Health inspection·September 30, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve protein portion sizes as shown for the lunch meal.This applies to 8 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R9) reviewed for insufficient foods in the sample of insufficient foods in the sample of 10.The findings include:Facility menu spreadsheet for Monday (Week 4) included 6 ounces of Vitamin C juice for breakfast and 3 ounces of Baked Ham as the main entree for lunch.Facility also provided deli sandwiches as a substitute item for baked ham. Nutrition facts on Turkey Deli meat packaging label showed that 4 slices of turkey meat=10 grams of protein.On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray, and it included a half (disposable) cup of orange juice. R5 was still at dialysis. On September 29, 2025, at 9:44 AM and 10:18 AM, R3 and R1 respectively stated that the drinks served are only half or less than half filled in the cup and watered down. On September 29, 2025, at 9:56 AM, R2 stated that the portion sizes are much smaller and that the resident families have to bring extra food as the residents are still hungry. R2 added that the juices are watered down. On September 29, 2025, at 11:33 AM, during tray line service R2 ordered a turkey deli sandwich. On checking the contents of the sandwich, it contained 2 slices of deli turkey with one slice cheese and a piece of lettuce. V10 (Dietary Aide) stated that the turkey sandwiches were made the day before. On September 29, 2025, at 11:33 AM, V11(Interim Dietary Manager) was platting the food at the tray line service, and the ham slices were noted sliced into varying thickness. V11 served R3, R4, R5, R6 and R7 one slice of ham along with the other side items consisting of scalloped potatoes and carrots. V12 (Cook) who was in the vicinity was requested to weigh one slice of the ham on a weighing scale. V12 took one of the thicker sliced pieces from the steam table and when weighed the same and it showed 2.3 ounces. On September 29,2025, at 12:19 PM, R4 stated There is more vegetables than meat on the plate. On September 29, 2025, at 3:18 PM, R9 stated There is not enough food at all. We have big people here. My whole life I have never gone to bed hungry, but now I am going hungry. On September 30, 2025, at 9:07 AM and 9:29 AM, V11 stated that the juices are supposed to be served in a 7 oz plastic cup for breakfast. V11 stated that the juice from the dispenser is put in a container and that the facility adds ice to the container prior to taking it to the unit. V11 added that the ham was already pre-sliced when he had come in to assist to serve at tray line. On September 30, 2025, at 2:33 PM, V14 (Dietitian) stated that the residents should have received 3 ounces of ham and 6 ounces of orange juice as shown on the menu spreadsheet to meet the dietary requirements. V14 stated that the facility should not add ice as it waters down the juice. V14 stated that the substitute menu item should be comparable to the main menu entree. V14 stated that 1 oz of meat=7 grams of protein. V14 added that by serving 2 slices of deli turkey meat with one slice of cheese, the facility is not giving adequate amount of nutrition (protein) as main menu entree. Facility policy and procedure titled Food Preferences included: Policy: The facility will attempt to accommodate the residents' requests as available. Procedure: 1 The Page 1 of 3 145338 145338 09/30/2025 Oakwood Rehab and Nursing Center 512 East Ogden Avenue Westmont, IL 60559

F 0803 Level of Harm - Minimal harm or potential for actual harm facility will ensure that menus are developed and prepared according to national guidelines. 3. The facility's dietitian or other qualified nutrition professional will review the resident's nutrition status to ensure the nutrition provided meets the needs of residents. Residents Affected - Few 145338 Page 2 of 3 145338 09/30/2025 Oakwood Rehab and Nursing Center 512 East Ogden Avenue Westmont, IL 60559

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 observation, interview and record review, the facility failed to provide cold foods to meet acceptable palatable temperatures requirements for the residents. This applies to 5 of 5 residents (R1, R2, R3, R6, R8) reviewed for poor prep and quality of foods. The findings include: On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray that was set on a bedside table while he was still in dialysis. The breakfast meal included an 8-ounce carton of whole milk and 4-ounce disposable cup of orange juice. R6 returned to room at around 11:30 AM to eat his breakfast. On September 29, 2025, at 9:44 AM, 10:18 AM and R3 and R1 respectively stated that the food that is supposed to be cold is hot. R3 and R1 added that the orange juice is served warm. On September 29, 2025, at 9:56 AM, R2 stated that cold foods are served warm and that the quality is poor.On September 29, 2025, at 11:33 AM, during tray line service, deli sandwiches wrapped in clear wrap with condiments were seen placed directly on the tray line counter next to the steam table. V10 (Dietary Aide) stated that the ham sandwiches were made fresh, and the turkey sandwiches were made the day before. The turkey sandwich contained wilted lettuce and cheese that appeared to be melting. On testing the temperature of the ham sandwich, it showed 70 degrees Fahrenheit. R2 had ordered turkey sandwich and R8 had ordered the ham sandwich. Both these residents received room trays around 12:00 PM with ordered deli sandwiches. On September 29, 2025, at 12:06 PM, the food temperature in degrees Fahrenheit of drinks from a test tray was taken by V1(Administrator) and showed that orange juice was 49.8 and milk was 46.7. On September 30, 2025, at 9:07 AM, V11 (Interim Dietary Manager) on request tested a cup of orange juice after it was dispensed from the dispenser and it showed 50.7 degrees Fahrenheit. V11 stated that the juice dispenser does not keep juices cold. On September 30, 2025, at 2:22 PM, V14 (Dietitian) stated that the orange juice should come out cold from the dispenser. V14 stated that cold items should be 40 degrees Fahrenheit at the serving station and should at least be 45 degrees Fahrenheit at point of service, Facility policy titled Serving/Tray Line-Safety and Palatability included: Policy: The temperatures of all food on the serving line will be measured and recorded at every meal. Procedure: 2. Cold foods are maintained at 41-degree Fahrenheit. 3. Temperatures are taken prior to service to ensure hot foods and cold foods are maintained at the appropriate temperatures. 4. If items are not at the correct temperatures, action will be taken so that the temperatures are restored to correct the temperature. Protocol:10. Cold foods will be prepared, dipped into individual serving dishes and chilled prior to service. Cold beverages will be added at the end of tray line to maintain the temperature. 11.Cold foods will be at 40-45 degrees at the time of service for palatability. Residents Affected - Some 145338 Page 3 of 3