Health inspection·October 5, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure R4's room entryway light was working properly and provided adequate lighting, and R9's special pressure reduction mattress was functioning correctly. This applies to 2 of 2 (R4, R9 ) reviewed for homelike environment in a sample of 15. Findings include: 1. R4's face sheet documents an [AGE] year old male admitted to the facility on [DATE], with diagnoses that include: Peripheral Neuropathy, spinal stenosis, muscle weakness, and unspecified abnormalities of gait and mobility. On 10/2/23 at 10:30 AM, R4's room entryway was noted to be dark and the room dimly lit. R4 stated the light in the entryway flickers and goes out, and there is only one light in the fixture behind him that works now. R4 stated he told V20 (Maintenance Supervisor) about it a couple weeks ago. The entry light was turned on and the light was noted to [NAME] and go on and off. On 10/3/23 at 9:54 AM, R4 stated the lights have not worked properly for 6 months. R4 stated he has told the staff several times. R4 stated he told V20 about his lights not working about 2 weeks ago. The entryway light was turned on and again it flickered and went off. On 10/3/23 at 10:51 AM, V17 (Director of Operations) stated if residents lights are not working, the staff that is going in and out of the room should be reporting to maintenance the issues with the lights. 2. R9's face sheet documents a [AGE] year old female admitted to the facility on [DATE], with diagnoses that include the following: Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with acute exacerbation, Atherosclerosis of aorta, Heart Failure, Legal blindness, and Muscle Weakness. R9's physician orders document the following: 8/3/2022 Pressure Redistribution/Reduction Mattress- Low Air Loss. 8/3/2022 Hospice On 10/2/23 at 10:07 AM, R9 was observed on 10/2/2023 at 10:07AM in bed lying on her back. The bed was noted to be concave and not properly inflated. The bed was noted to blinking 10lb and the orange service light was noted to be blinking, indicating the bed needs service. Page 1 of 11 146061 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/2/23 at 4:22 PM, R9 is lying on her back in her bed that still looks concave and improperly inflated. The bed is still beeping, blinking in white characters 10lb, and blinking orange light that indicates service. V19 (LPN) stated it does not look like R9's bed is correctly inflated. V19 stated, It is blinking 'service' so it probably needs someone to look at it. Work Order for R9, dated 10/2/2023 at 4:44 PM, documents the following: R9's air mattress is deflating unevenly. The air mattress pressure monitor is blinking signaling an issue and that it may be broken. 146061 Page 2 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

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** 3. R17's Face sheet, dated 10/4/23, shows R17's diagnoses include pneumonia, COVID19, Diabetes 2, dementia, Alzheimer's disease, congestive heart failure, respiratory failure with hypoxia, and bronchospasm. Residents Affected - Some MDS (Minimum Data Set), dated 7/4/23, shows R17 was cognitively intact and R17 required the extensive assistance from staff for bed mobility, dressing and was totally dependent on staff for transfers and toileting use, and and was always incontinent of bladder and frequently incontinent of bowel. Care plan, initiated 6/29/23, shows R17 had the potential for impairment of skin integrity related to incontinence of bowel and bladder and decreased mobility. The care plan shows facility staff were required to assist her with turning and repositioning as needed and provide incontinence care as needed. On 10/02/23 at 1:04 PM during resident council group interview, R17 stated staff normally take approximately thirty minutes to assist him with toileting. 4. R4's Face sheet, dated 10/4/23, shows R4's diagnoses include peripheral autonomic neuropathy, congestive heart failure, anxiety, dementia, depressive disorder, spinal stenosis, cellulitis, muscle weakness, and abnormalities of gait and mobility. R4's MDS, dated [DATE], shows R4 was cognitively intact and R4 required the extensive assistance of staff for bed mobility and was totally dependent on staff for dressing, toilet use, and R4 was always incontinent of bowel and bladder. Care plan, initiated 7/19/23, shows R4 was at risk for skin breakdown due to total incontinence of bowel and bladder and decreased mobility. The care plan shows R4 was to have staff assisting with incontinence care as needed On 10/02/23 at 1:04 PM during resident council group interview, R4 stated he waits over an hour approximately once a week during the night shift to receive assistance for toileting. Facility provided policy titled, Supporting Activities of Daily Living, dated 4/2022, showed, Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene .2. Appropriate care and services should be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .c. Elimination (toileting). Based on observation, interview, and record review, the facility failed to provide assistance with ADLs (Activities of Daily Living) for residents assessed as needing staff assistance for ADL (Activities of Daily Living) care and grooming. This applies to 4 of 5 residents (R1, R4, R17, and R187) reviewed for ADL care. