Health inspection·June 18, 2024

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 handle food in a manner that prevents potential contamination, failed to restrain hair and perform hand hygiene during food service. This failure potentially affects all 83 residents residing in the facility. Findings include: 1. On 6/13/24 at 8:15 AM V3, Certified Nurse Aide, CNA, was feeding R1 breakfast. V3 was holding the toast with her bare hand and trying to get R1 to take a bite. V3 put the toast down multiple times and then attempted again with her bare hands. 2. On 6/13/24 at 11:25 AM, the kitchen was entered to observe the noon meal preparation. V13, Dietary Aide, was wearing a head band with a ponytail. V16, Corporate Dietary Supervisor, was wearing a hairnet that is positioned in the middle of her head. V16 also had a long side bang that was not restrained in the hairnet as it is lying on the side of her face. Neither V13's or V16's hair were restrained. During meal preparation V13 was observed to be preparing the residents trays with silverware, the drinks, and side dishes, V12, Cook, would then place main course, and then V13 would place the tray onto the serving cart. V13 was observed to scratch her head and face multiple times without washing her hands in between. 3. On 6/13/24 at 12:18 PM, V2, Director of Nurses, was holding R13's bologna sandwich with her bare hands and tearing it in half. V2 then hands the half of sandwich to R13. V2 then went to R14 and picks up her grilled cheese and takes the crust off the sandwich. 4. On 6/13/24 at 12:25 PM, V17, CNA, was assisting R15 with her lunch. V17 with bare hands picked up the grilled cheese sandwich, dunked it into the tomato soup, and then fed it to V17. On 6/14/24 at 3:30 PM, V1, Administrator, stated all kitchen staff should be wearing hair nets, washing their hands when needed, and wearing gloves when appropriate. V1 further stated that staff should not be touching residents' food with their bare hands. The policy Hand Washing, dated 9/1/21, documents, 4. When to wash your hands, Wash your hands as often as possible. It is important to wash your hands: Before starting to work with food, utensils, or equipment. It continues, After touching skin, face or hair. The policy Staff Attire, dated 9/1/21, documents, All staff will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. (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: 145273 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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)