Inspection·August 22, 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 interview, observation, and record review, the facility failed to label and date food products, restrain hair, and ensure resident use refrigerators are only used for residents to prevent foodborne illness. This failure has the potential to affect all 51 residents residing at the facility. Findings include: On 8/19/24 at 10:30 AM, the main kitchen was observed. The walk in refrigerator had a container of meat (which appeared to be tuna). The container was not labeled or dated. The main kitchen freezer had a metal sheet pan lying on the floor. There was a frozen bag with red pasta sauce on the sheet pan. At 10:40 AM, the Summer hall kitchen refrigerators were observed. The was an employee lunch box, 3 premade salads, a storage container of cottage cheese, a storage container of what appears to be tartar sauce. None were labeled or dated with made on and expires on dates. There were 9 fruit cups and 9 applesauce cups that were not covered, labeled or dated. The freezer section had frozen meat that was not labeled or dated, an open storage bag of frozen waffles, and breakfast sausage that was undated. In the cabinet, there were 2 squeeze bottles- one has liquid butter and one has syrup, neither was labeled or dated. There was a box of cream of wheat that was open and not sealed. At 10:55 AM, the Reach hall kitchen refrigerators were observed. There was a block of cheese that is not labeled or dated. The freezer had a bag of unknown meat that was undated and not labeled that had freezer burn, and an employee's frozen meal. In the cabinet, there were 2 squeeze bottles- one has liquid butter and one has syrup, neither were labeled or dated. There was a box of cream of wheat that was open and not sealed. At 10:55 AM, V5, Cook, stated employees should not keep food in the refrigerator, all food should be labeled and dated, and all foods should be sealed properly. V5 stated, Unfortunately, I can not be here around the clock and things get missed. At 11:05 AM, the Spring hall kitchen refrigerators were observed. There was a a tray of cheese and pepperoni roll ups and a jar of minced garlic jar. V6, Cook, was questioned if the items were for residents or employees. V6 stated both of those are employees. There was a storage container of cottage cheese and fruit salad both are undated and are not labeled. There was 2 bags of frozen cookies that were open and not sealed properly. In the cabinet, there were 2 squeeze bottles one has liquid butter and one has syrup, neither were labeled or dated. There was a box of cream of wheat that was open and not sealed. On 8/21/24 at 11:25 AM, the noon meal was observed on the steam table, being plated, covered and placed in hot boxes to be taken to the halls. V18, Cook, was serving from the steam table and handing the plates to V17, Cook, who was covering the plates and putting the plates into the hot box. Neither V17 or V18 were wearing a beard net. On 8/19/24 at 10:30 AM, V4, Dietary Manager, stated, All food products should be labeled with the name, date prepared, and expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 2 of 4 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 146154 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Village Care Center 4101 West Iles Avenue Springfield, IL 62711 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 On 8/21/24 at 11:30 AM, V4 stated he would order some beard nets. Level of Harm - Minimal harm or potential for actual harm On 8/22/24 at 9:37 AM, V4 stated employees should not use refrigerators for residents for their personal food. Residents Affected - Many The policy Food Storage, dated 10/1/20, documents, 6. Items that arrive in their original packaging with a manufacturer's expiration date will utilize that date for discard. a. Should an item be opened and stored in a different container, it will be labeled with an open date and a discard date. The policy Preventing Foodborne Illness - Hygiene & Sanitary Practices, dated 9/ 2013, documents, 11. Hair nets or caps and / or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. The Long Term Care Facility Application for Medicare and Medicaid, dated 8/19/24, documents that the facility has 51 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 3 of 4 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 146154 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Village Care Center 4101 West Iles Avenue Springfield, IL 62711 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to perform hand hygiene, post a needed isolation sign, and use Personal Protective Equipment (PPE) for 2 of 24 residents (R40, R255) reviewed for infection control in sample of 29. Residents Affected - Few Findings include: 1. On 8/20/24 at 8:37 AM, V7, Licensed Practical Nurse, LPN, gave R40 his pill medication to take. R40 took all the medications. V7 donned gloves with no hand hygiene before, and then administered eye drops in R40's eyes. On 8/22/24 at 11:15 PM, V2, Director of Nursing, DON, stated hand hygiene should be done before donning gloves. The policy Hand Hygiene, dated 1/30/24, documents, 1. Perform hand hygiene before applying non - sterile gloves. 2. On 8/20/24 at 1:00 PM, V2 stated, (R255) just turned positive with COVID. On 8/21/24 at 8:45 AM, R255's door does not have an isolation and needed PPE sign on the door. On 8/21/24 at 8:50 AM, V2 stated ]R255 should have a signage indicating what personal protective equipment is need. R255's Clinical Note, dated 8/20/24, documents, Resident was tested for COVID via POC (Point of Care) test. COVID test was positive. The policy Covid - 19 Infection Prevention Control Measures, dated 4/1/24, documents, d. Post visual alerts at the entrance and in strategic places. These alerts should include instructions about current IPC (Infection Prevention Control) recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146154 If continuation sheet Page 4 of 4