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with 146061 Page 3 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses that include Parkinson's disease, history of falls, muscle weakness, and unspecified lack of coordination. R1's MDS (Minimum Data Set), dated 8/1/2023, showed R1 required one staff physical assistance for personal hygiene. R1's care plan showed resident has an ADL self-care deficit related to pain and shoulders and knees. R1 has contractures, staff shall provide skin care to keep clean and prevent skin breakdown. R1 has a terminal prognosis and has been admitted under hospice. Adjust provisions of ADLs to compensate for resident's changing abilities. On 10/03/23 12:30 PM, R1 was sitting up in her wheelchair in her room; she has long white hair on her chin and has several dark and light hairs on her upper lip (Mustache). R1 said she needs help with removing the facial hair. R1 also has long jagged and uneven nails. R1 said she has asked to have those cut, and no one has helped her. On 10/04/23 11:54 AM, R1 still has the long chin hairs and mustache. Nails have not been cut. 2. R187's EMR showed R187 was admitted to the facility 9/26/23, with diagnoses that include cellulitis of buttock, pressure ulcer of left buttock , anxiety disorder, major depression, muscle weakness, abnormal posture, displaced bi-malleolar fracture of the left lower leg, subsequent encounter for closed fracture with routine healing. R187's MDS was not completed due to recent admission. R187's care plan showed R187 has ADL self-care performance deficit, requires moderate assistance with her ADLs including bed mobility, transfers, bathing/showering, and toileting. On 10/02/23, at 10:40 AM, R187 had thick eye make-up on her eyes, [NAME] was flaking and was smeared on her cheeks. R187 wears a wig; it was uncombed and was not sitting on her head correctly. R187 said no one has washed her up or even helped her wash her face. R187 had long, jagged nails, with a yellowbrown substance underneath them. On 10/04/23 at 12:58 PM, R187 had long uneven nails with a yellow-brown substance under her nails. R187 said she she used wear her nails long when she worked. R178 stated she likes her nails long, and when asked about cleaning them, she said someone could help her with that. On 10/4/23 at 1:05 PM, V14 (RN/Registered Nurse) said, Yes we do need to clean under a resident's fingernails, comb their hair, and brush their teeth everyday, not just shower days. On 10/4/23 at 1:10 PM, V2 (DON/Director of Nursing) stated she expects all ADLs to be done as needed on shower day and also on non-shower days. V2 said shaving is also an expectation when providing grooming/ADL care. Residents can have long nails if that is their preference, but V2 said if there is a brown substance under them, staff should be cleaning under the resident's nails. 146061 Page 4 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 follow proper technique when administering a nasal spray to a resident. Residents Affected - Few This applies to 1 of 5 residents (R4) reviewed for medication administration. The finding included: R4's Face sheet showed R4 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, anxiety, dementia, major depression, muscle weakness, and idiopathic peripheral neuropathy. R4's MAR showed he gets Flonase Allergy Relief Nasal Suspension, one spray into each nostril two times a day for congestion. On 10/3/23 at 9:15 AM, V4 (RN/Registered Nurse) was administering R4's morning medications. R4 was placed in an upright position looking forward. R4 held the nasal spray tip at the entrance of the right nostril and did not insert the tip into the nasal cavity of the nose. V4 administered one spray into the right nasal. V4 placed the nasal spray tip at the entrance of the left nostril and administered one spray. V4 said she did not think she actually had to enter the tip of the nasal spray into the nasal cavity. On 10/03/23 at 4:03 PM, V2 (DON/Director of Nursing) said, When administering a nasal spray, the nurse needs to first explain to the resident what she is going to do. The nurse will need to hand the resident a tissue and have them blow their nose, dispose of that tissue and hand the resident a new tissue before administering the nasal spray. The nurse will take the nasal spray and insert into one nostril and up into the nasal cavity then administer one spray. The nurse then needs to repeat the same steps into the other nostril. If there is a second spray needed, the nurse needs to wait a few minutes and repeat again. Facility their Nasal Drops and Spray Medication Competency showed the steps to administer a nasal medication .5. Ask the resident to blow his nose, 6. Position resident correctly, 7. Administer the medication, 8. Keep the resident's head tilted back appropriately . 