Health inspection·November 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation and record review, the facility failed to serve residents with non-disposable cutlery. This applies to 6 of 6 residents (R5, R37, R38, R39, R40, R41) reviewed for dietary services in the sample of 41.The findings include:On November 19, 2025, at 8:54 AM, during room tray meal observations in the 1 South unit, it was noted that multiple trays only had silverware consisting of forks and knives and had plastic spoons for the cereal. V37 who was passing out food trays out to the residents in 1 South unit from the food cart stated, They (Dietary staff) only give plastic plates in the evening. How can the food stay warm?On November 18, 2025, at 9:10 AM, V11 (Regional Dietary Manager) stated the facility uses plastic disposable utensils and plates as a lot of the utensils and dishes don't come back from the resident's rooms. V11 added, Maybe it's still in the residents room.On November 18, 2025, starting at 12:10 PM, the lunch meal service was observed in the facility kitchen. Towards the at the end of the lunch meal service, the facility ran out of beef stroganoff with egg noodles and broccoli, and R5, R37, R38, R39, R40, R41 received a hamburger on bun with mashed potatoes and no additional vegetables. These residents also only received a fork with a disposable plastic spoon and no knives as the facility had run out of regular cutlery.Facility undated policy tilled Table Setting for Residents included:Policy: Individuals will be provided with an attractive table setting that enhances thedining experience and provides a home-like environment.Procedure:7. Dish ware should be durable and replaceable (free of cracks), appropriate forthose being served.8. Dishes, glasses, and silverware should be placed appropriately (see below) withthe dinner plate in the center, fork/s on the left of the plate, knife on the right of thedinner plate and spoon to the right of the knife. Page 1 of 13 145752 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents from physical abuse. This failure applies to 2 of 5 residents (R4 and R5) reviewed for abuse in a sample of 36.The findings include:Findings include: The Electronic Medical Record (EMR) indicated the following: -R4, a [AGE] year-old female resident admitted on [DATE]. Diagnoses include, but are not limited to major depressive disorder, anxiety disorder, alcohol abuse, bipolar disorder, and a history of falls.-R5, a [AGE] year-old female resident admitted on [DATE]. Diagnoses include chronic obstructive pulmonary disease, iron deficiency anemia, major depressive disorder, history of falls, weakness, need for assistance with personal care, difficulty walking, and dependence on supplemental oxygen.The facility's incident reports documented multiple verbal and physical altercations between R4 and R5:-May 4, 2025, at 9:45 PM: R4 reported to nursing staff that R5 grabbed the back of R4's shirt while R4 was mobilizing in her wheelchair. The facility's investigation noted R4 and R5 were previously friends but were no longer on speaking terms.-July 13, 2025, at 7:55 PM: R4 and R5 made physical contact while entering the facility. R5 sustained scratches. Although they resided on different floors, both were to be monitored closely. The investigation indicated R4 pulled sunglasses from R5's hair during the incident.-November 1, 2025, at 7:20 PM: R4 went to R5's room to apologize to R6 (R5's roommate) for a prior interaction. Upon entering, R5 told R4 to leave the room and pushed a rolling walker, causing R4 to fall. V19, (Registered Nurse), responded to the scene and reported a physical altercation between both residents. Further review showed that R6 was present and R4 asked her about cigarettes, at which point R5 got off her bed and pushed R4. Both residents were transported to the hospital for evaluation and returned the following day. The facility's investigation determined that physical contact occurred between R4 and R5.R4's care plan dated November 7, 2025, documented R4's maladaptive behavioral symptoms related to chronic mental illness, including aggressive behavior toward R5. The care plan directed R4 not to enter R5's room.-R5's care plan dated December 11, 2024, identified R5 as at risk for abuse, neglect, exploitation, and trauma related to diagnoses included bipolar disorder, schizoaffective disorder, depression, and anxiety. The care plan noted:-May 5, 2025: R5 reported R4 pulled her shirt during a verbal altercation.-July 8, 2025: R5 reported being kicked in the knee by another, unidentified resident.Interventions included instructing R5 to stay away from R4.Separate observations and interviews on November 19, 2025, 11:00 AM - 3:30 PM. were conducted: -11:00 AM. - R4, lying in bed, coherent, alert, and oriented. R4 stated she and R5 were previously friends but were no longer on good terms after R5 accused her of using R5's credit card to purchase alcohol. R4 stated R5 pulled her hair and engaged in verbal and physical altercations with her around May and July 2025. Regarding the November 1 incident, R4 reported R5 yelled at her to leave the room and pushed her, causing her to fall and experience back pain.