Indigo at Beavercreek, The

Based on staff interview and record review, the facility failed to maintain a Bureau of Criminal Investigation (BCI) log that contained the date the criminal records check request was submitted to the Bureau of Criminal Identification and Investigation (BCII). This affected one (Executive Director [ED] #42) out of four newly hired employees reviewed for criminal background checks. The facility census was 36.

Findings include:

Review of ED #42's personnel file, revealed ED #42 was hired at the facility on 11/16/25.

Review of the facility's undated BCI log, revealed ED #42 was hired by the facility on 11/16/25. Further review of the BCI log revealed the log stated new hire under ED #42's BCI date and the date the results were completed and received were not listed. The facility's BCI log did not contain the date ED #42's criminal record check request was submitted to the BCI).

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified the BCI log did not contain the date ED #42's criminal record check request was submitted to the BCII. Business Office Coordinator #50 verified ED #42 was actively working in the facility on 11/19/25 and Business Office Coordinator #50 was not aware of the date that ED #42's criminal record check request was submitted to the BCII.

Based on staff interview and record review, the facility failed to ensure newly hired employees were examined by a physician or other health care professional acting within their scope of practice prior to commencing work. This affected five (Resident Assistant [RA] #56 and RA #38) out of four newly hired employees reviewed for employee physicals and health examinations. The facility census was 36.

Findings include:

Review of RA #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed RA #56 did not have a physical or health examination on file.

Review of RA #38's personnel file, revealed RA #38 was hired at the facility on 07/28/25. Further review of RA #38's personnel file revealed RA #38 did not have a physical or health examination on file.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified RA #38 and RA #56 did not have physicals or employee health examinations on file at the facility.

Review of the facility's employee records policy dated 07/01/25, revealed employee records should include an exam showing the employee was medically capable of performing their duties.

Based on interview and record review, the facility failed to ensure newly hired Resident Assistants (RAs) received first aid training within 60 days of hire. This affected two (RA #38 and RA #56) out of three newly hired employees reviewed for first aid training. This also affected 36 out of 36 residents residing in the facility. The facility census was 36.

Findings include:

1) Review of RA #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed RA #56 did not receive first aid training within 60 days of being employed by the facility.

2. Review of RA #38's personnel file, revealed RA #38 was hired at the facility on 07/28/25. Further review of RA #38's personnel file revealed RA #38 did not receive first aid training within 60 days of being employed by the facility.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified the facility had no documentation that RA #38 and RA #56 received first aid training within 60 days of being employed by the facility.

Review of the facility's employee training policy dated 07/01/25, revealed the facility training program will include first aid training.

Based on staff interview and record review, the facility failed to ensure a staff member that provided personal care services to residents with cognitive impairment received four hours of continuing education on residents with cognitive impairments annually. The facility also failed to ensure newly hired staff members that provided personal care services to residents with cognitive impairment received two hours of initial training in the care of residents with cognitive impairment within fourteen days of their first day of work. This affected four (Resident Assistant [RA] #63, RA #56, and Medication Aide [MA] #59) employees out of five employees reviewed that provided personal care services to residents with cognitive impairments. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

1. Review of RA #63's personnel file, revealed RA #63 was hired at the facility on 08/28/24. Further review of RA #63's personnel file revealed there was no documentation that RA #63 received any education on residents with cognitive impairments from 11/19/24 to 11/19/25.

2. Review of RA #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed there was no documentation that RA #56 received two hours of initial training in the care of residents with cognitive impairment within fourteen days of their first day of work.

3. Review of RA #38's personnel file, revealed RA #38 was hired at the facility on 07/28/25. Further review of RA #38's personnel file revealed there was no documentation that RA #38 received two hours of initial training in the care of residents with cognitive impairment within fourteen days of their first day of work.

