Health inspection·September 12, 2025

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 observations, interviews and record reviews, the facility failed to serve palatable meals at temperatures per facility policy. This applies to all 83 residents residing in the facility receiving oral diets. The findings include:Facility Daily Census, dated 9/9/25, shows the facility census was 84 residents. POS (Physician Order Sheet) dated 9/11/25, shows one resident in the facility had a physician order for NPO (Nothing by Mouth).1. On 9/9/25 at 11:17 AM during lunch service, the facility was plating lunch foods which included sweet and sour pork, green beans, white rice and apple sauce. The plate warmer had hot plates in only one of the two sides of the equipment. The warmer had hot plates stacked in one side of the machine and the plates on the cooler side were only slightly warm but not hot. During lunch service, staff transferred some of the cooler plates into the hotter side of the warmer as they served food. At 12:10 PM a test tray was tasted. The pork and rice tasted only slightly warm, and the green beans tasted minimally warm. The temperatures of the pork measured 115 degrees F (Fahrenheit), the rice measured 118 degrees F, and the green beans measured 110 degrees F. The applesauce tasted room temperature, and the temperature of the applesauce measured 70 degrees F. On 9/9/25 during lunch service, R7 had her lunch in front of her and stated the food was served cold and was unappetizing. R7 stated she only had two warm meals in the last week. On 9/9/25 at 12:26 PM during lunch service, R1 had her lunch tray sitting in front of her uneaten and R1 was eating a chicken tender. R1 stated her lunch food did not taste appetizing and R1 was eating chicken tenders she received from her roommate. R1 stated the facility hot meals were sometimes served hot but not always.On 9/9/25 at 1:55 PM, R4 stated, The food is impossible! R4 stated she ordered out for food for lunch because she did not want to eat the facility-served lunch that day. R4 stated the hot sandwiches were prepared poorly and carelessly. On 9/9/25 at 2:50 PM, R3 stated Breakfast was so cold. It felt like they just took it out of an icebox! R3 stated she threw out her sandwich she was served the night prior because it was unappetizing. R3 stated the grilled cheese sandwiches were served with edges like rocks, one side was burnt, and the other side looked like untoasted bread. On 9/9/25 at 10:40 AM, R2 (Resident Council [NAME] President) stated the facility food service stopped using warming pellets under meal plates approximately a week prior and food that was supposed to be served hot was served cold to residents at times. R2 stated the meat was served tough and dry and vegetables are sometimes not cooked and were served tough and hard to chew. On 9/9/25 at 11:25 AM, V3 (Food Service Manager) stated she was not aware the facility had warming pellets and was made aware of the warming pellets were available for use in the kitchen only that morning. On 9/9/25, V4 (Food Service Worker) stated the facility stopped using warming pellets the prior week and one side of the plate warmer was less warm, so staff transferred plates to the other side during service to warm the meal plates.Facility Policy/Procedure Serving/Tray Line- Safety and Palatability, dated 10/25/23, shows, .For a palatable food temperature range for residents, hot foods can be slightly under 135 degrees Fahrenheit, between 120-130 degrees Fahrenheit, but should not be under 120 degrees Fahrenheit. Cold Residents Affected - Many (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: 145338 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 145338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Rehab and Nursing Center 512 East Ogden Avenue Westmont, IL 60559 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)