146061 Page 5 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify person-centered, non-pharmacological approaches for residents receiving psychotropic medications. The facility also failed to identify resident-specific behaviors to monitor the response/effectiveness of psychotropic medications. This applies to 4 of 5 residents (R1, R25, R29, and R187) reviewed for unnecessary medications in a sample of 15. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, atherosclerotic heart disease, and muscle weakness. R1 was admitted to hospice on 7/27/23 for end stage Parkinson's disease. R1's MDS (Minimum Data Set), dated 8/1/23, showed R1 was cognitively intact. R1's care plan, dated 8/30/23, showed R1 takes anti-anxiety medications- intervention initiated 4/26/2023 showed, 'administer medication as ordered, monitor and document side effects and effectiveness. (R1) has potential for impaired behavioral patterns. Behavioral services consult as needed and medications administered as ordered. Monitor/document for effectiveness and side effects. R1's POS (Physician Order Set) showed on 9/3/2023, R1's medications included Lorazepam 0.5 mg, give one tablet by mouth every 4 hours as need for anxiety. There was no end date for this medication order. Informed consent was signed for Lorazepam. There were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/2/2023 at 11:10 AM, R1 was down in activities. R1 said she enjoys coming down to participate in whatever activity is going on. On 10/3/2023, at 12:30 PM, R1 said she does not get anxious, but would say she is a little fearful when she is being transferred with the mechanical lift. 2. R25's EMR showed he was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, catatonic disorder due to known physiological condition, Covid-19, multiple sclerosis, major depression, encounter for palliative care, and unspecified psychosis not due to a substance or known physiological condition. R25's MDS, dated [DATE], showed R25 had severely impaired cognition. R25's care plan, 7/18/23, showed R25 had a communication problem (expressive aphasia) related to dementia with agitation. On 7/27/2023, care plan showed R25 uses an antidepressant medication related to depression. Interventions include: Give medication as ordered and monitor/document side effects 146061 Page 6 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and effectiveness, report to physician as needed any symptoms of depression unaltered by antidepressant medications, sad, irritable, anger, crying, shame, worthless, guilt, suicidal ideations, lethargy, changes in cognition, ect. (R25) is on a psychotropic medication, administer as ordered and monitor/ document effectiveness of medication. R25's POS showed R25's medications included, Citalopram 20 mg, give 1 tablet by mouth one time a day for Agitation. Risperidone 2 mg by mouth 2 times a day for agitation, and Depakote 125 mg, give 2 capsules by mouth three times a day for agitation (ordered12/26/22). Informed consents were signed for Citalopram and Risperidone, but there was no informed consent signed for Depakote. There were no resident-specific behaviors to monitor the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23 at 10:10 AM, R25 was in bed with eyes closed, he appeared to be asleep and comfortable. R25 is in isolation for Covid-19 diagnosis. On 10/4/23, R25 was observed through out the day and no behaviors were noted. 3. R29's EMR showed R29 was admitted to the facility on [DATE], with diagnoses that included unspecified convulsions, dementia with behaviors, anxiety, and major depression. R29's MDS, dated [DATE], showed R29's cognition was severely impaired. R29's care plan showed R29 has impaired cognitive function/dementia; interventions include: providing medication as ordered, ask yes/no questions, explain care and procedures to resident prior to beginning, approach resident in calm, gentle manner. (R29) uses psychotropic medications interventions included administer medications as ordered, consult with pharmacy, physician to consider dose reduction when clinically appropriate, monitor/record/report to physician any side effects and adverse reactions of psychoactive medications. (R29) to MD (Medial Doctor) as needed any symptoms of depression unaltered by antidepressant medications, sad, irritable, anger, crying, shame, worthless, guilt, suicidal ideations, lethargy, changes in cognition, ect. Resident uses an anti-anxiety medication - give as ordered and monitor/document side effects and effectiveness. R29's POS showed R29's medications included Quetiapine 25 mg, one tablet by mouth in the evening for major depression, Sertraline 100 mg, one tablet by mouth in the morning for major depression, and Lorazepam oral concentrate 2 mg/ml, give 0.5 ml by mouth every 4 hours as needed for 14 days. Informed Consent for Antipsychotic, Antidepressant, and Anti-anxiety were signed, but there were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23, R29 was sitting in his wheelchair in his room. He is in isolation for diagnosis of Covid-19. He is pleasant and has no concerns. 