4. Review of MA #59 personnel file, revealed MA #59 was hired at the facility on 07/28/25. Further review of MA #59's personnel file revealed there was no documentation that MA#59 received two hours of initial training in the care of residents with cognitive impairment within fourteen days of their first day of work.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified RA #63 did not receive any annual education on residents with cognitive impairment from 11/19/24 to 11/19/25 and RA #56, RA #38, and MA #39 did not receive two hours of initial training in the care of residents with cognitive impairment within fourteen days of their first day of work.

Review of the facility's employee training policy dated 07/01/25, revealed the facility shall ensure adequate and sufficient training for staff on duty at all times. The staff shall be trained and capable of providing for the current resident population and needs consistent with their individualized service plans. Cognitive impairment training is provided in the facility, and staff shall have initial, annual and as needed training.

Based on staff interview and record review, the facility failed to complete nurse aide registry checks on newly hired employees. This affected three (Resident Assistant [RA] #38, RA #56 and Executive Director [ED] #42) out of four newly hired employees reviewed for background checks. The facility census was 36.

Findings include:

1. Review of RA #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed no documentation that RA #56 had a nurse aide registry check completed upon hire.

2. Review of RA #38's personnel file, revealed RA #38 was hired at the facility on 07/28/25. Further review of RA #38's personnel file revealed no documentation that RA #38 had a nurse aide registry check completed upon hire.

3. Review of ED #42's personnel file, revealed ED #42 was hired at the facility on 11/16/25. Further review of ED #42's personnel file revealed no documentation that ED #42 had a nurse aide registry check completed upon hire.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified RA #38, RA #56 and ED #42 did not have nurse aide registry checks completed upon hire. Business Office Coordinator #50 also confirmed the facility did not have any nurse aide registry checks on file for ED #42, RA #38 and RA #56.

Based on staff interview and record review, the facility failed to monitor residents for communicable diseases and the facility failed to ensure the infection control designee had the Centers for Disease Control and Prevention (CDC) infection preventionist certificate. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

1. Review of the Resident #21's chart, revealed Resident #21 admitted to the facility on 10/14/25 with diagnoses including dementia, chronic kidney disease, hyperlipidemia, insomnia, cerebrovascular disease, liver disease and neurocognitive disorder with lewy bodies.

Review of Resident #21's Level of Care Evaluation dated 11/19/25, revealed Resident #21 was oriented to person. Resident #21 required assistance with ambulation, transfers, dressing, oral hygiene, grooming, toileting and bathing. Resident #21 required supervision with eating.

Review of the facility's infection control log on 11/19/25 at 9:13 A.M., revealed the facility did not have an infection control log.

Interview with Maintenance Coordinator #48 on 11/19/25 at 9:14 A.M., revealed he had noticed an increase in residents with diarrhea within the past two weeks. Maintenance Coordinator #48 also stated he was aware of one incident of vomiting from two days ago. Maintenance Coordinator #48 was not able to provide the names of the residents impacted but stated he believed the diarrhea and vomiting was from a virus.

Interview with Resident #21 on 11/19/25 at 11:21 A.M., revealed Resident #21 was sick with diarrhea a few days ago.

Interview with Resident Assistant (RA) #71 on 11/19/25 at 11:23 A.M., revealed she was aware of three residents with diarrhea within the past few weeks. RA #71 stated she believed the diarrhea was from a virus but she was not able to recall the names of the residents with diarrhea.

Interview with RA #65 on 11/19/25 at 11:34 A.M., revealed she had heard of residents having gastrointestinal (GI) symptoms but she was not able to give the names of the residents.

Interview with Executive Director (ED) #42 on 11/19/25 at 2:42 P.M., verified the facility did not have an infection control log to monitor infections in the facility. ED #42 stated that the facility was in process of creating an infection control log on 11/19/25. ED #42 stated that she and the Infection Control Designee, Healthcare Coordinator (HC) #73 were not aware of any residents having vomiting or diarrhea.

Interview with HC #73 on 11/20/25 at 11:44 A.M., revealed HC #73 was not aware of any GI illnesses at the facility. HC #73 stated that residents have GI issues occasionally and that no residents were placed on precautions for GI issues including vomiting and diarrhea.

