Health inspection·September 17, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 food portions as shown on the facility menu spreadsheet. This applies to 129 facility residents receiving oral diets. The findings include: The Facility Data Sheet dated September 15, 2025, shows the facility census was 132 residents. The facility's Diet Type Report dated September 15, 2025, shows two residents had diet orders for nothing by mouth and one resident was a vegetarian. On September 15, 2025, at 11:48 AM, during lunch tray line service with V5 (Cook) and V6 (Cook), V5 said the tray line consisted of a tray of cheese tortellini combined with meat sauce, a tray of green beans, a tray of garlic bread slices, a tray of chopped pasta combined with meat sauce, a tray of mashed potatoes, and containers of pureed meat sauce, pureed pasta, and pureed green beans were being served to residents for lunch. The tray line did not show a container of pureed garlic bread. V6 said he was using a 4 oz spoodle for the tray of pasta mixed with meat sauce, a 4 oz spoodle for the green beans, a 4 oz scoop for the mechanical soft pasta combined with meat sauce, and #8 scoops for the pureed pasta, pureed meat sauce, pureed green beans, and mashed potatoes. Using the 4 oz spoodle, V6 served one scoop of pasta mixed with meat sauce for the regular diet meal trays. Using the 4 oz scoop, V6 served one scoop of chopped pasta mixed with meat sauce, and one scoop of mashed potatoes for the mechanical soft meal trays. V6 did not serve the mechanical soft meal trays soft bread. V6 served one scoop of pureed pasta, one scoop of meat sauce, and one scoop of pureed green beans for the pureed meal trays. V6 did not serve the pureed meal trays pureed bread. The facility's Menu Extension for September 15, 2025, shows the serving instructions for the regular and mechanical soft diets were to be served a 4 oz spoodle sauce over an 8 oz spoodle pasta for a portion size of 12 oz. The mechanical soft diets were to be served soft garlic bread. The pureed diets were to receive one #16 scoop of garlic bread. The facility's recipe titled, Pasta with Meat Sauce dated September 15, 2025, shows when using canned spaghetti sauce mixed with ground beef, serve 6 oz sauce over 4 oz spaghetti. On September 16, 2025, at 8:38 AM, V5 said he used canned sauce for yesterday's lunch of pasta with meat sauce. On September 16, 2025, at 12:28 PM, V4 (Dietitian) said dietary staff should be following the facility's menu extension to a T for serving instructions and portion sizes. V4 said since the regular and mechanical soft diets were served one 4 oz spoodle of combined pasta and meat sauce, the residents did not receive the correct portion size according to the menu extension. V4 said V6 should have served the correct portion size for the regular and mechanical soft diets and should have served the pureed diets the pureed bread as shown on the menu extension. The facility's undated policy titled, Accuracy of Quality of Tray Line Service shows, Policy: Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. Procedure: 1. The menu extension display items and amounts for each regular or therapeutic diet. 2. The director of food and nutrition Page 1 of 3 145752 145752 09/17/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0803 Level of Harm - Minimal harm or potential for actual harm services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time.4. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. 6. Each meal will be checked for: a. Correct name, room number, and diet order b. Accuracy of following the therapeutic diet extension c. Proper portion sizes. Residents Affected - Many 145752 Page 2 of 3 145752 09/17/2025 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 Based on observation, interview, and record review, the facility failed to follow the facility's policy to serve food at a palatable temperature. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for dietary services in the sample 6. The findings include: On September 15, 2025, at 11:48 AM, during lunch tray line service with V5 (Cook) and V6 (Cook), V5 and V6 served resident room meal trays on hard plastic, non-warmed, room temperature plates with lids. V5 and V6 did not use thermal bases or heated plates. On September 15, 2025, at 12:47 PM, V6 prepared a test meal tray. V6 used a hard plastic, non-warmed plate and placed cheese tortellini with meat sauce, green beans, and one piece of a plain breadstick. V6 placed a lid on the plate and placed the plate directly onto a serving tray. The tray was placed on an open-air unit meal cart with the 1 North resident meal trays. At 12:51 PM, the meal cart was delivered to the 1 North resident hallway with the other resident meal trays. At 1:10 PM, when the last resident meal tray was delivered, V5 took the temperatures of the food on the test tray. V5 said the temperature of pasta with meat sauce was 110 degrees Fahrenheit and the green beans were 110 degrees Fahrenheit. The pasta with meat sauce and the green beans tasted lukewarm. On September 15, 2025, at 4:54 PM, R1 said her warm food is frequently served cold. On September 15, 2025, at 2:55 PM, R2 said his warm food is usually served cold. On September 15, 2025, at 5:23 PM, R3 said the facility food is disastrous and is almost always not served warm enough. On September 16, 2025, at 2:38 PM, R4 said the warm food is frequently served cold. On September 16, 2025, at 2:40 PM, R5 said he gets served cold food when it is supposed to be warm. On September 16, 2025, at 2:40 PM, R6 said food that is supposed to be warm is served cold and the food that is supposed to be cold is served warm. On September 16, 2025, at 12:28 PM, V4 (Dietitian) said the dietary staff should be using heated plates, warming bases, plate covers, and closed carts to transport food to resident rooms. V4 said the base and the lid help to maintain food temperatures. V4 said it is her expectation the food served to residents should not be less than 125 degrees Fahrenheit. The facility's policy titled, Food Temperatures at Point of Service dated July 14, 2023, shows, Policy: Food will be prepared, held, and served in a manner that preserves nutritive value and palatability.Procedure:.4. Best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary. The facility policy titled, Food Temperature Resident Service dated April 2022, shows, Policy: The facility will ensure foods are served in an attractive and at temperature that is palatable and acceptable to the residents. Procedure:.3. Food will be transported to the dining rooms or resident rooms in methods that maintain the proper temperatures of the food. 4. Hot foods will be served to the residents at a temperature palatable and acceptable to the resident, general practice should not be less than 125F. Residents Affected - Some 145752 Page 3 of 3