Health inspection·February 2, 2024

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained prior to delivering food to residents for three (R1, R3, R4) out of three residents reviewed for dietary services. Residents Affected - Few Findings include: On 1/30/24 at 11:06 AM R1 stated that the food is never warm. On 01/30/24 at 11:25 AM R3 stated that the food is cold occasionally. On 01/30/24 at 1:18 PM R4 stated the food is cold nine times out of ten. R4 stated that she eats her meals in the dining area and the food is always cold and arrives thirty to forty minutes late. R4 stated that she has personally told dietary department about the cold food. R4 reported that once she brought it up the following day, her food was hot or warm, but it returned to being cold after two days. On 1/31/24 at 11:25 AM surveyor observed the dietary staff on tray line. V6 (Dietary Manager) stated that dietary staff will be starting to serve trays for all residents. On 01/31/24 at 12:38 PM, surveyor observed the last meal tray that was handed out to the resident. On 01/31/24 At 12:39 PM, surveyor requested a test tray. Test tray consisted of BBQ Pork Riblette. Surveyor took the temperature of the BBQ Pork Riblette. Temperature came out to be 113.4-degree Fahrenheit. On 01/31/24 at 1:26pm V6 (Dietary Manager) stated that the food temperature when the meal trays leave from the kitchen should be 145 degrees or more Fahrenheit. V6 stated that the food should still hold at the same temperature on the floors. V6 stated that if the food temperature drops below the appropriate temperature, the residents can get sick. V6 stated that the facility has one microwave in the staff break room and another in the kitchen. V6 stated that there are no microwaves on the floors where resident reside. Facility presented documents: 1. Monitoring Food Temperatures for Meal Service(undated): documents in part, Guideline: Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit or higher (check your state specific regulations: some states require 140 degrees Fahrenheit (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: 145482 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 145482 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Village Nrsg & Rhb 5838 North Sheridan Road Chicago, IL 60660 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)