Inspection·August 30, 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, interview, and record review, the Facility failed to ensure the dish machine had the chemical level required for effective sanitation and failed to store food in accordance with professional standards for food service safety. This has the potential to affect all 70 residents residing in the Facility. Findings include: 1. On 8/27/24 at 12:02 PM, V5, Dietary Aid, removed a tray of dishes from the dish machine after the cleaning cycle was completed and placed the tray next to the machine on the clean side of the machine. V5 then placed a tray of dirty dishes in the machine and began another cleaning cycle. When the wash cycle began, V5 placed a sanitizer test strip in the dish water reservoir on the front of the machine. V4, Dietary Manager, was in the room and stated, Not yet prompting V4 to wait before attempting the test. V5 waited until the final rinse cycle began, then placed the strip in the reservoir. The test strip did not change color and remained white. V4 stated the dish machine was tested earlier that morning. On 8/27/24 at 12:15 PM, V4, Dietary Manager, brought a different test strip package into the dish room. She stated they were the sanitizer test strips, because the other strips were not working. V4 placed a test strip in the reservoir during the final rinse cycle. The strip turned light orange which correlated to 100 ppm (parts per million) on the test strip package. V5 stated it was supposed to be 200 ppm. On 8/27/24 at 12:21 PM, V4, Dietary Manager, stated she located a different kind of test strip, because they should be turning purple. V4 placed the strip in the water reservoir during the final rinse, and the strip remained white. V4 stated she would call the maintenance technician who comes monthly, because there is not much sanitizer coming out of the tubing during the rinse. 2. On 8/27/24 at 12:12 PM, There was a box of uncooked pork loin fritters on a shelf directly above a box of cookie dough. There was a box of uncooked beef loin fritters on a shelf directly above another box of cookie dough. There was a box of uncooked beef Philly steak that was placed on top of a box of pizza dough. There was a box of frozen uncooked shrimp on a shelf directly above a box of nutritional shakes. On 8/27/24 at 12:40 PM, V4, Dietary Manager, stated I was thinking it would be ok (to store uncooked animal protein on higher shelves) since they're frozen. On 8/28/24 at 2:30 PM, V1, Administrator, stated she was unable to find the dish machine specifications and may have to order a new user manual. On 8/30/24 at 9:45 AM, V2, Director of Nursing (DON), stated she expects dietary staff to follow all dietary policies. The Facility's Undated Dish Machine Operation Policy documents, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Check the dishwashing machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 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 145993 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coulterville Rehab & Hcc 13138 State Route 13 Coulterville, IL 62237 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 Residents Affected - Many each morning before first set of dishes are to be washed. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. If a chemical sanitizer is used, check the concentration using the correct test tape for type of sanitizer in use. The Facility's Undated Food Storage (Dry, Refrigerated, and Frozen) Policy documents, Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/27/24 documents there are 70 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145993 If continuation sheet Page 3 of 3