Inspection·December 26, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent co-mingling of dented food cans with undented ones; failed to ensure that the ice machine is in a clean condition and failed to label, discard left-over food items, and prepared food items according to their food labeling policy and procedure. This failure has the potential to affect all 145-residents eating from the facility kitchen. Findings include: On 12/24/24, at 10:10 AM, during kitchen observation with V1 (Administrator) and V5 (Dietary Manager) the following were observed: In the dry storage room [ROOM NUMBER] LBS banana pudding can and 6.5 LBS diced peaches were observed dented and co-mingled with un-dented cans. V5 stated that I don't usually put them together (stored) but it a is a small dent and it's nothing. V1 who was present at the time stated, they should be removed. In the 2nd dry storage area, a white bucket labelled breadcrumbs noted with no open date and no used by date. In the walk-in freezer, seven (7) individual packed beef paddies with no open date or used by date and not in manufacturers container noted in a bowl. V5 stated it was just a mistake from the dietary staff that it was not labelled. A tray of sliced meat that was identified as Pastrami noted with a preparation date 12/04/24, and no used by date noted which is over 13-days over the seven days allowed. V5 stated that it should be labelled with prep date, but it has a storage life of 9 months like a Frankfurters (high beef). Ice Machine observed in the kitchen area when wiped from inside with a white paper tissue showed blackish and brownish color particle/substances inside the machine. The outside has splashes of whitish substance all over ice machine. V5 stated it should be cleaned once a month, but I can see what you are saying. V5 could not provide a cleaning log and was unable to show the last time it was cleaned. In the refrigerator a large white bowl of puree chicken with open preparation date 12/19/24, and no used by date. Baked salmon fish open date 12/16/24, which is one day over the seven-day allowed. Pureed sweet potatoes with open date 12/08/24, an no used date, which was nine days over the seven days allowed. At 12:50 PM, V5 stated that the new label been use by the kitchen staff is confusing the staff. V5 stated I will have to (educate) staff that all the food that has been prepared and kept in the fridge must be labelled with the date it was prepared and the use by date. V5 stated this is done so that it will not be used after seven days to prevent food borne illness. V11 (Administrative Consultant) who was present at the time stated that this needs to be corrected by V5 through in-services. The facility policy on Storage of Dry Food with no date presented documented that the purpose of the policy is to prevent foodborne illness. Listed procedures includes but not limited to dented cans will be stored separately for pick up. The facility policy titled Food Labelling documented in part that all cooked food items stored in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 2 of 3 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 145532 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Plaza 1426 West Birchwood Chicago, IL 60626 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 0812 Level of Harm - Minimal harm or potential for actual harm the refrigerator should be labeled with the name of the food item, the date it was prepared and the time of day it was placed into refrigerator. cooked food items should be discarded within seven (7) days. The facility policy for Cleaning of Ice Machine documented that ice machine is to be thoroughly cleaned once a month. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145532 If continuation sheet Page 3 of 3