Health inspection·December 18, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide dignity to a resident during provisions of care.This applies to 1 of 26 residents (R118) reviewed for dignity in the sample of 26.The findings include: R118's EMR (Electronic Medical Record) showed R118 was admitted to the facility on [DATE], with diagnoses that included intervertebral disc disorder with radiculopathy, lumbar region, acute respiratory failure with hypoxia, generalized muscle weakness, other chronic pain, dizziness, and giddiness. R118's MDS (Minimum Data Set), dated October 27, 2025, showed R118 was cognitively intact and was dependent on staff for showering.On December 16, 2025, at 9:04 AM, R118 said there was an incident, he thinks it was maybe two weeks ago, when the CNA (Certified Nurse Assistant), whose name he said he could not remember, took him to the shower room and turned on the water. The CNA told R118 she would be right back; she had to go to the other shower room for another resident. R118 said it was around 15 minutes later when the CNA returned, and he was shivering cold. R118 said he was not able to wash himself, so he was just sitting there naked, waiting, and it was cold. On December 16, 2025, at 2:16 PM, V2 (DON/Director of Nursing) said when giving a resident a shower, the resident should never be left alone in the shower room or left naked. On December 16, 2025, at approximately 3:30 PM, V1 (Administrator) said she spoke with R118, and he pretty much told her the same thing. V1 said it was common sense that the staff member should not have left [R118] in the shower room by himself. Page 1 of 2 146077 146077 12/18/2025 Serenity Estates at Morris 1223 Edgewater Morris, IL 60450

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 provide foods at a palatable temperature acceptable to the residents. This applies to 13 of 13 residents (R3, R7, R23, R27, R31, R35, R48, R73, R105, R107, R111, R118, R123) reviewed for dining in the sample of 26. The findings include: Facility Fall/Winter menu (Week 3, Tuesday) for lunch included (hot) Italian Beef Sandwich, Potato Wedges, and 3 Bean Salad. During initial tour the following residents stated the food is cold: On December 15, 2025, at 11:00 AM, R105 stated, I eat in the room and dining room. The food is not really hot. On December 15, 2025, at 11:23 AM, R73 stated, Food is high quality, but they have trouble keeping it warm.On December 15, 2025, at 11:39 AM. R111 stated, I eat in the room. Food is not very edible and is cold.On December 15, 2025, at 11:55 AM, R35 stated the food is ice cold. R35 stated she eats in her room and remarked she does not understand why her food is cold, as her room is closer to the kitchen. On December 15, 2025, at 12:17 PM, R23 was eating in dining room and stated the food is usually served cold.On December 16, 2025, at 9:04 AM, R118 stated the food is sometimes served cold. On December 16, 2025, at 9:53 AM, R3 stated the food is sometimes served cold. On December 16, 2025, at 1:30 PM, during Resident Counsel Meeting, R7, R27, R31, R48, R107, R111, R123 stated the food is usually served cold. On December 16, 2025, starting at 11:25 PM, during meal service, the plates were noted heated by a heating lamp above the steam table. Once the food was plated, it was placed on a tray and covered by a metal lid for room trays. These trays were then loaded onto a free-standing cart, and then covered by a plastic liner and rolled unto the unit. On December 16, 2025, at 12:13 PM, the meal temperatures tested by V3 (Dietary Manager) after last meal tray was served and showed Italian roast beef sandwich 104.5 degrees Fahrenheit, potatoes wedges 134.9 degrees Fahrenheit. Other item served was cold item of 3 bean salad. When asked, V3 responded the facility does not have heating pellets for each plate and has only one insulated enclosed cart for the C-Wing. On December 17, 2025, at 9:26 AM, V18 (Dietitian) state the palatability of foods should be between 110-120 degrees Fahrenheit. V18 added the facility does not have a policy for palatability of food. Residents Affected - Some 146077 Page 2 of 2