2. Review of HC #73's Centers for Disease Control and Prevention (CDC) infection preventionist certificate, revealed HC #73 did not have an infection preventionist certificate.

Interview with HC #73 on 11/20/25 at 11:44 A.M., revealed HC #73 did not have an infection preventionist certificate.

Review of the facility's infection control policy dated 06/15/25, revealed the facility will implement a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents.

Based on staff interview and record review, the facility failed to implement their tuberculosis (TB) control plan for TB testing of newly hired employees and completing a TB risk assessment. This affected two (Resident Assistant [RA] #56 and Medication Aide [MA] #59) out of four newly hired employees reviewed for TB testing. This also had the potential to affect all 36 out of 36 residents residing in the facility. The facility census was 36.

Findings include:

1. Review of RA #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed RA #56 did not have a tuberculosis skin test completed upon hire.

2. Review of MA #59 personnel file, revealed MA #59 was hired at the facility on 07/28/25. Further review of MA #59's personnel file revealed MA #59 did not have a tuberculosis skin test completed upon hire.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified the facility had no documentation that RA #56 and MA #59 received a tuberculosis skin test upon hire.

3. Review of the facility's TB risk assessment on 11/19/25 at 1:27 P.M., revealed the facility did not have a TB risk assessment on file.

Interview with Executive Director (ED) #42 on 11/19/25 at 1:28 P.M., verified the facility did not have a TB risk assessment on file.

Review of the facility's tuberculosis policy dated 06/15/25, revealed the facility will establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the Centers for Disease Control and Prevention (CDC). The facility will complete an annual tuberculosis risk assessment using the CDC tool to determine the level of risk. Staff will be screened and tested for tuberculosis prior to the staff being exposed to residents and staff will be tested within seven days after being employed.

Based on observation, staff interview and record review, the facility failed to maintain food items and the kitchen in a manner to prevent foodborne illness. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Observation of the kitchen on 11/19/25 at 8:22 A.M., revealed there was a gray substance on the vent of the ice machine, a gray substance on the air vent in the wall of the kitchen near the dry storage, a gray substance on the vent in the ceiling above the ice machine, and a gray substance on the lights near the facility's steam table. Further observation of the kitchen revealed there was an undated bag of tortillas in a ziplock bag in the dry storage, a open and undated bag of corn dogs in the freezer, an open and undated bag of riblets in the freezer, a container of tartar sauce with an expiration date of 11/07/25 in the refrigerator, three containers of ranch dressing with an expiration date of 9/24/25 in the refrigerator, a container of stir fry sauce with an expiration date of May 2025 in the refrigerator, eight containers of cream cheese with an expiration date of 10/07/24 and three containers of maraschino cherries with an open date of 03/12. There were also brown debris on the deep fryer and brown debris on the storage shelf under the tray line.

Interview with Culinary Coordinator #47 on 11/19/25 at 8:22 A.M., verified there was a gray substance on the vent of the ice machine, a gray substance on the air vent in the wall of the kitchen near the dry storage, a gray substance on the vent in the ceiling above the ice machine, and a gray substance on the lights near the facility's steam table. Culinary Coordinator #47 confirmed there was an undated bag of tortillas in a ziplock bag in the dry storage, a open and undated bag of corn dogs in the freezer, an open and undated bag of riblets in the freezer, a container of tartar sauce with an expiration date of 11/07/25 in the refrigerator, three containers of ranch dressing with an expiration date of 9/24/25 in the refrigerator, a container of stir fry sauce with an expiration date of May 2025 in the refrigerator, eight containers of cream cheese with an expiration date of 10/07/24 and three containers of maraschino cherries with an open date of 03/12. Culinary Coordinator #47 also verified there were also brown debris on the deep fryer and brown debris on the storage shelf under the tray line.

Review of the facility's food storage, handling and labeling policy, revealed food labels should be checked daily and out dated food should be discarded. Food storage areas should be cleaned daily.

This violation represents non-compliance investigated under Complaint Number OH00168885.

