Health inspection·May 23, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interview and record review, the facility failed to accommodate a resident's food allergies and preferences. This applies to 1 of 3 residents (R1) reviewed for food allergies in a sample of 4. Residents Affected - Few The findings include: On 5/20/25 at 12:05 pm, R1 said that she is allergic to shellfish, squash, all melons in the melon family, bananas, and cucumbers. R1 said that she made the facility aware of her allergies, but she continues to be served food she is allergic to. R1 said that on 5/18/25, she was served a salad with a cucumber on it, and she told the staff, and on 5/17/25 she was served melons on her lunch tray, and she told the CNA (Certified Nurse's Assistant). R1 then showed a picture on her phone of a meal tray with a bowl of melons on the tray. On 5/22/25 at 10:45 AM, R1 said that she is still being served food that she is allergic to. R1 said that on the previous Monday (5/19/25) she was served a salad with a cucumber in it again. R1 reiterated that she is allergic to cucumbers, and she has told the facility. On 5/20/25 at 12:59 PM, V4 (CNA) said that R1 has gotten food on her tray that she is allergic to. V4 said 1-2 weeks ago, she had served R1 her meal tray during the day and the tray had melons on it. V4 verified that R1 told her that she was allergic to melons. On 5/20/25 at 2:01 PM, V6 (Dietary Manager) said that he had no knowledge of R1's allergies and he was aware R1 had gotten cucumbers. V6 pulled R1's 5/20/25 lunch meal ticket out of his pocket which showed R1's food allergies included melons and cucumbers, but the word cucumber was lined out in ink and in handwriting above the word cucumber, was the word cantaloupe, and above the list of food allergies was handwritten in ink, Dislikes: cucumber:. On 5/20/25 at 1:46 PM, V5 RD (Registered Dietitian) said that she did not ask R1 if she was allergic to cucumbers and her daughter told her that R1 dislikes cucumbers. V5 said that R1 should not be served any food that she is allergic to. V5 said that if someone has a food that they are allergic to, an array of things could happen including having a GI reaction, respiratory reaction, skin hives, swelling, edema, and even as far as an anaphylactic reaction. On 5/22/25 at 2:30 pm, V1 (Administrator) said that he was made aware of over a month ago that R1 was served a cucumber in her salad. V1 said that in the middle of April the facility held a care conference for R1 and R1's food allergies and food preferences including cucumbers were addressed in the conference. V1 said that the facility is aware that R1 is allergic to melons but thought that R1 Page 1 of 2 145338 145338 05/23/2025 Oakwood Rehab and Nursing Center 512 East Ogden Avenue Westmont, IL 60559

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few only had a dislike for cucumbers; not that she was allergic to them. V1 said that his expectations are that residents are served food in accordance with their dietary orders, including dietary food restrictions and preferences. On 5/22/25 at 12:28 pm, V2 DON (Director of Nursing) said that she was aware that R1 was served a house salad with a cucumber on it. V2 said that she was also made aware of R1 being served melons as well by the CNA who served it to R1. V2 said that V4 (CNA) told her that she served R1 melons, but she did not know that a honeydew was a melon. V2 said that it is important that residents don't get served food that they are allergic to because it can lead to anaphylactic shock or even death. V2 said that her expectations are that the staff do a double check to ensure they are following any food allergies. R1's face sheet showed 4/4/25 allergen: Melon family, Squash, Raw Bell Pepper, Cantaloupe. R1's 4/22/25 Order Summary Report showed 4/22/25 General diet Allergic to melon family, raw bell peppers, squash, fish, shellfish, banana, and cantaloupe. R1's 4/8/25 care plan showed, R1 will benefit from liberalized diet with supplementation. Has various nutritional allergies and preferences concerning her diet as indicated in her record. The care plan showed interventions including encourage resident to indicate further preferences with dietary management. Offer substitutions for food she's allergic to or intolerance of. Provide, serve diet as ordered. Resident provided with dietary menu slip to complete her preferences. On 4/29/24 the facility resident Grievance/Complaint form showed R1's daughter called to go over her mom's preferences because her mom gets nauseous and has a poor appetite and has dislikes. The Actions or Recommendations showed that the menus are done with R1 on a weekly basis, R1's tray is double checked for lunch and breakfast by dietary director and for dinner by PM supervisor. The Resolution showed, R1 will be served exactly what she is asking for. There will not be unwanted items on her tray. The facility's food Allergies and Intolerances policy dated June 2023 showed that the residents with food allergies or intolerances will be identified and steps will be taken to prevent residents' exposure to allergens. In accordance with a resident's care plan the culinary service department will be informed of residents with food allergies and intolerances meals will be specially prepared for residents with severe food allergies so that cross contamination with allergens does not occur. Residents with food intolerance and allergies will be offered appropriate substitutions for foods that they cannot eat . 145338 Page 2 of 2