Health inspection·June 24, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm 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 items to residents as shown on the facility's planned and approved menu. Residents Affected - Many This applies to all 27 residents residing in the facility reviewed for missing food items and menus served as planned. The findings include: The Facility Data Sheet dated June 18, 2024 shows 27 residents reside in the facility. The facility's Client List Report dated June 18, 2024 shows all 27 residents have physician orders for an oral diet. On June 18, 2024 at 10:41 AM, a general tour of the kitchen was conducted with V5 (Cook). The walk in cooler and walk in freezer shelves were sparse, with very few food items. Also noted was that the facility did not have eggs, mayonnaise in a jar or in individual packets, and no ketchup in a jar or individual packets. V5 said the facility ran out of bread over the weekend while serving hot dogs. On June 18, 2024 at 10:54 AM, R1 was lying in bed in his room. R1 said, On Sunday, it was Father's Day. We were supposed to be served roast beef. Instead, we got two cold hot dogs. They ran out of bread and buns, so I was served two plain hot dogs with no ketchup, no mayo, and no apple juice. Wow, happy Father's Day to me! Yesterday, I asked for a ham sandwich. They did not have mayonnaise, so they gave me tartar sauce instead. Would you want to eat a ham sandwich with tartar sauce? This has been going on for a few weeks now. On June 18, 2024 at 11:00 AM, R2 was sitting in a chair in his room. R2 said, The other day they did not have mustard for the hot dogs. They also ran out of yogurt, which I really enjoy. They serve hard boiled eggs almost every day for breakfast. I don't like hard boiled eggs, but what choice do I have? I just eat the dry cereal and give my eggs to my roommate because he likes hard boiled eggs. When we do get condiments like ketchup and mustard packets, I keep the ones I don't use for a rainy day when they are out of them. On June 18, 2024 at 11:10 AM, R3 was sitting in a chair in his room. R3 said the facility recently ran out of ketchup, hot dog buns, bread, and apple juice. They run out of everything. We never get what they say they are going to serve us. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 146065 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)