145752
07/01/2025
Forest View Rehab & Nursing Center
535 South Elm Itasca, IL 60143
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food prepared for residents were nutritive, palatable, and attractive. This applies to all 119 residents who receive food from the kitchen.
Residents Affected - Many
Findings include: On 6/30/2025 at 1:32 PM, V3 (ADON, Assistant Director of Nurses) stated 119 residents out of 130 received food prepared in facility's kitchen. The menu for 6/25/2025 showed the main entree for lunch was Skillet Lasagna. On 06/25/2025, during lunchtime, staff delivered lunch trays to many residents including R8, R10, and R14. R8 called the writer and showed the meal card and skillet Lasagna that was served, and asked the writer if it looked like Lasagna. R10 asked the staff who served her tray what was on her plate, and the staff said it was Lasagna. R10 said, It didn't look like Lasagna. R14 went outside the room with her lunch plate, with anger and frustration, in front of V1 (Administrator), V3 (Assistant Director of Nursing), and V7 (Licensed Practical Nurse), who were in the hallway, and asked who could eat it. Skillet lasagna lacked appearance, texture, distinct layers, vibrant color, with no visible sauce, ground meat, a variety of different cheeses, herbs, and spices. The facility provided the recipe for Skillet Lasagna for 119 residents which included 12.5 pounds of ground beef, 6 pounds of mozzarella cheese, 15 ounces of parmesan cheese, and 5.5 pounds of ricotta or cottage cheese. On 06/25/2025 at 2:00 PM, V17 (Dietary Aide) and V18 (Cook) stated they know how to cook but did not have the required ingredients to prepare the Skillet Lasagna. V17 and V18 stated the kitchen did not have ground beef and parmesan cheese and had only three pounds of mozzarella cheese instead of six pounds, and two pounds of ricotta or cottage cheese instead of five and a half pounds. V17 and V18 stated they are expected to prepare a dish using available ingredients. On 06/25/2025 at 2:30 PM, V16 (Dietary Manager) stated since May 2025, a new company has taken over the food department, supplying items once a week. V16 stated some items were missing, which prevented them from cooking the Lasagna properly. On 06/25/2025 at 1:30 PM, V1 (Administrator) stated since the new company took over, they have had some concerns with the food, which they are continuously addressing. V1 said it's not acceptable and
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145752
145752
07/01/2025
Forest View Rehab & Nursing Center
535 South Elm Itasca, IL 60143
F 0804
will follow up with the company.
Level of Harm - Minimal harm or potential for actual harm
On 06/27/2025, at 11:00 AM, V28 (Registered Dietitian) stated it's essential for residents to have appetizing, attractive, and palatable meals with nutritional value. V28 said it's not acceptable for residents not to have protein in their meals.
Residents Affected - Many 1. The review of R8's EMR (Electronic Medical Records) showed R8 is a [AGE] year-old male, and his diagnoses included type 2 diabetes mellitus, cardiac diseases, depression, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE] (Admission) showed that R8's cognition was intact, and he was independent in most of his daily living activities. R8's diet order included a low-concentrated sweets diet with regular texture. R8 expressed concerns regarding consuming more carbohydrate-rich foods quite often since last month. 2. The review of R10's EMR (Electronic Medical Records) showed R10 is a [AGE] year-old female and diagnoses included depression, multiple sclerosis, peripheral vascular disease, chronic kidney disease stage 2, cardiac disease, and osteoarthritis. R10's Minimum Data Set, dated [DATE], showed that R10 was cognitively intact and required two staff members for assistance with incontinent care, mobility, and transfer. R10's diet order included a general diet with Regular texture. R10 said lately the food's appearance and taste was getting worst, and she keeps complaining about it, but nothing has been done. 3. The review of R14's EMR (Electronic Medical Records) showed R14 is a [AGE] year-old female with diagnoses including malignant neoplasm, cardiac disease, anemia, and weakness. R14's Minimum Data Set, dated [DATE], showed that R14 was cognitively intact and required minimal assistance for activities of daily living. R14's diet order included no Added Salt and regular texture. R14 said she had never seen Lasagna that way, and how could it be Lasagna without meat, cheese, and flavor? R14 said the food's taste and appearance were getting worst at the facility, and it's very disappointing. Resident Council concerns from meeting notes dated 05/21/2025 and 06/19/2025 included excessive number of starches on the plate. A review of the facility's policy on standardized recipes, which did not include a date, showed that a standardized recipe shall be used for the preparation of each menu item. Staff members are to notify their supervisor if they don't have the necessary ingredients to prepare a recipe, and the supervisor will procure the needed items.
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