-11:30 AM. - R5 reported that R4 entered her room yelling, prompting R5 to push R4, resulting in R4 falling. R5 acknowledged that R4 was not supposed to enter her room. R5 stated that both residents were yelling, had physical contact, and were separated by V19 before being sent to the hospital.-11:45 AM. - R6, had declined to participate, stating, I do not want to talk to anyone.-1:00 PM. - V19 reported hearing yelling from R5's room while stationed at the Unit 100 North Wing nurse's station. Upon entering the room, V19 observed R4 and R5 physically fighting and punching each other like boxing. V19 reported that R4 kicked him during his attempt to separate them and stated that R4 had been the aggressor. V19 noted he did not see R4 pass the nurse's station due to focusing on charting.-1:15 PM. - V27 (CNA) stated that around 7:30 PM on November 1, 2025, she heard yelling from R5's room. When V27 arrived, she observed 145752 Page 2 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0600 Level of Harm - Minimal harm or potential for actual harm both residents yelling, with R4 on the floor, and both attempting to strike each other.-2:30 PM. - V1 (Administrator), confirmed the investigation substantiated physical contact and altercation between R4 and R5. The facility's Abuse Prevention Program policy dated March 1, 2021, states that the facility prohibits and prevents abuse against any resident and strives to maintain a resident-sensitive and secure environment. Residents Affected - Few 145752 Page 3 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

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 observations interview and record review, the facility failed to provide portions as shown on the menu spreadsheet.This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO (nothing by mouth) status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun, potato wedges, green peas, baked cookie. The extension spread sheet for the same meal showed to serve pureed potatoes (#12 scoop) for pureed diets. On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. It was noted pureed potatoes or mashed potatoes were not prepared. On enquiry what the residents on pureed diets are getting, V30 (Regional Dietary Director), who was at the steam table, stated the pureed diets are getting pureed hot dog, pureed bread and pureed green peas. When asked why the pureed diets are not getting pureed potatoes, V30 stated V3 prepared the meal. V30 then directed V3 to make mashed potatoes for the pureed diets.Facility scoop equivalents guidance showed #12 scoop =1/3 cup.2. The Week at a glance menu (Week 3) for breakfast meal on November 18, 2025, included Western egg casserole. The extension spread sheet for the same meal showed to serve 1 slice of Western egg casserole for Regular and Mechanical soft diets. Additional serving instruction included the Western egg casserole prepared in a 6 x (times) 4 [inches] hotel pan to be sliced into 24 pieces.On November 18, 2025, starting at 7:35 AM, during the breakfast meal service in facility kitchen, the Western egg casserole prepared in a pan was cut into 40 slices and the residents on Regular and mechanical soft diets were served 1 slice each (except for around 8 residents who received boiled eggs or scrambled eggs per choice). When this pan was completed, another pan containing Western egg casserole was cut into 35 slices was placed on the steam table and the residents on Regular and mechanical soft diets were served 1 slice each. V32 (Cook), who was seen cutting the prepared sheet pan of Western egg casserole, stated the pan is 6 x 4 [inches]. When showed the directions on the menu extension sheet for slicing the Western egg casserole into 24 pieces, V30 stated, I don't know why I cut it into 35 and 40 slices.3. The Week at a glance menu (Week 3) for lunch meal on November 18, 2025, included beef stroganoff with egg noodles and broccoli florets. The extension spread sheet for the same meal showed to serve 4 oz (ounces) of beef stroganoff over 6 oz egg noodles (total 10 oz) for Regular diet, 2 #8 scoops of pureed beef stroganoff with egg noodles.On November 18, 2025, starting at 12:10PM, during the lunch meal service in the facility kitchen, the residents on Regular diets received an 8 oz ladle portion of beef stroganoff and noodle mixture. The residents on pureed diets received one #8 scoop of pureed beef stroganoff with egg noodles mixture. When V30 (Regional Dietary Director), who was at the steam table, was asked why the residents on Regular and pureed diets received the same instead of what is shown on the menu extension sheet, V30 stated the facility does not have a 10 oz scoop. V30 added the server should have served one 8 oz ladle and a little more using the same ladle for regular