needed. On 12/13/23 at 8:50 AM, R6 was lying in bed and covered with a light blanket. R6 was awake but sleepy. R6 was slightly confused and refused to be interviewed. At 10:43 AM, V17 (R6's daughter) was at the bedside and R6 was asleep. V17 stated R6 had a recent toe amputation and is on IV antibiotics for an infection. V17 stated R6 had a motorized wheelchair in her room for a few days and accidentally ran it into the side of the bed. V17 said the right lower leg was ripped open and she had to go to the emergency room for stitches. V17 said R6 is somewhat confused at times, but especially recently, due to the toe amputation and medications being given to treat the infection and pain. On 12/14/23 at 10:36 AM, R6 was seated in her room next to her bed. R6 lifted her right pant leg and a C-shaped area with multiple sutures was observed on the right lower leg. A baseball size dark, purple bruise was covering the area. The leg wound was at the same level as the metal mattress platform on her bed. R6 was asked what happened and stated she took herself to the bathroom using a motorized wheelchair. R6 said she got off the toilet and pushed the button on the wheelchair. R6 said she ran super hard into the side of her bed and hit a metal rail. R6 said she had been using the wheelchair for a couple of days, including back and forth to the group dining room. R6 said her daughter brought it in for her and the staff knew she was using it. R6's progress note dated 12/6/23 stated: At 19:25 (7:25 PM) heard resident scream. CNAs and RN rushed to check on resident and noted resident on motorized wheelchair next to bed, stated she hit her right leg on the bed. Resident just came out of bathroom, stated she ran into the bed while using motorized wheelchair. Resident (complains) of severe pain to right shin. When checked blood gushing out on a laceration. Applied pressure to stop bleeding. Resident screaming in pain, does not want anybody look under her pants due to tightness of clothing rubbing into wound. RN needed to cut pants open to look at injury. Noted large flap of skin and bleeding a lot. Applied pressure to stop bleeding. Notified MD and ordered for resident to be sent to hospital for eval and treat. 911 was called for transport. Daughter (name omitted) and notified of incident. DON/ADON notified of incident. 146166 Page 3 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Paramedics took resident to hospital at 19:45 (7:45 PM). Level of Harm - Actual harm On 12/13/23 at 2:47 PM, V12 (Certified Nurse Assistant/CNA) stated R6 rammed her motorized wheelchair into the side of her bed and needed sutures. V12 said she had no idea how long it was in her room or why she was using it. V12 said R6 was able to walk with one assist prior to the incident and had no need for a wheelchair. Residents Affected - Few On 12/13/23 at 2:59 PM, V13 (CNA) stated he had no knowledge of a motorized wheelchair being used by R6. On 12/14/23 at 8:20 AM, V15 (Occupational Therapist) stated R6 should not be using a motorized wheelchair. She (R6) had one in her room that her daughter had brought into the facility and R6 ran into the bed with it. V15 said she thought the chair had been in the room about 24 hours before the incident occurred. V15 said residents need an assessment done prior to use to ensure they can operate it safely. V15 said R6 should have definitely been trained on it first. V15 said the wheelchair was taken away as soon as the therapy department found out about the incident. V15 said R6 is sleepy and not always alert. V15 said R6 is confused at times and cannot be wheeling herself around safely. V15 said R6 can stand and pivot therefore there was no need for a motorized wheelchair. V15 said it would not have been recommended for use until it was determined she could operate it safely and that has never been done. V15 said it is not appropriate for R6 to use a motorized wheelchair now or prior to the incident. R6's family just brought it in one day and she was never assessed on it. On 12/14/23 at 8:35 AM, R6's motorized wheelchair was in the corner of the therapy gym. A piece of paper was taped to the back of it with handwritten instructions on how to use the chair and a contact phone number for the family member. V15 stated the paper was put there by her family member when the chair came it. V15 said it is irritating the nursing staff never told the therapy department she had it in the room. She needed training on it before they let her use it. On 12/14/23 at 10:47 AM, V17 (R6's daughter) stated she did bring the motorized wheelchair in for her mother. V17 stated R6 was able to get herself in and out of it alone. V17 said it was in R6's room for about one week. R6 used it several times and even went out on a doctor's appointment in it. V17 said her and another family member showed R6 how to use it. V17 said they left an instruction manual for the staff to use. V17 said she was told staff would be sure to tell the therapy department she had it and also show R6 how to use it. V17 said she was not sure if that was ever done, and the