Based on observation, staff interview and record review, the facility failed to maintain at least a two day supply of perishable food items for residents at all times. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Review of the facility's menu dated 11/19/25 at 8:20 A.M., revealed residents were to receive one banana nut muffin, one egg of choice, a half cup of hash browns, and a half cup of fresh fruit for breakfast. The menu also stated milk would be offered at every meal. The menu was signed by Registered Dietician (RD) #500 on 10/12/25.

Observation of the kitchen on 11/19/25 at 8:22 A.M., revealed there was no milk in the kitchen.

Interview with Culinary Coordinator #47 on 11/19/25 at 8:22 A.M., verified there was no milk in the facility. Culinary Coordinator #47 stated that the facility ran out of milk on 11/18/25 and the milk delivery was scheduled to arrive on 11/20/25. Culinary Coordinator #47 confirmed the facility had no milk at breakfast on 11/19/25.

Based on observation, staff interview and record review, the facility failed to follow the menu and maintain a substitution log for menu substitutions. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Review of the facility's menu dated 11/19/25, revealed residents were to receive one banana nut muffin, one egg of choice, a half cup of hash browns, and a half cup of fresh fruit for breakfast. The menu also stated milk would be offered at every meal. The menu was signed by Registered Dietician (RD) #500 on 10/12/25.

Review of the facility's substitution log on 11/19/25, revealed the facility did not have a substitution log.

Observation of the kitchen on 11/19/25 at 8:22 A.M., revealed Culinary Coordinator #47 was serving residents four ounces of egg bake and 2.7 ounces of apple sauce for breakfast. Further observation of the kitchen revealed there was no milk in the kitchen.

Interview with Culinary Coordinator #47 on 11/19/25 at 8:22 A.M., verified Culinary Coordinator #47 was serving residents four ounces of egg bake and 2.7 ounces of apple sauce for breakfast. Culinary Director #47 also verified there was no milk in the facility. Culinary Coordinator #47 stated that the facility ran out of milk on 11/18/25 and the milk delivery was scheduled to arrive on 11/20/25. Culinary Coordinator #47 confirmed the facility had no milk at breakfast on 11/19/25.

Interview with Executive Director (ED) #42 on 11/19/25 at 11:38 A.M., verified the facility did not follow the menu for breakfast on 11/19/25 and the facility did not have a substitution log.

Based on staff interview and record review, the facility failed to ensure fire drills were conducted on each shift every three months as required. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Review of the facility's fire drill records from 11/19/24 to 11/19/25, revealed the facility completed a fire drill on third shift on 11/23/24. The facility did not complete any additional fire drills on third shift from 11/24/24 to 11/19/25.

Interview with Maintenance Coordinator #48 on 11/19/25 at 9:39 A.M., verified the facility did not complete any fire drills on third shift from 11/24/24 to 11/19/25.

Review of the facility's drills policy dated August 2025, revealed staff fire drills with alarms will occur monthly on alternating shifts.

Based on staff interview and record review, the facility failed to ensure disaster preparedness drills were completed twice per year. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Review of the facility's disaster preparedness drill records dated 03/23/23 to 11/19/25, revealed a tornado drill was completed on 03/23/23 and 07/08/25. Further review of the facility's disaster preparedness drills revealed the facility did not complete any other disaster preparedness drills from 03/23/23 to 11/19/25.

Interview with Maintenance Coordinator #48 on 11/19/25 at 9:39 A.M., verified the facility did not complete two disaster preparedness drills from 11/19/24 to 11/19/25.

Review of the facility's drills policy dated August 2025, revealed two disaster preparedness drills shall be done per year.

Based on staff interview and record review, the facility failed to maintain written transfer agreements with other facilities. This affected 36 out of 36 residents that resided at the facility. The facility census was 36 residents.

Findings include:

Review of the facility's written transfer agreements with other facilities on 11/19/25 at 1:27 P.M., revealed the facility did not have any written transfer agreements with other facilities.

Interview with Executive Director (ED) #42 on 11/19/25 at 1:28 P.M., verified the facility did not have any written transfer agreements with other facilities.