diets and the pureed diets should have received 2 #8 scoops.It was noted towards the at the end of the lunch meal service, the facility ran out of beef stroganoff with egg noodles and broccoli, and 6 residents (R5, R37, R38, R39, R40, R41) received a hamburger on bun with mashed potatoes and no additional vegetables. On November 18, 2025, at 8:47 AM, V25 (Certified Nursing Assistant) who was passing out meal trays in the 1 South unit stated, If the resident asks for second portion, they (dietary staff) say we don't have enough. That's not right. The food is for the residents. On November 20, 145752 Page 4 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2025, at 11:47 AM, V31 (Dietitian) stated the menu is preplanned and approved by dietitian of the new company oversees the kitchen. V31 stated the facility should follow the diet extension sheets and recipes to meet the requirements of calories and proteins for the meal. Facility scoop Conversions and Measurements guidance showed #12 scoop =1/3 cup, #8 = 1/2 cup. Facility Diet Order Listing printed on November 19, 2025, showed there were 13 residents on pureed diets, 28 residents on mechanical soft diets and 85 residents on Regular diets. 145752 Page 5 of 13 145752 11/24/2025 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 observations interview and record review, the facility failed to serve meals at required meal temperatures and appearance/consistency for palatability. This applies to all residents that receive foods prepared in the facility kitchen.The findings include: Facility Data sheet dated November 18, 2025, showed there was a census of 126 residents in the facility. Facility provided information there was one resident on NPO status.1. The Week at a glance menu (Week 3) for dinner meal on November 17, 2025, included hot dog with hot dog bun.On November 17, 2025, at 4:27 PM, the dinner meal items were on the steam table in the facility kitchen and V3 (Cook) stated they were ready for meal service at 4:45 PM and he has already taken the food temperatures of the meal items. On request, V30 (Regional Dietary Director) measured the food temperatures at the steam table and showed as follows in degrees Fahrenheit. Mechanical Soft hot dog=110.4, Pureed hot dog =129.7.2. The Week at a glance menu (Week 3) for breakfast meal on November 18, 2025, included Western egg casserole and hot cereal.On November 18, 2025, at around 8:30 AM, during breakfast meal service, it was noted the room trays served for the residents first floor did not have hot plates/thermal pellets and only had an insulated dome cover over the plate. The hot cereal did not have a lid. These meal trays were placed in a rolling cart and covered with a plastic liner.On November 19, 2025, at 8:54 AM, V37 who was passing out food trays out to the residents in 1 South unit from the food cart stated, They (Dietary Staff) sometimes give us coffee is clear and not even black. They only give plastic plates in the evening. How can the food stay warm?On November 19, 2025, at 9:04 AM, the food temperatures were monitored from a test tray by V11 (Regional Dietary Manager) prior to passing out all the meal trays in the 1 South unit. The Western egg casserole and hot cereal measured 120 degrees Fahrenheit. V11 remarked if the meal temperatures were taken after the room trays were passed out it will be below 110 degrees Fahrenheit. V11 stated, We do not have enough hot plates for this site. V11 added they run out of plates and utensils as its probably still in the resident's room and not returned to the kitchen. 3. The Week at a glance menu (Week 3) for lunch meal on November 18, 2025, included beef stroganoff with egg noodles and broccoli florets.On November 18, 2025, starting at starting at 12:10 PM, the lunch meal service was observed in the facility kitchen. The beef stroganoff with egg noodles mixture appeared like mushy with overcooked noodles and shredded beef. The broccoli appeared also overcooked and dull green in appearance.On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated the meal temperatures at the steam table should be 135-140 degrees Fahrenheit and palatability of foods served should be at least 125 degrees Fahrenheit.Facility undated policy and procedure titled Food Temperature Management at Bedside/Table-side ServiceIncluded: Purpose- To ensure patient safety and quality of care by maintaining food temperatures in accordance with CMS guidelines and Food Code, while prioritizing palatability and timely reheating practices.1.Temperature Standards: Initial Serving Temperatures (Staring Point)- The recommended starting temperature for hot foods at bedside/table-side service should begin at 135 degrees Fahrenheit (57 degrees Centigrade) or higher.3. Palatability consideration: In addition to meeting specific temperature targets, all hot foods must be prepared and served in a manner remains palatable (e.g., texture, moisture, aroma, and appearance suitable for immediate consumption).4. Time/Temperature