Inspection·April 28, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On April 26, 2023, at 2:18 pm V3 MDS Coordinator stated she makes the MDS schedule monthly and provides it to the receptionist to send out invitation letters and makes calls to invite and schedule time that family representative can participate. On April 26, 2023, at 2:58 pm V28 Social Worker stated the facility documents the care plan meeting occurred by using the sign in sheet. There is not always a progress note written. Some care plan meetings have been missed. On April 26, 2023, at 4:16 pm V3 stated a progress note is not necessarily written to document the care plan meeting. The resident's care plan is updated and use the sign in sheet. On April 27, 2023, at 8:23 am V3 presented an updated sign in sheet. V3 stated the meeting occurred, but she forgot to get signatures. V3 stated she signed R7 and R34's names on the sign in sheet because they are unable to sign for themselves. V3 stated she got signatures from the staff, but they would not have signed if they had not attended. On April 27, 2023, at 12:02 pm V28 stated she signed the updated attendance sheet for R7 and R34. V28 stated she is a member of the interdisciplinary team, but she did not realize she was participating in a care plan meeting at the time they occurred this month. On April 27, 2023, at 12:40 pm V14 Dietary Manager stated he signed the multi-disciplinary attendance sheets for R7 and R34, but he did not participate in their care plan meetings in January and April of this year. V14 stated V3 handed him a stack of papers and instructed him to sign them. On April 26, 2023, at 2:55 pm R34 stated he declined to participate in his care plan meetings. R34's EHR (Electronic Health Record) was reviewed. No documentation was noted regarding R34's IDT (Interdisciplinary Team) care plan meeting. Review of the Signature of the Multidisciplinary Team sign in documents R34's last IDT meeting occurred on October 20, 2022. The facility provided an Upcoming Care Plan Meetings at a Glance for April 2023, R7 and R34 were not listed. The facility did not provide an Upcoming Care Plan Meetings at a Glance for January 2023. The facility policy Care Planning -Interdisciplinary Team revised date September 2013 states the Care Planning / Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a care planning / interdisciplinary team that includes, but is not limited to the resident's attending Physician, Register Nurse who has responsibility for the resident, Dietary Manager / Dietician, Social Services Worker, Activity Director / Coordinator, Therapist, Consultants, Director of Nursing, Charge Nurse, and Nursing Assistant. The resident, their family or legal representative are encouraged to participate in the development of and revision to the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 2 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care and a bed bath to promote cleanliness and prevent infection. This applies to 2 of 2 residents (R28 and R33) reviewed for ADLs (Activities of Daily Living) in a sample of 19. Residents Affected - Few The findings include: 1. R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility with diagnoses including lack of coordination, reduced mobility, generalized muscle weakness, legal blindness, and benign prostatic hyperplasia with lower urinary tract symptoms. R28's MDS (Minimum Data Set) dated April 10, 2023, showed R28 was cognitively intact and was totally dependent on staff for bed mobility, dressing, toileting, and personal hygiene. On April 25, 2023, at 11:05 AM, R28's room had a strong odor of urine. R28 said he could not remember the last time the staff cleaned him up and he was not too happy about it. V10 (CNA/Certified Nurse Assistant) and V11 (CNA) entered R28's room and began to provide incontinence care for R28. R28's incontinence brief was removed and R28 was turned to the side. R28's incontinence brief was very full and R28's incontinence pad had a large urine stain, with both wet and dry areas, covering 75% of the incontinence pad. V10 wiped R28's buttocks with soapy water, patted it dry, applied cream, and then placed new incontinence brief under R28. V10 did not change gloves or perform hand hygiene when going from dirty care to clean care. R28 was rolled onto his back and V11 fixed incontinence brief on the opposite side and closed the brief. R28 did not receive perineal care during incontinence care. R28 continued to smell of urine. On April 25, 2023, at 11:15 AM, V10 said she cleaned R28's skin along his stomach fold but did not clean the perineal area and thigh folds. On April 26, 2023, at 12:15 PM, V2 (DON/Director of Nursing) said the staff should clean the perineal area for male residents when providing incontinence care. The facility's Perineal Care policy dated November 2022, shows to cleanse the shaft of the penis, cleanse the scrotum, and to clean and dry the bottom of the scrotum and the anal area. 2. R33's EMR showed R33 was admitted to the facility with diagnoses including Parkinson's disease, seizures, dementia, hypertension, and