Forest View Rehab & Nursing Center

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 (Resident R5, Resident R37, Resident R38, Resident R39, Resident R40, Resident 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 Resident R5, Resident R37, Resident R38, Resident R39, Resident R40, Resident 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.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0600 Level of Harm - Minimal harm or potential for actual harm

both residents yelling, with Resident 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 Resident R4 and Resident 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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 (Resident R13, Resident R21, Resident R31, Resident R32, Resident 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. (Resident R21, Resident R31, Resident R32, Resident R33) did not receive these. V33 stated that

the facility does not have yogurt as they have run out for a while.1. Resident R13's meal ticket included whole milk, fruit yogurt. On November 17, 2025, at 2:19 PM, Resident R13 stated he prefers whole milk and that he only gets 2% milk. On November 18, 2025, at 9:31 AM, Resident R13 received a bedside tray, Resident R13 received 2% milk and did not receive yogurt. Resident 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. Resident R21's breakfast meal ticket included pudding 4 oz/ounce.Resident 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. Resident R31's breakfast meal ticket included fruit yogurt.Resident 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. Resident R32 breakfast meal ticket included cottage cheese and plain yogurt.Resident 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. Resident R33's breakfast meal ticket included fruit yogurt.Resident R33 care plan dated October 16, 2025, listed lactose free diet. Resident 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.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.Resident R24's care plan dated September 7, 2025, showed that Resident 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. Resident R25's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, cognitive communication deficit, dysphagia, oral phase.Resident 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).Resident R25's care plan dated August 23, 2025, showed Resident 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. Resident 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.Resident R26's diet order in POS included General diet, Regular texture, Thin Liquids consistency, Double portions at breakfast.Resident R26's care plan dated November 13, 2025, showed Resident 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. Resident R27's EMR showed multiple diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, need for assistance with personal care.Resident R27's diet order in POS showed Double Portions diet, Regular texture, Thin Liquids consistency, No added Salt.Resident R27's care plan dated August 18, 2025, included that Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 (Resident R1, Resident R2, Resident R8 Resident R9, Resident R10, Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forest View Rehab & Nursing Center

535 South Elm Itasca, IL 60143

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)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident 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 Resident R9's room and the room was treated for mice on June 26, 2025. Resident 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.

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Facility ID:

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