4. R187's EMR showed R187 was admitted to the facility 9/26/23, with diagnoses that included cellulitis of buttock, pressure ulcer of left buttock, anxiety disorder, major depression, muscle weakness, abnormal posture, and C-diff (Clostridium Difficile). R187's MDS was not completed due to her recent admission. 146061 Page 7 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R187's care plan showed she is on an anti-anxiety medication related to anxiety disorder, Interventions include: monitor/ document adverse reactions and effectiveness. (R187) uses antidepressant medication related to insomnia. Medication is to be given as ordered, monitor/document adverse reactions and effectiveness. R187's POS showed R187 has been prescribed Diazepam 10 mg, one tablet by mouth every 24 hours as needed for anxiety for 14 days. R187 is on Trazodone tablet 50 mg by mouth at bedtime for major depression. R187 Psychological progress note showed R187 was seen on 9/28/2023. Plan is to work on coping skills with the physical health changes and anxiety. Continue 1:1 psychotherapy 1 to 4 times a month to regulate mood, thoughts and behaviors. Informed Consent for an Anti-anxiety and sedative/hyptonic medication were signed, but there were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23 at 10:40 AM, R187 was hallucinating and saying there was high powered rifle up there (pointed to ceiling). V21 (Physician) came into the room, and R187 told him, Be careful where you walk, I'm not sure what traps they on the floor. I am trying to stay alive, and hoping everyone else in here stays alive too. V21 said he was going to check her urine to see if she has an UTI (Urinary Tract Infection). On 10/3/2023 at 8:45 AM, V5 (LPN/Licensed Practical Nurse) said R187 seems confused at times, and they are waiting to see what her Urinalysis and Culture show. She has not mentioned anything about rifles or has not seemed paranoid to her. On 10/04/23 at 8:31 AM, V2 (DON/Director of Nursing) said there has not been any behavior monitoring on R1, R25, R29, or R187. V2 said R25 did not have a consent for Depakote, somehow, they missed it. They called the family last night and now have a signed consent. V2 said the staff should be monitoring the resident for behaviors and document in the progress notes or on the MAR (Medication Administration Record). Facility provided their policy titled, Psychotropic Drug Management Policy, with the last revision date of 10/2022. The policy overview showed, Non-drug interventions should be implemented to the extent possible to assist the resident attain a satisfactory quality of life .An unnecessary drug is any drug when used .without adequate monitoring, without adequate indication for it's use .To avoid the use of unnecessary drugs .psychotropic medications will be used only after non-drug interventions alone have failed to manage behavioral symptoms .Policy Detail A. Health care Provider Responsibilities .The psychotropic medication order shall include the following information: b. manifestations of the disorder treated, d. monitoring parameters, as appropriate. 3. The health care provider shall write a progress note describing the behaviors and the reason for ordering the psychotropic drug and include a risk versus benefit statement .PRN(as needed) psychotropic .b. PRN orders for anti-anxiety, anti-depressant, and hypnotic drugs are limited to 14 days unless the Health Care Provider (HCP) believes it is appropriate for the PRN order to be extended beyond 14 days. The HCP shall document their rationale in the resident's medical record and indicate the duration of the PRN order .B. Nursing Responsibilities .2. The nurse shall implement non-drug interventions to help modify the resident's behavior 3. Nursing shall not administer the psychotropic medication until the informed consent has been obtained from the resident and/or legal representative .5. Document the following information 146061 Page 8 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0758 Level of Harm - Minimal harm or potential for actual harm about specific behaviors: a. number and frequency of behaviors, b. preceding or precipitating factors, c. interventions attempted (if psychotropic drug is used as an intervention, institute appropriate behavior monitoring and adverse consequences), d. side effect documentation of the side effects should occur each shift within the EMR (Electronic Medical Record) behavior monitoring, when applicable. Residents Affected - Some 146061 Page 9 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

