Inspection·February 15, 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, and interview the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen and that food was stored, prepared, and served under sanitary conditions. This has the potential to affect the 138 residents living in this facility. Findings include: On 2/13/2024 at 9:12 AM, in the refrigerator there were 12 cases of milk stacked in crates containing 4 gallons in each milk in each container stacked 3 crates high. The milk was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the refrigerator, next to the milk was a pull-out cart that had a large clear container of cabbage and a clear plastic bag of green onions. Both items were cut into small pieces, and there was no date and/or label. On 2/13/2024 at 9:18 AM, in the refrigerator there was a large industrial metal pan that had turkey inside of it, but the plastic was missing partially on the one side and the turkey meat was being exposed to the air in the refrigerator. On 2/13/2024 at 9:15 AM, in the freezer area there was a large industrial 13-pound box labeled breadsticks that was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the freezer on the opposite side of the breadsticks was a large industrial box labeled white meat sitting directly in the floor. On 2/13/2024 at 9:18 AM, V12, Dietary Manager stated I would expect all items to be dated and labeled and no items to be sitting directly on the floor. I would expect all items to be completely covered. I just pushed the cabbage on the cart back into the refrigerator when I heard that you all were in the building. The cabbage and onions are fresh, I am cooking them today, but it does not have a date and or label. Everything should be dated and labeled. On 2/13/2024 at 9:22 AM, in the dry storage area there was large industrial bin of white substance that had the scoop inside touching the powdery substance. On 2/13/2024 at 9:24 AM, V12 stated, I would not expect the scoop to be inside the container, and it should be hanging and not inside the thickener. (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: 145733 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 145733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jerseyville Manor 1251 North State Street Jerseyville, IL 62052 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)