hypothyroidism. R33's MDS dated [DATE], showed R33 had severe cognitive impairment and was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. On April 26, 2023, at 11:47 AM, V12 (CNA) provided a bed bath and incontinence care for R33. V12 gathered two water basins, one with clean water and one with soapy water. V12 placed a washcloth in the soapy water basin and began wiping legs and feet and dipping back into soapy water basin. V12 did not rinse R33 after with clean water before patting her dry. V12 turned R33 away from her and R33's incontinence brief had a large, formed bowel movement. V12 took disposable wipes and wiped as much stool off R33's buttocks. V12 then took the same washcloth from soapy water basin and wiped R33's buttocks and puts washcloth back into soapy water and wiped R33's buttocks again. V12 did not throw (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 3 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few away the dirty water and get new soapy water in basin. V12 applied a new incontinence brief under resident without providing perineal care, changing gloves, or performing hand hygiene. V12 puts a new washcloth into the dirty soapy water bucket and began wiping residents' face, arms, and chest. On April 26, 2023, at 12:15 PM, V2 said the staff are supposed to clean the entire perineal care even if the resident only had a bowel movement. V2 said the staff should use clean water to rinse after using soapy water. V2 also said the staff should get new, clean water after using the water to clean the resident after having a bowel movement. V2 also said the staff should be changing their gloves and performing hand hygiene when going from dirty to clean during incontinence care. The facility's Bed Baths policy, dated November 2022, shows to expose the back and buttocks and wash, rinse and dry the area, change the bath water in the basin, obtain a clean washcloth, perform hand hygiene, and don new gloves. For females, expose the perineal area washing the pubic area with downward strokes from the front to the back. The facility's Hand Hygiene policy, dated May 2022, shows the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene should also be used when, during resident care, moving from a contaminated body site to a clean body site, and after assistance with personal body functions (e.g., elimination, hair grooming, smoking). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 4 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and ensure a resident on a gastrostomy tube feeding was receiving the total amount ordered. This failure resulted in a 10.44 percent weight loss in three months. This applies to 1 of 2 residents (R36) reviewed for gastrostomy tube feedings. Residents Affected - Few The findings include: According to the Electronic Health Record (EHR) R36 had diagnoses including Parkinson's Disease, protein calorie malnutrition, hypertension, gastroesophageal reflux disease, and acute embolism and thrombosis of left lower extremity. The Minimum Data Set (MDS) dated [DATE] showed R36 was totally dependent on one staff for feeding, and was receiving gastrostomy tube feedings. R36 was 69 inches tall and weighed 143 pounds on admission. The MDS showed R36's cognition was severely impaired. A Care Plan showed R36 had unplanned weight loss with interventions to contact the physician and dietitian immediately if weight decline persists. The Physician Order Sheet (POS) showed an order dated 03/14/2023 for Osmolite 1.5 calorie at 80 milliliters per hour (ml/hr) to start at 3:00 PM and end at 9:00 AM. The EHR showed the following weights: on 01/26/2023, 142.7 pounds; on 02/23/2023, 142.8 pounds; on 02/13/2023, 142 pounds; on 03/01/2023, 129 pounds; on 03/08/2023, 128.6 pounds; on 03/15/2023, 129 pounds; on 03/22/2023, 131 pounds; on 03/29/2023, 130 pounds; on 04/05/2023, 130 pounds; on 04/12/2023, 132 pounds; on 04/19/2023, 130 pounds; on 04/26/2023, 127.8 pounds; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 5 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0692 on 04/27/2023, 127.6 pounds. Level of Harm - Actual harm On 01/26/2023, the resident weighed 142.7 pounds and on 04/26/2023, the resident weighed 127.8 pounds which is a 10.44 % loss. Residents Affected - Few On 04/25/2023 at 11:35 AM, R36 was lying in bed and did not have any bottles of Osmolite hanging at the bedside. V17 (R36's family member) said R36 receives a feeding through his gastrostomy tube from 3:00 PM until 9:00 AM. V17 said the nursing staff usually starts the feeding later than 3:00 PM sometimes 5:00 PM and V17 does not know what time they discontinue it at. V17 said the dietitian started the continuous feedings to make sure R36 was receiving the correct amount consistently to keep his weight stable. On 04/26/2023 at 8:50 AM, R36 way lying in bed and did not have the Osmolite feeding infusing. V10 (Certified Nursing Assistant/CNA) and V15 (CNA) said they had provided incontinence care for R36 at 8:00 AM and the feeding was not infusing and was no longer even connected. V10 and V15 