Health inspection·April 28, 2022

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 date opened food, date food received or thawed, date thawed health shakes, clean the convection oven, ensure a covering for a food cart to keep food warm, and failed to wear a hair net in the kitchen. These failures have the potential to affect all 61 residents except R32 who is NPO (nothing by mouth). Findings include: Facility Food Receiving and Storage policy, revised 2017, documents, All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date). Facility Sanitization policy, revised 2008, documents, The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Facility Resident Council minutes, dated January 20, 2022, September 16, 2021, August 19, 2021, July 15, 2021, June 24, 2021, May 20, 2021, and April 22, 2021, document Resident Council complaints on cold food. On 4/26/22 at 10:15am, R25 verified there were complaints on cold food at the resident council meetings. On 4/26/22 between the hours of 10:00am and 11:00am, a tour of the kitchen was conducted with V5 Dietary Manager/DM. In the drink cooler there were four 64 fluid ounce apple juice containers opened and undated; 59 four fluid ounce containers of Ready care vanilla shakes no sugar added that had no expiration dates, no received dates, and no pull dates from the freezer. The outside of the Ready care vanilla shakes documents, Storage and handling- Store frozen. Thaw under refrigeration 40 degrees or below. After thawing, keep refrigerated. Use within 14 days after thawing. There was a note posted in the cooler hanging on a shelf that documents Put date on all liquids when opened. At that same time, V5 DM stated I posted the paper in the cooler because we have had a problem with staff dating things that are opened. It is a work in progress. V5 verified the apple juices had no open dates, and the vanilla shakes had no dates on them. The cooks' cooler had a five-pound sour cream container opened (half empty) and undated; a whole roast beef (no weight) in plastic packaging had no expiration date or pull date noted on the package. At that same time, V5 stated, I don't know when we had roast beef last, but I see no dates on the beef and the sour cream needs an open date. I will have to talk to staff. I have had a lot of things I have been working on getting fixed here. Facility single convection oven had a large amount of brown sticky substance on the sides and (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: 145697 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 145697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knox County Nursing Home 800 North Market Street Knoxville, IL 61448 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)