Control Standards: If any hot food item drops below 125 degrees Fahrenheit at bedside/table side, it must be reheated promptly to reach 165 degrees Fahrenheit before serving to the patient.Facility policy and procedure titled (reviewed June 27, 2023) Palatability and Nutritive Value included:Policy: Food will be prepared, held, and served in a manner preserves nutritive value and palatability.Procedure: 1. Hot foods will be held at temperatures 135 degrees or above.4. Best efforts will be made to present hot and cold foods at point of service by using thermal lids Residents Affected - Many 145752 Page 6 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0804 and bases, heated or chilled plates and thermal pellets as necessary.5. Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council minutes. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 145752 Page 7 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observations, interviews and record review, the facility failed to provide meal preference as shown on the meal tickets.This applies to 5 of 5 residents (R13, R21, R31, R32, R33) observed for dietary services in the sample of 41.The findings include:On November 18, 2025, starting at 7:35 AM, the breakfast meal service was observed in the facility kitchen with V33 (Dietary Aide) platting the food and V53 (Dietary Aide) placing the nutritional supplements, thickened drinks and condiments on the tray. V53 stated that the cartons of milk and juice and coffee in pitchers are sent up for CNA's (Certified Nursing Assistants) to pass out. The milk cartons sent up in coolers were noted to be 2% milk. The residents' meal tickets did not show yogurt, pudding nor cottage cheese. (R21, R31, R32, R33) did not receive these. V33 stated that the facility does not have yogurt as they have run out for a while.1. R13's meal ticket included whole milk, fruit yogurt. On November 17, 2025, at 2:19 PM, R13 stated he prefers whole milk and that he only gets 2% milk. On November 18, 2025, at 9:31 AM, R13 received a bedside tray, R13 received 2% milk and did not receive yogurt. R13's care plan revised August 20, 2025, showed diet order of General, Regular, thin liquids, prefers whole milk at meals. Interventions included to determine food preferences through resident and family interview. Prepare & serve the resident's nutritional diet as ordered.2. R21's breakfast meal ticket included pudding 4 oz/ounce.R21's care plan dated November 18, 2025, included yogurt with meals for diet and interventions included to determine dietary preferences, provide dietary supplements, as ordered.3. R31's breakfast meal ticket included fruit yogurt.R31 care plan dated June 30, 2025, included yogurt per request, lactose free milk. Interventions included to determine food preferences through one-to-one interview and/or family interview, provide dietary supplements, as ordered.4. R32 breakfast meal ticket included cottage cheese and plain yogurt.R32's care plan dated October 29,2025, listed cottage cheese at breakfast and yogurt. Interventions included to determine food preferences through resident & family interview, prepare & serve the resident's nutritional diet as ordered.5. R33's breakfast meal ticket included fruit yogurt.R33 care plan dated October 16, 2025, listed lactose free diet. R33's meal ticked showed yogurt fruit. Interventions included to determine food preferences through one-to-one interview and /or family interview and to provide dietary supplements, as ordered.On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated that if the food preferences are on the meal ticket/tray cards, it should be given. 145752 Page 8 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observations interview and record review, the facility failed to serve diets as ordered.This applies to 8 of 8 residents (R1, R21, R22, R23, R24, R25, R26, R27) reviewed for dietary services in the sample of 41. The findings include:On November 18, 2025, starting at 7:35 AM, the breakfast meal service was observed in the facility kitchen with V33 (Dietary Aide) platting the food. The resident meal tickets which showed double portion (R25, R26, R27) received 2 pieces of toasts with one small piece of western omelet and a bowl of cereal. The resident meal tickets that showed yogurt (R1) did not receive the same. V33 stated that it's her understanding that double portion is giving two toasts instead of one. V33 added that the facility does not have yogurt as they have run out for a while. The resident meal tickets that showed superceral (fortified cereal) (R21, R22, R23, R24, R25) received grits or cream of rice.On November 18, 2025, at 9:02 AM, V32 (Cook) stated he did not prepare superceral as they had run out of oatmeal. V32 added that he prepared the grits and cream of wheat by adding boiling water and cooking it. 1.R1's EMR (electronic medical records) showed multiple diagnosis including multiple sclerosis nutritional deficiency, unspecified, age-related osteoporosis without current pathological fracture.R1's diet order in POS (physician order summary) included yogurt with meals.On November 18, 2025, at 8:37 AM, R1 received a room tray and her R1 's breakfast meal ticket showed plain yogurt, but she did not receive the same. R1 stated, I haven't got yogurt in a while.R1's plan revised October 14, 2025, included that R1 was on General, Regular, thin liquid, cottage cheese with fruit per request, yogurt with meals, orange juice preference.Interventions included to prepare & serve the resident's nutritional diet as ordered. Determine food preferences through resident & family interview. 