Inspection·December 19, 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, labeled, and prepared in a manner which prevents potential contamination. This has the potential to affect all 49 residents living in the facility. Findings include: On 12/13/2023 at 3:05 PM, a tour of the kitchen was conducted. A large clear container containing a soggy salad with dressing on it with a date of 12/9/2023 was in the walk-in refrigerator. On 12/13/2023 at 3:07 PM, in the walk-in refrigerator there was a large clear 8-quart container labeled nuggets and it was dated 12/5/2023. On 12/13/2023 at 3:09 PM, in the walk-in refrigerator there was a clear 8-quart container of some type of noodle with a red sauce on top of it and what looked like some ground meat. There was no date and/or label on it to identify it. On 12/13/2023 at 3:11 PM, in the freezer upon opening the door, one had to push very hard, when the door opened there was large amount of white colored ice approximately 1 foot in length and 2 feet in width. All the boxes on the shelf were covered with white crystals, there was a large industrial box of 4.5 pounds of mini cake donuts, 6 cream pies, a box of 48 ice cream cups of vanilla and a box of 48 ice cream cups wild berry flavored that were all covered in ice crystals. There was a 5 -pound box of tater tots, and a box of 6 banana cream pies covered in white ice crystals, an industrial box of puff pastry, cheese garlic biscuits, case of 210 biscuits, a box of hamburger patties that was open and the meat was exposed to the air, a 14-pound box of garlic toast. On 12/13/2023 at 3:15 PM, in the freezer there was a box of 2.5 pounds of asparagus tips covered in ice. The two fans in the back of the freezer were both covered in ice and the ice condensation was dripping and covering all the boxes in the freezer. On 12/13/2023 at 3:33 PM, in the dry storage area was a large industrial 20-liter container with a white substance that was not dated or labeled. On 12/13/2023 at 3:48 PM, V6 (Dietary Cook) stated, the ice in the freezer has been a problem for a while now. The boxes are always covered in ice crystals. I am not sure how long it has been doing that, but it has been like that for a while. On 12/13/2023 at 3:52 PM, V7 (Dietary Aid) stated, The freezer has been acting up for some time. The dietary Manager is aware of it, and they are supposed to be getting it fixed. It has been like that for a while, but I cannot tell you the exact date. I am not sure how long. On 12/19/2023 at 8:13 AM, V8 (Dietary Manager) stated, I expect all food to be dated and labeled. If the food is not labeled, then I throw it out. We have been having some ice and snow build up in the freezer. I let maintenance know about it and they looked at it and notified corporate so they could order a part. The Food Storage Policy undated provided by the Facility documents, It is the policy of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 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 145897 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Lebanon 1201 North Alton Lebanon, IL 62254 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 (Facility) that any item placed in the refrigerator and freezers must be covered, dated and labeled with a date marking system that tracks when to discard perishable food. [NAME] container with name on it. [NAME] the date the original container is opened or date of preparation. The Resident Rooster dated 12/13/2023 documented the facility had a census of 49 residents. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 3 of 3