Inspection·April 26, 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 properly label and date refrigerated items and remove expired food items in the kitchen. This applies to all 16 residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 4/23/24 documents that the total census was 17 residents. On 4/23/24 at 11:14 AM, V3 (Dietary Manager) said there is 1 resident that does not eat from the facility kitchen. On 4/23/24 (starting at 10:01 AM), the facility kitchen was toured in the presence of V3 (Dietary Manager), and the following was found: In the walk-in cooler: 1. Quarter of a large processed turkey breast, opened 4/12/24, expiration date 4/18/24 (expired 11 days earlier). 2. Thawed ground beef sitting on a tray with juices leaking out of the bottom, wrapped in plastic wrap with no label or date. 3. 1.25 lbs. (pounds) Swiss cheese opened 3/13/24, not sealed with a good through date of 3/19/24. Expired. 4. 24-ounce provolone cheese with a received-on date of 12/29/23 on box, no expiration date on package. 5. Medium silver bin of approximately 20 hot dogs, not in original bag, undated. 6. Half of a large processed ham, opened, expiration date 4/20/24. Expired. 7. Medium silver bin labeled tomatoes with a good through date of 4/10/24. Expired. 8. 26 half pint lactose free low-fat milks with expiration date of 4/21/24. Expired. 9. 3 hard-boiled eggs with expiration date 4/22/24. Expired. (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: 146056 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 146056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Kankakee 901 North Entrance Avenue Kankakee, IL 60901 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)