2. R21's EMR showed multiple diagnosis including cerebral infarction due to unspecified occlusion or stenosis of unspecified, other vitamin B12 deficiency anemias, dysphagia, pharyngeal phase, vascular dementia, severe, with anxiety.R21's diet order in POS included General diet, Pureed texture, Thin Liquids consistency, Fortified Oatmeal in the morning for dietary supplement at breakfast.R21's care plan dated November 18, 2025, included the following medical &/or mental health conditions/behaviors which may compromise my nutritional status in the future and is on Pureed diet with regular fluids, yogurt with meals, super cereal, med pass, fortified oatmeal. Interventions included to prepare/serve my nutritional diet as ordered.3. R22's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia, oropharyngeal phase.R22's diet order in POS included General diet, Pureed texture, Nectar consistency, super cereal at breakfast.R22's care plan dated July 30, 2025, included that R22 is on Pureed meat texture, Nectar Thick liquid, double portion, at meals, super cereal at AM. Interventions included to prepare/serve the resident's nutritional diet as ordered. 4. R23's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia, oropharyngeal phase.R23's diet order in POS included General diet, Pureed texture, Thin Liquids consistency, Fortified Oatmeal.R23's care plan dated November 13, 2025, showed that R23 is at risk for compromised nutritional status related to: Diagnosis of Alzheimer's disease or related dementia, clinical diagnosis &/or expression of depression resulting in loss of appetite, lethargic behavior requiring cueing & stimulation. Diet Order: General, Pureed texture, Thin Liquids, fortified cereal at breakfast.Interventions included to prepare/serve the resident's nutritional diet as ordered. 5. R24's EMR showed multiple diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, unspecified severity, with other behavioral disturbance.R24's diet 145752 Page 9 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some order in POS included General diet, Mechanical Soft, chopped meat texture, Thin Liquids consistency, Fortified Oatmeal one time a day for supplement Super cereal in AM.R24's care plan dated September 7, 2025, showed that R24 has the following medical &/or mental health conditions/behaviors which may compromise his/her nutritional status in the future: diagnosis of dementia. Diet Order: General, mechanical soft, texture-chopped meat with straw, super cereal at breakfast.Interventions included to prepare/serve the resident's nutritional diet as order.6. R25's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit, dysphagia, oral phase.R25's diet order in POS included General diet, Mechanical Soft, ground meat texture, Thin Liquids consistency, super cereal in the morning for supplement every morning @ breakfast, double portions with meals, pudding bid (two times daily).R25's care plan dated August 23, 2025, showed R25 may be at risk for weight loss related to diagnosis of dementia or delirium, resulting in mental status changes, mental instability, confusion, disorientation, clinical diagnosis &/or expression of depression resulting in loss of appetite., behavioral patterns/symptoms, poor ability to communicate. Diet Order: Double Portion Mechanical soft-ground texture, super cereal at breakfast. Intervention included to prepare/serve the resident's nutritional diet as ordered. 7. R26's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease with late onset, malignant neoplasm of prostate.R26's diet order in POS included General diet, Regular texture, Thin Liquids consistency, Double portions at breakfast.R26's care plan dated November 13, 2025, showed R26's nutritional status is compromised secondary to diagnoses of dementia, heart failure. Interventions included to prepare/serve the resident's nutritional diet as ordered.8. R27's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, need for assistance with personal care.R27's diet order in POS showed Double Portions diet, Regular texture, Thin Liquids consistency, No added Salt.R27's care plan dated August 18, 2025, included that R27 is presently within his/her ideal body weight 32%(IBW) range. Resident has the following medical &/or mental health conditions/behaviors which may compromise his/her nutritional status in the future. Interventions included to prepare/serve the resident's nutritional diet as ordered.On November 18, 2025, at 8:47 AM, V25 (Certified Nursing Assistant) who was passing out breakfast meal trays in the 1 South unit stated If the resident asks for second portion, they (dietary staff) say that we don't have enough. That's not right. The food is for the residents. On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated that whatever is on the diet order per Physician should be served to meet the resident's nutritional needs. V31 added that double portion means to serve two of all main food items offered for breakfast including egg or meat portion, cereal and toast. 