Based on staff interview and record review, the facility failed to provide and obtain written acknowledgements that staff received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and local offices of the Department of Aging, and the Ombudsman program. The facility also failed to provide and obtain written acknowledgements that staff received a copy of the resident rights and the home rules. This affected three (Resident Assistant [RA] #56, Medication Aide [MA] #59 and Executive Director [ED] #42) out of four newly hired employees reviewed for required written acknowledgements. The facility census was 36.

Findings include:

1. Review of Resident Assistant (RA) #56's personnel file, revealed RA #56 was hired at the facility on 01/02/25. Further review of RA #56's personnel file revealed no documentation that RA #56 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local offices of the Department of Aging, and the Ombudsman program.

2. Review of Medication Aide (MA) #59's personnel file, revealed MA #59 was hired at the facility on 07/28/25. Further review of MA #59's personnel file revealed no documentation that MA #59 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local offices of the Department of Aging, and the Ombudsman program. MA #59's personnel file also did not contain any documentation MA #59 was provided or signed a written acknowledgement that MA #59 received a copy of the resident rights and the home rules.

3. Review of Executive Director (ED) #42's personnel file, revealed ED #42 was hired at the facility on 11/16/25. Further review of ED #42's personnel file revealed no documentation that ED #42 was provided or signed a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local offices of the Department of Aging, and the Ombudsman program. ED #42's personnel file also did not contain any documentation ED #42 was provided or signed a written acknowledgement that ED #42 received a copy of the resident rights and the home rules.

Interview with Business Office Coordinator #50 on 11/19/25 at 3:50 P.M., verified RA #56, MA #59 and ED #42 were not provided and did not sign a written acknowledgement that they received a copy of the addresses and telephone numbers of the County Board of Health, the County Department of Human Services, the State Departments of Health and Human Services, the State and Local offices of the Department of Aging, and the Ombudsman program. Business Office Coordinator #50 also verified ED #42 and MA #59 were not provided and did not sign a written acknowledgement that they received a copy of the resident rights and the home rules.

Based on record review and staff interviews, the facility failed to timely identify, assess and intervene as soon as possible, and notify the resident's sponsor of a resident's significant weight loss. This affected one (#14) of three residents reviewed for weight loss. The facility census was 37.

Findings include

Review of the medical record for Resident #14 revealed an admission date of 10/04/24. Diagnoses included Alzheimer's disease, hypertension and anxiety.

Review of the assessment dated 10/04/24 revealed Resident #14 was cognitively impaired.

Resident #14 had been off hospice since 07/14/25 per the Executive Director.

Review of the facility's weight log revealed Resident #14 had the following weights: 155.2 pounds (lbs.) in 08/2025 and 144.4 lbs in 09/2025. This was a weight loss of 10.8 lbs in one month, which was a 6.96% significant weight loss in one month.

Resident #14's medical record from 08/01/25 to 10/22/25 revealed there was no mention of Resident #14's significant weight loss.

Review of the physician orders dated 10/08/25 revealed an order for magic cup (high calorie nutritional supplement) three time each day.

Interviews on 10/22/25 from 12:30 P.M. to 3:40 P.M. with the Executive Director and Director of Nursing (DON) revealed no residents in the facility had excessive weight loss in the past three months. After reviewing the facilities recorded weights of the residents from 08/2025 to 10/2025 revealed there was one resident (#14) who had significant weight loss. The facility was unable to provide evidence the facility was aware of Resident #14's significant weight loss, addressed Resident #14's significant weight loss in the medical record, any intervention to address the weight loss, and notify the resident's sponsor of the weight loss.

Interview on 10/22/25 at 3:14 P.M. with Dietician #100 revealed facility staff should follow and monitor weights and should alert them to any concerns of weight loss so the resident(s) could be assessed and recommendation and follow up could be made.

This violation represents non-compliance investigated under Complaint Number OH00168423.