weighed R36 using the total body mechanical lift and R36's weight was 127.8 pounds. On 04/26/2023 at 9:05 AM, V6 (RN) said she had discontinued R36's feeding around 8:45 AM because the bottle was empty. She did not start another Osmolite feeding bottle. On 04/26/2023 at 3:19 PM, V17 said R36's feeding was started at 3:30 PM on 04/25/2023, a half hour later than scheduled. On 04/27/2023 at 10:24 AM, V19 (Registered Dietitian) said she only visits the facility once a month and that if the resident receiving gastrostomy tube feedings is losing weight, they should notify her and the doctor. V19 said the facility did not notify me regarding R36's weight loss yesterday. R36 should be receiving a total of 1440 ml of Osmolite 1.5 calorie. V19 said weight loss could happen if he was not receiving the full amount of 1440 ml. V19 said if a feeding was started late, it was more important to ensure the total amount of 1440 ml was received, instead of ending it at a certain time. On 04/27/2023 at 10:38 AM, V22 (Medical Doctor/MD) said he would not expect any weight loss in residents receiving tube feedings. V22 was not notified of R36 having a weight loss. On 04/27/2023 at 2:20 PM, V26 (nurse) said she works the night shift from 10:00 PM until 6:00 AM and said the same container, which had been started on the evening shift, will usually last for the entire shift and would not be empty at 6:00 AM. V26 said she did not start a new feeding bottle for R36 on 04/26/2023. On 04/27/2023 at 4:29 PM, V2 (Director of Nursing/DON) said either she or the nurse should notify the dietitian and the physician when a resident has weight loss. According to V2, the physician and dietitian have not been notified with R36's weight loss as of now. V2 said the Osmolite containers are 1000 ml containers. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2023 do not show any documented total feeding amounts infused. The facility's Care and Treatment of Feeding Tubes policy dated 12/2022 included the staff should be ensuring the administration of enteral nutrition is consistent with and follows the practitioner's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 6 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0692 orders. Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 7 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to communicate pertinent clinical information with the dialysis provider, failed to document a post dialysis assessment, failed to ensure necessary precautions to protect the access site, and failed to document adherence with fluid restriction for 1 of 1 resident (R49) reviewed for dialysis in a sample of 19. Residents Affected - Few Findings include: According to the face sheet R49 had diagnoses including end stage renal disease, atrial fibrillation, and cerebral infarction. The Minimum Data Set (MDS) dated [DATE] showed R49's cognition was moderately impaired and required limited assistance with activities of daily living (ADLs). R49 walks with a cane and was able to feed himself. The Physician Order Sheet (POS) shows R49 received hemodialysis treatment three times per week. An order dated 3/23/23 showed R49 was on one liter fluid restriction. On 4/26/2023 at 12:17 PM, V16 (Registered Nurse/RN dialysis center) stated communication between the nursing home and dialysis center would be written exchange of clinical information. The dialysis center expects to receive information regarding the resident's vital signs, medication given that day, new medication ordered, any new change in condition and any abnormal labs be sent with the resident to the dialysis center. After treatment the dialysis center would document the resident's vital signs, weights, amount of fluid removed, any medication administered, and any change in condition on the communication form received from the facility. V16 stated the communication between the facility and dialysis center for R49 has been inconsistent. V16 said R49 had an arteriovenous fistula (AV fistula) in the left upper arm for dialysis access. On 4/26/23 at 4:00 PM, V18 (RN) stated R49 usually returns from dialysis around 8:30 PM on Mondays, Wednesdays and Fridays. V18 could not provide any documentation of clinical information received from the dialysis center. V18 said if they receive any documents, they would be placed in the basket at the nurses station to be scanned into the electronic medical record. V18 stated upon return from dialysis the nurse should document the resident assessment in the progress notes in the Electronic Health Record (EHR). During April 2023 R49's nursing progress notes had only one post dialysis resident assessment dated [DATE]. No dialysis communication forms were found in the EHR. After multiple requests, the facility did not provide any post dialysis communication documentation for R49. On 04/26/2023 at 04:05 PM, V6 (RN) stated she only sends R49's transfer sheet to dialysis, but not a communication form. R49's care plan for dialysis treatment did not include interventions to protect the AV fistula by not taking blood pressure or blood draws on the arm with the fistula. No cautionary sign was observed in R49's room. No cautionary alert was noted in the EHR. R49's care plan erroneously identifies the AV fistula on the left lower arm, it is located in the left upper arm. R49's April 2023 Medication Administration Record (MAR) did not have documentation of assessment for AV fistula bruit and thrill. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 8 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 0698 Level of Harm - Minimal harm or potential for actual harm R49's care plan does not indicate the amount of fluids served from dietary or given by nursing to establish a plan to adhere to the fluid restriction. On 4/26/23 and 4/27/23, R49 had a water pitcher filled with 900 milliliters (mls) of water, a half full twelve ounce bottle of coca cola, and eight ounce cup of ice on the over the bed table. Residents Affected - Few On 4/26/23 at 12:35 PM R49 was served coffee with cream in eight ounce cup with three ounces gone, eight ounce glass of red juice was empty, eight ounce cup of white liquid with six ounces gone, eight ounce glass of water with three ounces gone, a total of 690 mls consumed at the end of the meal. On 4/27/23 at 9:05 am R49 was served eight ounce cup of coffee with four ounces gone, four ounces of apple juice and eight ounces of water not consumed, a total of 120 mls consumed by the end of the meal. There is no documentation of liquid intake to verify adherence to the fluid restriction order. The facility's Hemodialysis policy dated 3/2023 includes there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing and dialysis staff. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding and other complications. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access is located. The nurse will ensure that the dialysis access site is checked before and after dialysis treatment every shift for patency by auscultating for bruit and palpating for a thrill. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 9 of 10 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 145663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Bella of Aurora 1017 West Galena Boulevard Aurora, IL 60506 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 - Some 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 follow the diet spreadsheet and standardized recipes to serve the portions as shown for pureed diets. This applies to 8 of 8 residents (R8, R11, R12, R13, R14, R33, R37, R207) observed for meal service in the sample of 19. The findings include: The Diet Spreadsheet Menu: Ontray Fall/Winter 2022/2023 Week 2 Day:11- Wednesday pureed lunch meal included: pureed chicken alfredo #6 dip over fettuccini #10 dip pasta, pureed carrots #12 dip, and pureed bread stick #20 dip. The Pureed Chicken [NAME] Over Fettuccine recipe instructions say To Puree Chicken Alfredo, Place prepared chicken alfredo in a washed and sanitized food processor. Blend until smooth. To Puree Pasta, Place prepared pasta and melted margarine in a clean and sanitized food processor. Blend until smooth. Pureed Bread Stick recipe instructions say, Place bread sticks in a clean and sanitized food processor. Add melted margarine. Gradually add milk as needed and blend until smooth. On April 26, 2023 at 11:50 AM, V28 (Dietary Aide) was observed serving two #8 dip scoops of a combined pureed mixture of pureed pasta and chicken alfredo, #20 dip pureed carrots, and no pureed breadstick to the 8 pureed diet residents. V13 (Cook) said she did not puree the pasta according to the recipe. V13 said she prepared the pureed chicken alfredo over fettuccine by adding 9 pasta scoopers of pasta and 9 #8 dip scoops of chicken alfredo into the food processor together and pureed it. V13 said the CNAs who feed the residents ask me to mix it together. V13 said pureed bread was not served because she did not make any. On April 27, 2023 at 10:54 AM, V19 (Dietician) said the bread on the menu should be pureed and served to the residents. V19 said by omitting the pureed breadstick from the meal, the pureed diet residents did not get the carbohydrates or correct nutrients they should have gotten. On April 27, 2023 at 12:26 PM, V14 (Dietary Manager) said the pureed diets yesterday had less carbohydrates on their trays because they did not receive pureed bread. V14 (Dietary Manager) said V13 (Cook) should have prepared a separate pureed pasta and not pureed the pasta and chicken alfredo together. V14 said the pureed diets were not served in the correct portions according to the menu and recipe; therefore, the pureed diet residents did not get the required nutrition which can lead to weight loss. The facility policy titled Food Preparation Guidelines (3/2023) states, Policy Explanation and Compliance Guidelines: 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. The facility policy titled Standardized Recipes (2020) states, Guideline: Standardized recipes will be used for all menu items, including pureed and therapeutic diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145663 If continuation sheet Page 10 of 10