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 interview and record review, the facility failed to plan and serve menus which provided variety and the minimum servings of grains as per facility policy. Residents Affected - Some This applies to 4 of 4 residents (R4, R15, R18, and R25) reviewed for menu planning in a sample of 15. The findings include: 1. On 10/2/23 at 1:04 PM during resident council group interview, R4 stated the facility serves meatloaf too often on the menus, and sometimes he gets meatloaf twice in a row. R4 stated he often receives repetitive menu items served at meals. Review of facility regular diet menu food offerings to non-selecting residents, dated 9/1/23 to 10/7/23, show a total of 16 servings of planned meatloaf entrees, 14 versions of meatball entrees, and over 75 fish entrees planned and served on the menu during the timeframe. Ono 10/4/23 at 10:30 AM, V10 (Dietitian) stated there should not be as many servings of meatloaf, meatballs, or fish on the facility planned menus. 2. Menu Planning Criteria policy, revised 4/2013, shows the facility will provide regular diets no less than 6 servings of grains daily. Review of facility regular diet menu food offerings to non-selecting residents, dated 9/1/23 to 10/7/23, show on the following dates, residents who did not select their menus were served less than 6 grains each day: 9/1, 9/3, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/18, 9/20, 9/26, 9/28, 9/30, 10/3, 10/4, 10/5, and 10/7/23. The menus also showed a total of 16 servings of meatloaf, 14 servings of meatball entree versions, and over 75 servings of fish were served during the timeframe. The menus show breads and grains were planned to be served with all meals. On 10/03/23 at 2:00 PM, V11 (Skilled Dining Manager) stated R15, R18, and R25 received the standard general menus as planned because they did not individually select their menu items. V11 reviewed the non-selective general menu items, and stated the menus were often short on grain servings. V11 stated she was unsure why the facility was not serving the minimum servings of grains per the facility policy. At 12:32 PM, V11 stated the facility did not serve the daily bread servings at meals as indicated at the bottom of their menus, and those servings of breads were not served to residents not selecting menus their menus. On 10/02/23 at 2:49 PM, V11 the menus are planned by corporate, and then an onsite menu manager makes substitutions at the facility. V11 stated facility Dietitians also look over the menus and ensure all menu requirements are met. On 10/04/23 at 10:30 AM, V10 (Dietitian) stated she needed to review the menus because several of the days reviewed were short of grains per the facility policy. V10 stated the food service staff required further training to be able to make changes to the menus and still meet the minimum requirements of the menus. 146061 Page 10 of 11 146061 10/05/2023 Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one resident with a diagnosis of dysphagia received pudding thick liquids per the doctor's order. This applies to 1 of 4 residents (R18) reviewed for food/nutrition in a sample of 15. Findings include: R18's face sheet documents an [AGE] year old female admitted to the facility on [DATE], with diagnoses including the following: Progressive Supranuclear Opthalmoplegia, Dysphagia, and Muscle Weakness. R18's physician orders document the following: 10/11/2022 Pureed diet refer to diet type for texture, pudding liquids consistency, aspiration precautions. On 10/02/23 at 12:15 PM, V16 (CNA- Certified Nursing Assistant) was in the 2nd floor dining room feeding R18 her lunch. V16 stated R18's meal consisted of mashed potatoes, chicken, broccoli soup, banana pudding, cranberry juice, and water. V16 stated R18 is on a pureed diet and pudding thick liquids. R18's soup did not look pudding thick. It poured out of the spoon like a thin liquid. R18 was coughing during feeding of pureed food, thickened liquids, and soup. On 10/2/23 at 12:24 PM, V19 (Registered Dietician) stated R18 is on pureed diet and pudding thick liquids. V3 (Dietitian) looked at R18's soup and stated the soup is not the correct consistency. V3 stated the soup should be thickened more, then V3 took R18's soup away. On 10/2/23 at 12:30 PM, V3 came back with thickened soup that looked appropriately thickened, and stated the soup is wedding soup, not broccoli soup. 146061 Page 11 of 11