Health inspection·February 16, 2024

F 0812 the semolina was expired on 11/28/23 and should have been discarded. Level of Harm - Minimal harm or potential for actual harm 10. Four 1 gallon containers of honey mustard dressing with received date of 6/16/23. V6 and V5 said these dressings have a six month shelf life and were expired on 12/16/23 and should have been discarded. Residents Affected - Many In the produce refrigerator: 11. A medium sized silver bin of mashed potatoes, not labeled or dated. 12. A medium sized silver bin of green beans, not labeled or dated. 13. A small silver bin of watermelon, not labeled or dated. 14. A small silver bin of mashed potatoes, not labeled or dated. 15. An opened large bag of mixed greens- not sealed, not dated, and not labeled and browning/wilted. 16. A bag of pureed bacon mix not sealed with ingredients open to air, and outside of bag is sticky. In the freezer: 17. A large opened plastic bag of 20+ frozen hot dogs dated 1/12/24, not sealed with a large build-up of freezer burn on meat. 18. A large resealable bag of 15+ sausages dated 1/27/24 with a large amount of freezer burn build-up on meat. V6 (Executive Chef) said the freezer burn could have happened from the staff putting the meat in the freezer when they were still warm. For the duration of the kitchen tour, V5's (Director of Food and Nutrition) hair net was not worn appropriately to restrain her hair. V5's bangs were exposed, and the hair net was only restraining the hair on her head from the top middle of her head and back down to the top of her neck. The top front of V5's hair was not restrained. On 2/14/24 at 11:41 AM, V4 (Dietician) said all food items in the kitchen should be labeled and dated so foods can be rotated and outdated foods discarded. V4 said expired foods should be discarded to prevent foodborne illness of residents, especially because the age group that the facility serves is vulnerable. V4 said all opened items need to be sealed/wrapped well and dated with an opened date and expiration date. V4 said sealing opened food items is important to conserve freshness/quality and prevent contamination from pests. V4 said all canned items should be inspected upon delivery and dented cans should be removed from circulation. V4 said dented cans should be put in designated dented can area and returned to supplier. V4 said the risk with serving food from a dented can is bacteria growth, spoiled food, and contamination. V4 said all freezer burned food items should be discarded right away because that food item has been damaged by the freezer and would be a risk to serve. V4 said while wearing a hairnet, all hair needs to be restrained, including bangs, because that hair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 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 146128 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Place 315 North LA Grange Road LA Grange Park, IL 60526 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 can fall out and into food causing contamination. V4 said hair is a contaminate and we try in food service to prevent contamination. The facility's policy titled Labeling and Dating dated 10/19 states, Purpose: All foods will be appropriately wrapped, labeled and dated based on food storage guidelines . Procedure: 1. All foods will be labeled, dated, and securely wrapped or covered. 2. Labels with use-by dates will be clearly displayed on each item, and the dates will follow shelf-life guidelines. All products past the use by date will be discarded . The facility's policy titled, Receiving Goods and Storage of Goods dated 10/19 states, Purpose: Proper storage procedures will be utilized for all dry and refrigerated food storage. Procedure: .2. Food is inspected upon arrival, especially perishables .6. Products must be checked to detect unacceptable items, i.e. dented, swollen, or rusted cans, thawed or refrozen items, crushed cases, etc . The facility's policy titled, Food Safety/HACCP dated 10/19 states, Purpose: The Dining Services Department will adhere to food safety standards and education. Procedure: .4. Employees must wear clean uniforms, approved hair restraints .10. All foods prepared in the facility must be covered, labeled and dated indicating the contents, date of preparation, use-by date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146128 If continuation sheet Page 3 of 3