Health inspection·June 2, 2023

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 stored, prepared, and served in a manner which prevents potential contamination and food-borne illness. This has the potential to affect all 87 residents living in the facility. Findings include: 1. On 5/30/23 at 9:51 AM, the ice scoop was inside the ice machine in the second-floor dining room. There was a cooler on top of the ice machine that also had a scoop inside on the ice. On 5/30/23 at 11:34 AM, on the kitchen preparation counter, there was a clear container holding approximately 16 ounces of a white powdery substance that was labeled (Thickener) and was not dated. On 5/30/23 at 11:38 AM in the beverage refrigerator next to the prep counter, there was a 32-ounce bag of walnuts that had been opened and resealed but was not dated. There was a pitcher containing a red liquid that was labeled 4/23 and cranberry. There was a plastic gallon storage bag with a light tan colored creamy substance inside with no label or date. V5 (Dietary Aide) stated, I'm not even sure what that is. On 5/30/23 at 11:42 AM in the small storage closet there were four large, clear bins that were approximately three feet tall each. One contained a white powder and was not labeled or dated. The other three were labeled instant food thickener, oats, and sugar and were not dated. There was a plastic storage bag containing banana cake mix that had been opened but was not dated. On 5/30/23 at 11:45 AM in the walk-in refrigerator there was a container labeled chicken gravy dated 5/20 5/26. V4 (Dietary Manager) stated 5/26 is the date it should have been thrown out. I'll throw it out now. There was a container of an unknown substance that was not labeled or dated. V4 stated, That is pea salad, and it can come out since it's not labeled. There was a shallow pan containing a red liquid covered with plastic wrap labeled SB (gelatin) that was not dated. On 5/30/23 at 11:47 AM in the walk-in freezer, there was a pan with 3.5 pies that were covered with plastic wrap. None were labeled or dated. V4 (Dietary Manager) told V5 (Dietary Aide) to throw it out. There was a banana split in a container from a fast-food restaurant that was not labeled or dated. There was a plastic bag labeled diced potatoes that was not dated, and another plastic bag labeled salmon patties that was not dated. On 5/30/23 at 11:55 AM, V6 (Dietary Aide) was washing dishes in the three-compartment sink. V4 (Dietary Manager) stated, (Testing) is not done as often as we should. You probably know that since I Page 1 of 3 145729 145729 06/02/2023 Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many had to go look for the strips. V4 placed the test strip into third part of the sink with the sanitizing solution. V4 pulled out the strip and compared it to the chart on the test strip tube. V4 stated, It looks like 10 ppm (parts per million) but should be in the 50-100 ppm range. I'm going to say I have the wrong strips or it's not right and I need to call the (maintenance) company about the chemicals. On 5/30/23 at 12:00 PM in the first-floor dining room V7 (Cook) pointed to the refrigerator, and stated, I don't feel like this is cold enough. V4 (Dietary Manager) read the dial on the thermometer inside and stated, It's not. It's 50 (degrees Fahrenheit). Everything in there is going to have to go. On 5/30/23 at 12:40 PM, V8 (Dietary Aide) took a can of cream of mushroom soup out of the cupboard on the first-floor dining room. V8 opened the can, poured contents in a bowl, and placed bowl in the microwave for 60 seconds. V8 began working on other tasks, then stopped microwave with 19 seconds remaining. V8 removed the bowl and gave to V4 (Dietary Manager) who served the bowl to R77. V4 or V8 did not check the temperature before serving to resident. 2. On 5/30/23 at 1:11 PM, obtained temperatures of food from the steam table using a metal calibrated thermometer on the first-floor dining room after the last resident tray was served. The pureed pork measured 98 degrees (º) Fahrenheit (F). The mechanically altered pork measured 100º F. The pureed vegetables measured 99ºF. The French fries measured 87º F. The Facility's Modified Diet List documents three residents were on Dental Soft (Mechanical Soft) Diets (R7, R43, R79) and 3 residents on Pureed Diets (R5, R11, R56). 3. On 6/1/23 at 12:08 PM V6 (Dietary Aide) was serving residents in the second-floor dining room. V6 pulled a dish towel out from her cleavage underneath her shirt with gloved hands and placed it on the side of her neck. V6 then placed the same towel in her pant pocket. V6 did not change gloves but resumed plating food at the steam table and delivered a plate to R79. On 6/1/23 at 9:58 AM, V1 (Administrator) stated she expects staff to follow food service policies. The Facility's Food Storage (Dry/Refrigerated/Frozen) Policy, 2011 Edition, documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Keep potentially hazardous foods out of the temperature danger zone (41ºF - 135ºF, or per state specific regulations). Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Refrigerated storage guidelines to be followed: Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41ºF or lower. Wrap food properly. Never leave any food item uncovered and not labeled. Any food item at greater than 41º for an unknown duration of time, such as during opening of the kitchen, will be discarded immediately. The Facility's Steam Table Serving Temperatures for Hot and Cold Foods Policy, 2011 Edition, documents, Staff will follow the guidelines below when serving hot and cold beverages and food Foods will be served at the following temperatures to ensure a safe and appetizing experience. Meat, Casseroles: 135 ºF to 170 ºF. Vegetables, Potatoes: 135 ºF to 170 ºF. 145729 Page 2 of 3 145729 06/02/2023 Carlyle Healthcare & Sr Living 501 Clinton Street Carlyle, IL 62231

F 0812 The Resident Census and Condition of Residents Form, (CMS 672), dated 5/30/2023 documents there are 87 residents living in the Facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 145729 Page 3 of 3