145752 Page 10 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a substantial evening snack when the mealtimes exceed 14 hours per resident.This applies to all residents that receive foods prepared in the facility kitchen.The findings include:Facility Data sheet dated November 18, 2025, showed that there was a census of 126 residents in the facility. Facility provided information that there was one resident on NPO (nothing by mouth) status.Facility Mealtimes chart showed as follows:Breakfast: 2 North Unit -7:45 AM 8:00 AM, 2 South Unit 8:00 AM - 8:15 AM, 2 Main Unit 8:15 AM -8:25 AM, Main Dining room [ROOM NUMBER]:25 AM - 8:40 AM, 1 South Unit 8:40 AM - 8:55 AM, 1 North Unit 8:55AM-9:10 AM.Dinner: 2 North Unit -4:45 PM - 5:00 PM, 2 South Unit 5:00 PM - 5:15 PM, 2 Main Unit 5:15 PM -5:25 PM, Main Dining room [ROOM NUMBER]:25 PM - 5:35 PM, 1 South Unit 5:35 PM - 5:45 PM, 1 North Unit 5:45 PM-5:55 PM.This showed that there was a 15-hour duration between the dinner and breakfast meal.On November 18, 2025, and November 19, 2025, between 8:30 AM-4:00 PM, multiple residents (R1, R2, R8 R9, R10, R13) stated that they do not receive a bedtime snack after the dinner meal.On November 18, 2025, at 4:11 PM, V11(Regional Dietary Manager) stated the facility sends cookies or graham crackers and Kool aide with the dietary staff to each unit around 6:30 PM when they go to collect the dinner meal trays. V11 stated the dietary staff put the snacks at the nurse's station. V11 stated he sends about 20-30 cookies per unit and that residents who want snacks get it from the nurse's station. V11 stated only 5 residents receive a labeled hs (evening) snack consisting of half a sandwich and these are mainly for the diabetic residents.On November 20, 2025, at 11:47 AM, V31 (Dietitian) stated the facility does not give a nourishing snack at bedtime currently. V31 stated if the time exceeds 14 hours between the dinner and breakfast meal, a substantial snack should be given.Facility policy and procedure titled Meal Snack Hours and Frequency (revised August 15, 2023) included: Policy-The facility provides three meals daily at regular times comparable to normal mealtimes in the community. The facility will also offer an evening snack to the residents. Meals and snacks will be served in a timely manner.Procedure: 4. As long as the facility is serving the evening meal and the breakfast meal 14 hours apart (or less), a nourishing snack if offered to all residents not on diets prohibiting bedtime nourishment. A nourishing snack is defined as a verbal offering of items, single or in combination, from the basic food groups. The facility will choose the snacks that are served at bedtime. However, the dietary manager, RD [Registered Dietitian] or DTR [Diet Technician] will solicit input from the residents and/or the resident council.5. If the time span between the evening meal and the next day's breakfast meal exceeds 14 hours, the facility is required to provide a substantial evening meal. A substantial evening meal is defined as offering three or more menu items at one time, one of which includes a high-quality protein, such as meat, fish, eggs, or cheese. The meal represents no less than 20% of the day's nutritional requirement. 145752 Page 11 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 implement an effective pest control program and failed to respond to sightings of rodent excrement, and dead and live rodents. The facility failed to take measures to eradicate and contain rodents including patching holes in walls, informing pest control vendor of rodent sightings, provide effective room cleaning, and staff failed to notify the Administrator of any evidence of pest or rodent presence in accordance with facility policy. This has the potential to affect all 126 residents who reside in the facility as reported on the Facility Data Sheet, dated November 18, 2025, completed by V1 (Administrator). The findings include:On November 18, 2024, at 10:34 AM, V24 (Pest Control Vendor Employee) stated he visits the facility weekly. V24 stated mice can enter a structure through a hole the size of a dime or under a door if there is enough space to see light. V24 stated he had instructed V22 (Maintenance Supervisor) to patch all holes in walls and that had not been completed yet. V24 stated last week on his