Health inspection·June 26, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure the breakfast meal was a smooth pureed consistency for 1 of 1 residents (R1) reviewed for pureed diets in the sample of 6. Residents Affected - Few The findings include: R1's Swallow Screening Note dated 5/13/25 showed R1 had diagnoses of dementia and an unspecified muscle disorder. The note showed during the swallow evaluation, R1 remained inconsistent in his ability to swallow and adequately clear (food) bolus, resulting in expectorating (coughing up) bites . It is recommended that the patient's diet be downgraded to a pureed consistency for safety and improved nutritional intake. R1's Dietary Note date 5/23/25 showed R1 was evaluated by V3 Registered Dietician for weight loss. The note showed R1's diet had been downgraded to a pureed consistency for safety. On 6/26/25 at 8:00 AM, V5 [NAME] plated R1's breakfast tray. At 8:01 AM, R1 was served breakfast which included scrambled eggs, pureed sausage, applesauce, and oatmeal. Clumps of eggs were noted in the scrambled eggs. Clumps of oatmeal were noted in the oatmeal. R1 picked up his fork and began eating his eggs. R1 appeared to be chewing his eggs. When R1 was asked if he needed to chew his food, R1 stated, Yes, I have to chew it. What else would I do? At 8:05 AM, V5 [NAME] walked over to R1's table and was shown the clumps of food in R1's eggs and oatmeal. V5 stated, I see the clumps in his eggs. I did blend them when I made them, but they got clumpy on the steam table. I want my purees with no clumps in them. I should not have served his eggs. I should have blended them with milk to smooth them out. V5 stated she also saw clumps in R1's oatmeal but stated, I don't puree his oatmeal because he won't eat it if I do. On 6/26/25 at 8:59 AM, V3 Registered Dietician stated the consistency of pureed foods should be silky smooth with no clumps. V3 stated residents should not have to chew pureed foods. The facility's Guidelines for Pureed Preparation policy (dated 2021) showed, The pureed diet provides food with a semi-liquid to semi-solid consistency (i.e. pudding-like) . If the pureed food appears to be thick you may add more liquid or if it appears thin you may add more thickener until desired consistency is achieved . Page 1 of 3 146069 146069 06/26/2025 East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111

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 interview and record review the facility failed to accommodate residents' food preferences and choices for 4 of 6 residents (R2, R3, R5, R6) reviewed for residents' food preferences and choices in the sample of 6. The findings include: The facility's daily menus dated 6/11/25-6/24/25 showed primarily cold foods and/or room-temp foods, such as cold cereal, canned fruit, deli meat sandwiches, potato chips, salads, ice cream, and pudding, were listed as the available food items on the menus. A limited selection of hot foods were listed as menu choices which included scrambled eggs, oatmeal, hamburgers, mashed potatoes, and grilled cheese sandwiches. The menus showed, Due to complication in the kitchen we will be in emergency mode until further notice we do apologize for the inconvenience. On 6/26/25 at 8:59 AM, V3 (Registered Dietician) stated on 6/11/25, the facility began serving primarily cold foods, including sandwiches, salads, and fruit to residents at meals because the dumbwaiter (elevator that carries food from the kitchen to the facility's dining room) had broken. V3 stated the facility was concerned about the safety of their kitchen staff if they required the kitchen staff to carry hot meals/dishes up the stairs from the kitchen to the facility's dining room, while the dumbwaiter was broken. V3 stated that due to this potential safety concern for their kitchen staff, they initiated an emergency cold food plan to serve primarily cold foods to the residents until the dumbwaiter was fixed. However, due to resident complaints related to the cold food menu/service, the facility resumed their regular hot food menu on 6/25/25. V3 stated, The dumbwaiter is still broken but we went back to serving hot foods yesterday because so many residents complained about the cold food. People said they were tired of getting bread and sandwiches. I was here when the dumbwaiter went down and did approve the emergency cold food menus. We did offer some hot foods during that time such as oatmeal and instant mashed potatoes . On 6/26/25 at 8:48 AM. R2 was asked about the foods served to her last week in the facility. R2 stated, I ate a lot of turkey sandwiches, tuna, and chicken salad. They said no hot foods because a lift was down. That's not what I wanted to eat. Last Friday night, I was served 10 pieces of watermelon, cottage cheese, and pudding. I couldn't eat that. I sent my boyfriend to go get me food. On 6/26/25 at 8:40 AM, R3 stated last week he was served all cold foods. R3 stated, I ate what they brought but it was mostly sandwiches. We kept getting the same foods over and over. I understand getting cold foods for a couple of days, but it went on far too long. A couple of days ago, I said I wasn't going to eat that stuff anymore. I had my son bring me food. On 6/26/25 at 8:26 AM, R5 stated they told us the waiter was down and they couldn't bring up hot foods from the kitchen. R5 stated, I'm a meat and potatoes guy. A couple of days of sandwiches I can understand but not a whole week. On 6/26/25 at 11:44 AM, R6 was asked about the foods served to him last week in the facility. R6 stated, I couldn't eat anymore sandwiches or oatmeal. Every day it was a sandwich for lunch and dinner. One night they tried to serve me a tray of fruit and cottage cheese. I prefer hot foods for at least one meal. I spent most of the week having food brought in by my daughter or ordering out. 146069 Page 2 of 3 146069 06/26/2025 East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111

F 0806 Level of Harm - Minimal harm or potential for actual harm A facility Complaint/Grievance Report dated 6/24/25 showed a complaint from R3 and his family in regard to foods served while the facility's emergency cold food plan was in place. The facility's Therapeutic Diets Client's Right to Choose policy (dated 2021) showed, Client's right to be served food they choose and prefer will be honored. Residents Affected - Some 146069 Page 3 of 3