Health inspection·June 23, 2022

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide residents properly cooked food for 1 of 20 residents (R20) reviewed for food temperatures in the sample of 18. Residents Affected - Few Findings include: R20's Care Plan dated 2/29/2020 documents, Regular Diet, Mechanical Soft texture, thin consistency. On 6/22/2022 at 11:32 AM, during the lunch service V8, Dietary Aid, prepared a plate of mechanical meat for R20 and it was served to her at the dining room table. On 6/22/2022 at 11:28 AM, the mechanical meat temperature was taken with a metal, calibrated thermometer and registered 121.1 degrees Fahrenheit (F). On 6/22/2022 at 11:27 AM, during the lunch service the lid to the mechanical meat was not hot to the touch. On 6/22/2022 at 11:00 AM, the Food Log Temperature Book was reviewed and does not document any temperatures were taken for the mechanical meat. The area was blank. On 6/23/2022 at 9:35 AM, V7, Dietary Manager, stated, After we talked (V8) went and added the temperature to the mechanical meat food log book. I was there with you and it was blank and not filled out when you asked to see it. I am not sure where she got that temperature but I know it was not correct. On 6/22/2022 at 11:30 AM, V8, Dietary Aid, stated, I did not take a temperature on the mechanical meat, only the regular meat, and it was within range. The area was blank because I did not take it for the mechanical soft meat. On 6/22/2022 at 11:32 AM, V7, Dietary Manager, stated, I expect all food on the steam table to be at least 135 degrees (F) or higher. The mechanical meat should have been at a higher temperature and the temperatures should have been taken. On 6/23/2022 at 1:45 PM, V14, Dietician, stated, On 6/23/2022 at 2:01 PM, V14, Dietician stated, I would expect all of the food on the steam table to be held at 135 degrees Fahrenheit (F) or higher. If a food item temperature is lower than 135, I would not expect it to be served to the residents. When the food is under 135 F, it can be a danger zone/hazardous. The danger zone is an ideal environment for bacterial growth. (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: 146025 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 146025 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clinton Manor Living Center 111 East Illinois Street New Baden, IL 62265 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)