visit there was a dead mouse found under a dining room table in the second-floor dining room.On November 18, 2025, at 10 :38 AM, V22 stated he had not completed patching all the holes on the second floor yet.On November 18, 2025, at 11:27 AM, V22 stated staff inform him of maintenance needs either by verbally telling him when he is in the building or entering the information into the TELS system. V22 stated for urgent needs the TELS system sends a notification to his phone.On November 18, 2025, at 2:48 PM, tour with V22, on the second-floor memory care dining room there was an approximate 3 inch hole seen under the heating vent around the pipe that runs into the wall.On November 18, 2025, at 2:54 PM tour with V22, inside the second-floor memory care unit soiled utility room closet, there was a hole approximately 2 inches under the bottom shelf along the wall around the heating pipe. V22 stated he had not finished patching all the holes yet.On November 19, 2025, at 10:10 AM in R9's room, on the first floor, V28 (Housekeeping Supervisor) and V22 moved the bed away from the wall. V22 shined a light behind the bed and observed small brown rice sized substance on the floor that V22 stated were mice droppings. V28 then shined the light to observe the same floor under the bed and described the substance on the floor as mouse droppings.R9's MDS dated [DATE], showed R9 was cognitively intact and required assistance with ADL's including supervision with eating, oral hygiene, bed mobility and transfer, partial assistance with upper body dressing and personal hygiene and substantial assistance with lower body dressing, bathing, and toileting, On November 18, 2025, at 3:37 PM, R9 stated over the past 6 months he had caught 9 mice in a mouse trap in his room. R9 stated on Saturday November 15, 2025, he and V6 (CNA) noticed a foul odor in his room. R9 stated they found a dead mouse under his bed. R9 stated V6 removed it and put it in a plastic garbage bag and removed it from the facility.On November 20,2025, at 1:01 PM, V6 stated she did notice a foul odor in R9's room on November 15, 2025, during the 3PM to 11PM shift and convinced R9 to take a shower. V6 stated while making R9's bed, she lifted the mattress to place the sheet and noticed the dead mouse under the bed. V6 stated R9 pulled the mouse from under his bed using his Reacher. V6 stated based on the smell and appearance of the mouse carcass, it looked like an adult mouse, and she thought it had been there for about 4-5 days. V6 stated she did not inform V22 or V1 because it was about 10:30 PM and R9 told her he would report it to V1 in the morning. V6 stated she had worked in the facility for about a year and did not know what a TELS system was. V6 stated she thought the nurse would write the finding of the mouse in the shift report, pass it on in the report and that V22 would be informed the next day. V6 stated she had seen live mice around the building and stated the mice usually come out in the evening shift and can be seen running out of the vents on the second floor or by the walls in various rooms on the first floor. V6 Residents Affected - Many 145752 Page 12 of 13 145752 11/24/2025 Forest View Rehab & Nursing Center 535 South Elm Itasca, IL 60143

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated everyone knows there are mice around here and nobody, especially the owner does anything about it.On November 18, 2025, at 4:00PM, V8 (LPN) who works the 1 south unit with V6, stated he has seen live mice on the unit on occasion but does not remember where exactly or when and did not recall if he reported the sighting or not.On November 18, 2025, at 4:08 PM, V1 stated he was unaware and had not been informed of the dead mouse found in R9's room on Saturday November 15, 2025. V1 stated the last report of mice in the building he was aware of was around 6 months ago. V1 stated if staff see live or dead mice or mice droppings, they should report the sighting to V1.Review of the pest vendor reports showed there were mice seen in R9's room and the room was treated for mice on June 26, 2025. R9's room was not checked again for rodents in the reports reviewed through November 18, 2025.On November 19, 2025, at 1:15 PM, V42 (Regional Director) stated if evidence exists of the presence of rodents mitigation steps should be taken immediately.The facility's policy titled Guidelines for Pest Control (Policy), dated October 31, 2025, showed It is the policy of the facility to ensure that an effective pest control program is in place. An effective pest control program is defined as measures to eradicate and contain common household pests, including mice. The Maintenance staff and all other staff will be cognizant of the necessity to maintain a clean, safe, and comfortable, homelike environment that is free of pests or rodents. Upon sighting of any pest or rodent or any evidence of a pest or rodent by any person in the facility, the Administrator will be notified. 145752 Page 13 of 13