Based on observations, record review, staff interviews and policy reviews, the facility failed to ensure the menus were prepared in advance, were being followed, and maintain the previous menus including therapeutic diets and substitution log for at least three months. This had the potential to affect all 37 residents residing in the facility.

Findings include:

Review of the scheduled menu for lunch on 10/22/25 revealed residents should have received a three ounce portion of barbecue pork rib patty, half cup of roasted potatoes, half cup of green beans, and a roll and slice of angel food cake.

Review of menu serving sizes for a similar meal in the month rotation revealed residents should receive a three-ounce serving of protein, a half cup serving of rice and a half cup serving of vegetables.

Observation on 10/22/25 at 11:32 A.M. revealed the residents were eating the lunch meal. The main meal served was bourbon chicken with rice and carrots. Several residents also received crab cakes and peanut butter and jelly sandwiches.

Interview and observations on 10/22/25 at 11:45 A.M. with Kitchen Manager (KM) #50 reported he started work at the facility three days ago. He revealed the meal did not follow any menu and staff would look around and see what they have in food stock and would come up with a meal to serve. KM #50 stated the previous Kitchen Manager did not follow the menu. KM #50 was unaware of any substitution log. KM #50 stated he served one-third cup of rice, a six-ounce scoop of carrots and an unmeasured spoonful of chicken. KM #50 said the residents on puree diets could not have pureed rice stating it wasn't able to be pureed so instead the residents were served pudding. The residents with mechanical soft diets were not served rice stating it was a choking hazard and were not served a substitution for the rice. KM #50 and another unidentified dietary staff member were unaware where facility documented and kept a log of resident preferences and dietary needs and requirements including likes, dislikes, allergies, preferences, and specialized equipment needed for meals. KM #50 confirmed facility did not use meal tickets, but thought the information may be on the computer somewhere. KM #50 was unable to explain why certain residents received peanut butter and jelly sandwiches and others did not. KM #50 confirmed it was not part of the scheduled meal but stated residents could request a sandwich. KM #50 confirmed Resident #7 had received sweet potato tater tots, crab cakes, and a peanut butter and jelly sandwich for the finger food diet.

Interview on 10/22/25 at 12:30 P.M. with the Executive Director (ED) revealed the facility had a newly hired Kitchen Manager and acknowledged training was needed. The ED confirmed the prior cook did not follow the menu and recipes either. The ED confirmed facility had contracted with a new dietician company, will plan for some education and the facility had no documentation related to menu spreadsheets identifying what each diet should be receiving, no evidence of a substitution log monitored, and no evidence menu substitutions were appropriate. The ED confirmed when making menu substitutions, they should be similar a starch for a starch and a vegetable with another vegetable. He acknowledged substituting rice with pudding was not an appropriate substitution.

Interview on 10/22/25 at 3:14 P.M. with Registered Dietician (RD) #100 revealed facility staff should follow the menu, keep a substitution log and ensure substitutions were appropriate for similar items. RD #100 revealed if facility had questions, they could reach out to the dietician for guidance. She revealed facility should be ensuring nutritious meals and providing appropriate serving sizes.

Review of the facility policy titled Approved Diets dated 08/01/23 revealed facility shall provide adequate nutrition and ensure the residents were consuming appropriate calories, vitamins and fluids. Food allowed for mechanical diets and puree diets include rice. For the finger food diet, food can be cut into bite size pieces or made into sandwiches.

The facility policy titled Meal Planning dated 08/01/23 revealed the facility shall follow the menus to provide three nutritious meals each day.

The facility policy titled Food Therapeutic Diets dated 08/01/23 revealed facility shall use instructions prepared for therapeutic diets on the menu spreadsheet by referring to the correct column when preparing a special diet. All meals shall be prepared by good nutritional standards.

The facility policy titled Dietary Services dated 08/01/24 revealed the facility shall provide three set meals at scheduled times accommodating preferences and needs. Therapeutic diets include modifications from the regular menu and shall be prescribed by the physician. For therapeutic diets, the facility shall work closely with the dietician.

This violation represents non-compliance investigated under Complaint Number OH00168423.