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. Page 1 of 5 146065 146065 06/24/2024 Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On June 18, 2024 at 12:30 PM, R4 was sitting in the dining room eating a pulled chicken barbeque sandwich. R4 said, I thought today was going to be taco Tuesday. I really wanted tacos. Now they served us barbeque chicken on a bun. Also, they gave us mashed potatoes but no gravy. They were supposed to give us Spanish rice. The potatoes are too dry to eat. On June 18, 2024 at 12:04 PM, The facility's Daily Spreadsheet entitled S/S 24 (Spring/Summer 2024) Week 1 was reviewed with V3 (FSD-Food Service Director) and V4 (Dietitian). The spreadsheet shows the following menu items should have been served to the residents: Sunday (June 16, 2024): Lunch: Herb rubbed roast beef (2 ounces protein) Brown gravy (2 fluid ounces) Cauliflower mash (1/2 cup) Green peas (1/2 cup) Lemon cheese bar (1 bar) Bread (1 slice) Margarine (1 teaspoon) Coffee/Tea (6 ounces) Condiments (1 each) V3 (FSD) said the following items were substituted for the planned menu and served to the residents on Sunday, June 16, 2024 for lunch: Hot dogs Tater tots Bread/bun Oatmeal pies Coffee/Tea/Juice V3 said she made the choice to substitute hot dogs for the roast beef on the planned menu because she was told to cut the dietary budget and the beef roast was too costly. V3 continued to say the facility ran out of bread and ketchup on Sunday so some residents did not receive bread or a hot dog bun with their meal. V3 also said no green peas were served, and the oatmeal pie was the substitution for the lemon cheese bar. V3 continued to say the alternate food options of peanut butter and jelly 146065 Page 2 of 5 146065 06/24/2024 Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sandwich, grilled cheese sandwich, and deli meat sandwich could not be served at lunchtime because the facility did not have bread. The only substitute available to residents was cottage cheese with fruit. V3 also said the facility ran out of ketchup packets and mayonnaise packets. The Daily Spreadsheet continues to show the following items were to be served on Sunday, June 16, 2024 for dinner: Turkey and Swiss cheese sandwich (1 sandwich) Cucumber and tomato salad (1/2 cup) Chilled pears (1/2 cup) Sandwich bread 2 slices 2 percent milk (8 ounces) V3 said she substituted chicken pasta salad with veggies for the turkey and Swiss cheese sandwich, garlic bread, Italian ice cup and coffee/tea/juice. V3 continued to say she substituted the Italian ice cup for the pears on the menu. V4 (Dietitian) said Italian ice is not a substitution for fruit. V4 continued to say she had not been consulted regarding the menu substitutions made by V3 to ensure the same nutritive value food items were being served to the residents. The facility Daily Spreadsheet for Week 1 Monday shows the following items should have been served for breakfast on Monday, June 17, 2024: Choice of Vitamin C Juice (6 ounces) Choice of hot or cold cereal (1/2 cup or 3/4 cup) Scrambled eggs with cheese (2 ounces protein) English Muffin (1 slice) Jelly (1 each) Margarine (1 each) 2 percent Milk (8 ounces) Decaf coffee (6 ounces) Condiments V3 said the facility served hot or cold cereal, a sausage patty, and a biscuit with jelly for breakfast because the facility ran out of eggs and also did not have English muffins. V3 said the facility also ran out of apple juice. V3 continued to say the reason she ran out of eggs was due to the budget cut. V3 said she was only able to order one case of eggs, so the residents were not served scrambled eggs. V3 continued to say she did not order yogurt for the residents because of the budget cuts 146065 Page 3 of 5 146065 06/24/2024 Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172

F 0803 she was told to make. Level of Harm - Minimal harm or potential for actual harm Monday's Daily Spreadsheet Week 1 shows the following items should have been served for lunch on June 17, 2024: Residents Affected - Many Pulled pork and bean burrito (1 each) Mexican rice (1/2 cup) Roasted corn (1/2 cup) Fresh melon cubes (1/2 cup) V3 said the residents were served mostacciolli with sausage, mixed vegetables, and a cookie on Monday June 17, 2024 at lunch. V3 said she ran out of fresh melon and did not substitute another fruit option for the melon. The facility's Daily Spreadsheet Week 1 for Tuesday shows the following items should have been served for breakfast on June 18, 2024: Choice of Vitamin C Juice (6 ounces) Choice of Hot or Cold Cereal (1/2 cup or 3/4 cup) Scrambled Eggs (1 ounce protein) Sausage Gravy (2 ounces) Biscuit (1 each) 2 percent milk (8 ounces) Decaf coffee (6 ounces) Condiments (1 each) V3 said she was unable to serve the scrambled eggs on Tuesday, June 18, 2024 because the facility ran out of eggs. V3 said she also was unable to serve the planned biscuit from the menu because she used the biscuits the day before with breakfast, and also did not serve the sausage gravy. V3 said she did not substitute another protein for the sausage gravy. The facility's Daily Spreadsheet Week 1 for Tuesday shows the following items should have been served for lunch on June 18, 2024: Pierogi Casserole (1 piece) Buttered cabbage (1/2 cup) Parslied carrots (1/2 cup) 146065 Page 4 of 5 146065 06/24/2024 Abbington Vlge Nrsg & Rhb Ctr 31 West Central Roselle, IL 60172

F 0803 Rice Krispie bar (1 bar) Level of Harm - Minimal harm or potential for actual harm Coffee/Tea (6 ounces) Condiments (1 each) Residents Affected - Many The menu cards provided to the residents on Tuesday June 18, 2024 showed a change from the planned menu. The diet card dated Tuesday, June 18, 2024 showed chicken tacos, Spanish rice, mandarin oranges, bread, and margarine were going to be served for lunch in place of the pierogi casserole. On Tuesday June 18, 2024 at 12:15 PM, the residents were served a pulled chicken barbeque sandwich on a bun, mashed potatoes without gravy, broccoli, and mandarin oranges. V3 said she made the change from pierogi casserole to chicken tacos due to the hot temperatures outside and wanting to keep the kitchen cooler and not have to turn on the oven to cook the pierogi casserole. V3 continued to say she ran out of the taco shells due to the budget cuts. V3 served the pulled barbecue chicken in place of the chicken tacos. On June 18, 2024 at 2:39 PM, V1 (Administrator) said, We were over budget and working on decreasing the budget by decreasing the amount of money spent on food. [Corporate] provides the food menus and put the budget restriction on [V3] (FSD). The food budget was cut in half about three weeks ago. The facility's policy entitled Menu Changes, dated 2017 shows: Menu items will be served as planned whenever possible. Due to unavoidable circumstances, temporary changes may be made on the menu. Changes will be indicated on the posted menu prior to meal service. The menu change will be noted in a file kept for that purpose. The reason for the change will be noted. Changes made will be of similar nutritive value. Permanent changes in the menu must be approved by the dietitian. 146065 Page 5 of 5