wheelchair has been taken out of the room since the incident. V17 said the staff all knew R6 had it. The wheelchair was in her room and in plain sight. On 12/14/23 at 10:57 AM, V16 (Physical Therapist) stated R6 is very hazy and lethargic. She would not be able to operate a motorized wheelchair safely. R6 has safety deficits, is weak, and lethargic at most times. Residents need to be assessed first by the therapy department. Check off forms are used to assess for safety going forward, backward and turning. Residents need to be assessed for the ability to judge distances and obstacles. They need to be able to get on and off it correctly. The assessment ensures the resident is safe to use the motorized chair appropriately. V16 stated R6 was never assessed prior to her using the chair and it was never reported to the department that she had it in her room. V16 stated R6 was physically able to transfer in and out of a chair by herself, but not mentally able to do it safely by herself. On 12/14/23 at 11:17 AM, V2 (Director of Nurses) stated the incident with R6, and the chair never should have happened. Staff have no idea how long the motorized wheelchair was in her room prior to 146166 Page 4 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Level of Harm - Actual harm Residents Affected - Few the incident. It is not appropriate for family to just bring in equipment as they feel. There is the risk the resident may not be ready to operate it. R6 was never assessed or trained to use it safely before she jumped on it. It should never have been left in the room and staff should have removed it. R6 was never reviewed to use it safely. Nursing staff should have been aware it was in there. Nursing probably just assumed therapy okayed it. No one realized she would just jump on it and take off. R6's emergency room note dated 12/6/23 at 9:04 PM states: Patient presents from (facility name), was in her electric wheelchair when she lost control and hit the bed with her right shin. EMS reports an approximate 6-inch avulsion to the right shin. R6's most recent skin/wound note dated 12/13/23 at 8:00 AM showed: 1. Dressing changed to RLE (right lower extremity) laceration C shaped 17 cm (centimeters); area around the sutures/laceration gently cleansed with wound cleanser and pat dry. Dry gauze placed and secured with paper tape. No drainage, no c/o pain, no odor. Sutures in place. Peri wound with ecchymosis appears fragile. Currently the flap appears to be adhering and viable. The facility's Motorized Mobility Device (MMD) Use in Health Centers policy revision dated 10/31/20 states under the resident assessment due to medical condition section: A. In the event a resident has a medical condition that would interfere with the resident's ability to operate a MMD, nursing or therapy team members, including therapy vendors providing services to the resident, in consultation with the administrator, shall perform an assessment to determine whether the resident demonstrates evidence of sufficient skills/ability to follow all community safety rules and operate the MMD safely. The assessment shall be included in the resident's medical record. The facility was unable to provide a Motorized Wheelchair/Cart Skills Assessment form for R6. 146166 Page 5 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure peri care was performed in a manner to prevent cross contamination for 1 of 1 resident (R100) reviewed for incontinence in the sample of 12. The findings include: R100's computerized face sheet printed on 12/13/23 shows diagnoses including but not limited to heart disease, malignant breast and liver cancer, chronic kidney disease, diarrhea, and urinary tract infection. R100's facility assessment dated [DATE] shows no cognitive impairment and staff supervision or touching assistance required for toileting hygiene. The same assessment shows R100 is always incontinent of urine and bowel. R100's December 2023 Physician Order Sheet (POS) shows an order start dated 12/11/23 that states: Lomotil tablet 2.5-0.025 milligram (Diphenoxylate-Atropine) Give 1 tablet by mouth every 6 hours as needed for diarrhea. R100's POS shows an order start dated 12/6/23 that states: Azo tabs oral table (Phenazopyridine HCI) Give 2 tablets by mouth as needed for urinary pain for 3 days twice daily. On 12/12/23 at 1:45 PM, R100 was seated on the toilet in her room. R100 said she has been having terrible diarrhea lately and her chemotherapy medication is the cause. R100 said her buttocks skin is sore and irritated from having to go the bathroom so often. R100 said she needs staff to help clean her and put on a protective cream after each episode. At 1:47 PM, V14 (Certified Nurse Aide) entered the bathroom and said R100 has been having watery diarrhea for several days. She needs frequent toileting, and we use an extra absorbent pad inside the brief to keep her skin drier. V14 donned gloves and assisted R100 to a standing position. V14 used peri-wipes to clean R100's buttocks then wiped the vaginal area. V14 wore the same diarrhea contaminated gloves to wipe the vaginal