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 Page 1 of 2 145338 145338 09/12/2025 Oakwood Rehab and Nursing Center 512 East Ogden Avenue Westmont, IL 60559

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many food should be served between 40-45 degrees Fahrenheit but should not be over 45 degrees Fahrenheit. 6. Small batch cooking will be utilized, when possible, to minimize hot holding or to retain food quality. 10. Cold foods will be prepared, dipped into individual serving dishes and chilled prior to service.2. On 9/10/25 during lunch service in the kitchen, staff were plating servings of macaroni and cheese with beef and broccoli/cauliflower on resident lunch plates. The macaroni and cheese with beef was pale white with light brown ground beef mixed with the macaroni. The mixture tasted bland, had no flavor or seasoning, and lacked any cheese sauce. The noodles appeared oily and there were small amounts of chewy cheese throughout the mixture. The broccoli/cauliflower appeared to have white cauliflower mixed with pale green/gray broccoli. There was an approximately four inches by four inches by four inches block of margarine sitting on top of the broccoli/cauliflower mixture in the steamtable pan located in the steamtable. The vegetables tasted mushy in texture and could be swallowed after mashing the product with a tongue. On 9/10/25 during lunch service, the following residents commented on the facility food: R19 stated It doesn't taste like there was cheese in it! R11 stated, The mac and beef sucked! R12 stated, It's bad. I can't touch it. I can't eat it! R12 had all of his portion of macaroni and cheese with beef left on his plate except a few bites. R13 stated the macaroni and cheese with beef was bland and the broccoli was overcooked. R14 stated, I ate a few bites, and I am done. It doesn't taste good. R13 and R14 stated the facility food was not served hot at times. R14 stated the food was a problem at the facility. R20 stated Lunch was horrible. The mac and beef had no flavor, no seasoning. It was horrible. The food quality is horrible. R16 stated, The food is bland - no seasoning and no flavor. R18 stated The food is not good, not seasoned. R18 stated the hot foods were not served hot at the facility. R15 stated the hot food was served cold at times. R7 stated her breakfast was served cold that morning and the eggs were ice cold. R9 stated the food quality had gotten worse at the facility. R6 (Resident Council President) stated breakfast was cold that morning and lately the food had been served cold. Facility Macaroni and Cheese with Beef recipe, undated, shows the recipe ingredients included macaroni, ground beef, salt, margarine, flour, milk, cheddar cheese, and breadcrumbs. Facility recipe Broccoli and Cauliflower, undated, shows, Do not overcook. 3. On 9/11/25 at 12:15 PM, R1 had her lunch in front of her which had spaghetti noodles and very little red sauce on the noodles. At 12:25 while in R1's room , R2 stated her spaghetti at lunch was very weak and dry and had no spaghetti sauce when served. 145338 Page 2 of 2