area. V14 applied a barrier cream to R100's buttock then put a fresh brief on her. V14 pulled up her pants and assisted her back into the room recliner. V14 laid a blanket across her lap, then placed the call light, tissues, and coffee cup within reach. V14 was still wearing the dirty gloves. V14 bagged up the garbage in R100's bathroom. V14 exited the room with the same diarrhea contaminated gloves on, walked down the hallway, and coded herself into the soiled utility room to dump the garbage bags. On 12/14/23 at 9:25 AM, V2 (Director of Nurses/Infection Control Preventionist) stated gloves need to be changed after peri care is performed and before a new brief is put on. Aides should be changing gloves between dirty and clean areas. V2 said dirty gloves should never be worn when exiting a resident room. Dirty gloves can cross contaminate clean items, clothing, and skin. It is an infection control concern. Germs can pass from one resident to another resident. Peri care should always be done from the front to the back. Feces can contaminate the urinary tract and cause infections. The facility's Perineal Care policy revision dated 2/2018 states under the steps for procedure section: 1.) b.) Wash perineal area, wiping from front to back . 10.) Remove gloves and discard into designated container. The facility's Glove Use policy dated 2019 states: Sterile gloves and examination gloves are removed: a. As soon as practical when contaminated. d. Before touching uncontaminated surfaces or other area of the same resident's body that may be uncontaminated. 146166 Page 6 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician order was obtained and a care plan was in place prior to oxygen administration for 1 of 1 resident (R96) reviewed for oxygen in the sample of 12. Residents Affected - Few The findings include: R96's face sheet printed on 12/13/23 showed diagnoses including but not limited to acute respiratory failure, acute pulmonary edema, atrial fibrillation, shortness of breath, and dependence on supplemental oxygen. The face sheet showed an admission date of 12/3/23. R96's facility assessment dated [DATE] showed the use of continuous oxygen on admission and within the last 14 days. On 12/12/23 at 10:44 AM, R96 was seated in a wheelchair in her room. Oxygen was running via nasal cannula into her nose. The oxygen setting was at 1 liter per minute. At 12:24 PM, R96 was asleep in bed. The oxygen setting was at 1 liter per minute. On 12/13/23 at 8:36 AM and 12:05 PM, R96 was in bed and the oxygen was running at 2 liters per minute. On 12/14/23 at 8:40 AM, V8 (Registered Nurse) was applying a portable oxygen tank to the back of R96's wheelchair and set the oxygen level to 2 liters per minute. V8 stated she sets the oxygen at the level stated on the daily paper report or per the physician order. This surveyor and V8 viewed the daily report and electronic physician orders together. There were no orders for the use of oxygen. V8 said R96's oxygen needs to be running at the correct level. Too low can cause her to desaturate and not maintain 95% oxygen saturation levels. Too high can over oxygenate her. V8 said there should be orders and a care plan to show how to care for the oxygen system. On 12/14/23 at 9:20 AM, V2 (Director of Nurses) stated oxygen is a medication and needs a physician order. Orders should include the rate, if continuous or intermittent, liters, and oxygen saturation range. Orders should include how to care for the tubing system. V2 said a care plan is a good idea too. It directs staff how to provide that care. Lack of orders and a care plan have the potential for infection control issues and can affect the resident's overall health. Respiratory status can be negatively impacted. V2 reviewed R96's electronic medical record and stated she did not see any orders or care plan for R96's oxygen administration. The facility's Oxygen Administration policy revision dated 10/2010 states under the preparation section: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 146166 Page 7 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to document and maintain an accurate count of narcotic medications for 1 resident (R6) in the sample of 12 and 1 resident (R95) outside of the sample reviewed for pharmacy services. The findings include: On 12/12/23 at 9:30AM, V8 (Registered Nurse) administered Norco 5/325mg to R6. V8 documented the medication administration on R6's narcotic count sheet but did not record the administration on R6's medication administration record. On 12/14/23, R6's medication administration record contained no documentation that V8 had administered any Norco to R6. (The only documented dose of Norco for R6 on 12/12/23 was 7:15PM) On 12/13/23 at 1:44PM, Surveyor performed a narcotic count with V8. R95's Norco 5/325mg narcotic count sheet showed R95 had 52 doses remaining. R95's Norco pill card showed 50 tabs remaining. V8 stated she must have forgotten to sign out a dose she gave to R95 earlier in the day. On 12/14/23 at 9:23AM, V8 stated, When we administer any medication to a resident, we are to document it in the medication administration record so there is confirmation that the medication was given. When we administer narcotics, we also have to sign out on the resident's narcotic record, so our counts are accurate. If we don't do both of these steps, our count could be off, and we also can't be sure when a resident last received their medications and that could lead to a medication error. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, When staff are administering narcotics, they should first double check the count sheet to make sure the count is correct. After confirming correct count, they should document the amount removed on the count sheet, administer the medication, and then sign off on the resident's electronic medication administration record (EMAR). If a medication is not signed off on the EMAR, that's a problem because we need to know when the medication was last administered. If all of these steps are not followed, there could end up being a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . The facility's policy titled, Medication Administration dated 12/1/21 showed, Controlled Substances: Each medication is to be accounted for according to the Agency's procedure as it is removed from the container and before it is administered to the client. 146166 Page 8 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. This applies to 1of 5 residents (R145) outside of the sample reviewed for medication administration. Residents Affected - Few The findings include: R145's medication administration record for December 2023 showed R145 is to receive memantine 5mg, metformin extended release 500mg, and metoprolol 50mg at 9AM and 5PM. On 12/12/23 at 10:57AM, V7 (Registered Nurse) administered R145's memantine, metformin, and metoprolol. (1 hour and 57 minutes past the scheduled administration time). V7 stated she got a late start on her medication pass today because they were short staffed, and she had to help with patient care. On 12/14/23 at 11:44AM, V2 (Director of Nursing) stated, I wasn't aware that we were short staffed on Tuesday. I would expect the nurses to reach out to me if they are having trouble getting their medications administered in a timely manner or if there are staffing concerns. If a medication is not given within 1 hour before or after the scheduled administration time, then that is technically a medication error. The facility's policy titled, Administering Medications dated April 2013 showed, Medications shall be administered in a safe and timely manner, and as prescribed .4. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 146166 Page 9 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store medications per manufacturer's directions and facility policy for 2 of 2 residents (R11, R37) outside of the sample reviewed for medication storage. The findings include: R11's physician's orders for December 2023 showed R11 receives Lantus 23 units daily. R37's physician's orders for December 203 showed R37 receives Insulin Glargine 38 units every evening. A review of V8's (Registered Nurse) medication cart on 12/13/23 at 1:44PM showed R11's Lantus pen was unopened with a label stating, Refrigerate until opened. R37's Insulin Glargine pen showed the insulin pen had been accessed and had no opened or use by date. V8 stated she believes that insulin is supposed to be refrigerated until use and that all insulin that has been opened is to have an open and use by date on it per facility policy. On 12/14/23 11:44AM, V2 (Director of Nursing) stated, Unopened vials of insulin should be refrigerated until they are put into use per manufacturer's directions. It should be dated with open date & use by date to ensure we discard it after 28 days. If these directions are not followed it could affect the efficacy of the insulin. The facility's policy titled, Medication Labeling and Storage dated February 2023 showed, The facility stores all medications and biologicals in a locked compartment under proper temperature, humidity and light controls .6. Medications requiring refrigeration are stored in a refrigerator locked in the medication room at the nurse's station or other secured location .5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorts or longer date for the open vial. 146166 Page 10 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to provide evening snacks for 5 residents (R4, R19, R25, R26, R28). This applies to 5 of 5 resident's outside of the sample reviewed for frequency of meals and snacks. The findings include: On 12/13/23 at 10:00AM, A resident council meeting was held with R4, R19, R25, R26, and R28 who have no cognitive impairment. All resident's stated they do not receive snacks at the facility, and they have not been offered snacks prior to going to bed at night. All residents stated they are not diabetic and do not require any special diet that would prevent them from getting a snack. On 12/13/23 at 1:42PM, V2 (Director of Nursing) stated, We have a snack list posted in the dining area for resident's that want to ask for a snack. We don't routinely pass out snacks or offer them. They know they are there and should ask for them if they want them. We do pass water every shift though. If a resident has an order to receive a snack, then we offer them. I have never heard of a facility offering snacks to residents. The facility's policy titled, Frequency of Meals dated December 2009 showed, Each resident shall receive at least three meals and at least one snack daily .1. The facility will serve at least three meals or their equivalent daily at scheduled times .The following mealtimes have been established by our facility for residents: Breakfast 7:30am-9:30am, Lunch 11:30am-1:30pm, Dinner 4:30pm-6:30pm .6. Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment . 146166 Page 11 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was kept off the floor, failed to maintain food storage areas in a clean and orderly manner, failed to ensure ice cream freezer temperature was monitored, failed to maintain cleanliness of ice cream freezer, and failed to discard expired food items. These failures have the potential to affect all residents in the facility. The findings include: The facility's resident roster dated 12/12/23 showed 42 residents currently residing in the building. On 12/12/23 at 9:58AM, The facility's refrigerator had multiple pans of food and boxes of food stacked on top of each other. There were boxes filling all racks of the refrigerator, some boxes filled with plastic bags that were packed tightly into each box. Due to the large amount of food stored within the refrigerator, surveyor was unable to move food around to determine what food was present in the refrigerator. A pan of meat was also located on the floor of the refrigerator under a cart. On 12/12/23 10:05AM, The facility's freezer had 12 boxes of food placed on the floor and the shelves were piled with boxes of food so tightly and disorganized that surveyor was unable to move boxes around. On 12/12/23 at 10:12AM, The facility's dry storage room had 2 bags of corn tortillas with an expiration date of 10/19/23, an open container of cherries with no open or use by date, and 6 cans of diced peaches sitting directly on the floor. On 12/12/23 at 10:20 AM, The facility's ice cream freezer area had a bottle of raspberry sauce with an expiration date of 3/23/23 and a bottle of caramel topping with an expiration date of 11/9/23. Surveyor requested to visualize the thermometer for the ice cream freezer and V5 (chef) had to remove 8 containers of ice cream to locate the thermometer that had a large chunk of ice cream stuck to it on the bottom of the freezer. The ice cream freezer had several large scoops of ice cream sitting on the bottom of the freezer surround by crumbs, ice buildup around the entire top portion of the freezer, and large areas of dried, previously melted ice cream located all around the top of the freezer. On 12/12/23 at 10:30AM, V5 stated the temperature for the ice cream freezer is not checked routinely and there is no temperature log for it. V5 stated the kitchen staff have a cleaning list for their respective areas but the ice cream freezer is not on any of those lists. V5 also stated that he is aware that the food storage areas area a bit of a disaster and that is something he will be working on in the near future. The kitchen cleaning schedules were reviewed and showed no schedule for cleaning the ice cream freezer. On 12/12/23 at 11:40AM, V6 (Interim Dietary Manager) stated, I have been the interim director for about a week. I am aware that there are issues in the kitchen and storage is on the top of my list to start working on. We don't have a lot of room for food storage but it's an absolute mess in there 146166 Page 12 of 13 146166 12/14/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many right now. There should not be any food or pans on the floor as that is not our policy for food storage. I agree that the food storage situation is chaotic, and I have no idea how they even find anything in there or keep the foods rotated for a first in first out rotation. The ice cream freezer should have the temperature checked every day because that is a dairy product and if it's not kept at the right temperature, it could cause illness potentially. We should be cleaning that freezer out at least weekly and as needed when we identify concerns. The facility's policy titled, Storage of Food and Supplies dated 12/15/2020 showed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date .discard food past the use-by, sell-by, best-by, or enjoy-by date .arrange items neatly on the shelves in the same order as the inventory book .date and rotate items; first in, first out. Discard food past the use-by or expiration date .Refrigerated foods: Space foods on shelves to allow for air circulation. Do not crowd food .store items 6 above the floor, 2 from the walls, and 18 from the ceiling, consistent with local food protection codes .keep all food products at least 6 inches off the floor .Dry Storage: Store dry and staple items at least 6 above the floor and 2 from the walls and 18 from ceiling. 146166 Page 13 of 13