Health inspection·November 8, 2024

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to post the facility Daily Staffing Report daily and, in an area, visible to all residents and visitors. This failure has the potential to affect all 58 residents residing in the facility. Residents Affected - Many Findings include: The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in the facility. On 11/6/24 at 8:35 am, the facility's Nurse Staffing posting was located near the Receptionist desk, on the wall, behind a portable stand that held instructions for visitors to sign in on the facility's visitor log. This posting is not easily visible to staff, residents, or visitors. This Nurse Staffing posting was last completed on 10/29/24. On 11/8/24 at 10:20 am, 10:22 am, 10:24 am, and 10:25 am, R2, R9, R10, and R12 respectively stated they do not know where the Nursing Staff posting is located. On 11/6/24 at 9:12 am, V2 DON (Director of Nursing) walked with this writer to the Receptionist desk and confirmed the location of the Nurse Staffing posting on the wall behind a portable stand and confirmed it had not been completed since 10/29/24 and should have been. V2 DON stated V13 CNA Scheduler usually fills it out. V2 DON did not move the portable sign to enable visibility of the staff posting. On 11/7/24 at 3:20 pm, V1 Interim Administrator accompanied writer to the Receptionist desk and confirmed the Nurse Staff posting is not easily visible to residents, visitors, or staff due to being on the wall behind a portable sign and stated should be completed or updated daily. Page 1 of 3 145319 145319 11/08/2024 Arc at El Paso 555 East Clay El Paso, IL 61738

F 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on observation, interview, and record review the facility failed to accurately report the PBJ (pay-roll based journal) staffing information. This failure affects all 58 residing in the facility. Residents Affected - Many Findings include: The facility's PBJ (pay-roll based journal) Staffing Data Report, fiscal year Quarter 3 2024, dated April 1 through June 30, 2024, documents Excessively Low Weekend Staffing was triggered due to facility submission of excessively low staffing worked on the weekends. The facility's Midnight Census report, dated 11/6/24, documents there are currently 58 residents residing in the facility. On 11/6/24 and 11/7/24 at 7:30 am through 4:00 pm, there were six CNAs (Certified Nursing Assistants), two RNs (Registered Nurses) and one LPN (Licensed Practical Nurse) working on the day shift. On 11/6/24 at 11:05 am and 11:21 am, and on 11/7/24 at 7:45 am and 9:40 am R2, R10, R6 and R9 respectively stated the facility has two to three CNAs and a Nurse for each hallway in the facility and their needs are being met. On 11/8/24 at 8:30 am, R12 stated she is the President of Resident Council, and no one has complained about the staff or the staffing during the meetings. On 11/6/24 at 8:05 am, 8:16 am, 8:30 am, and 11:05 am, V10, V11, V12, V13 and V17 CNAs respectively stated the facility is staffed with six CNAs on the day and evening shifts and four on the midnight shift. V10 through V13 and V17 CNAs stated they feel there is enough staff and can complete their work assignments daily and Nurses help when needed. On 11/6/24 at 11:00 am, V6 RN and V8 LPN respectively stated there are three Nurses and five to six CNAs on the day shift, two Nurses and six CNAs on evening shift, and one Nurse and four CNAs on the midnight shift. V6 RN and V8 LPN stated the staff can get their work done daily and that everyone helps when needed. On 11/7/24 at 9:10 am, and 9:30 am, V4 SSD and V5 Activity Director respectively stated the facility has adequate staffing and they assist when needed. On 11/7/24 at 3:15 pm, V1 Interim Administrator stated the facility census is at 58 and normally stays consistent between 55 to 60. The staffing is based on the facility census and acuity of care. The staffing hours are submitted to the RDO (Regional Director of Operations), RDO uses a calculator, and we adjust the staffing accordingly. On 11/7/24 at 3:00 pm, V3 VP (Vice President) of Clinical Operations and V1 Interim Administrator provided staff timecard reports for April through June 2024 and stated the facility reports show there was adequate staffing on the weekends during the third quarter. V3 VP of Clinical Operations stated she did some investigating regarding the facility's PBJ staffing numbers, compared the staff timecard reports to the daily schedules, and can only concluded she believes V24 Former Administrator did 145319 Page 2 of 3 145319 11/08/2024 Arc at El Paso 555 East Clay El Paso, IL 61738

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not report the use of the Agency Nurses and CNAs during that quarter. V3 also stated the management staff are salary, but when they cover a shift or work other than their job, they are to punch the time clock which would post their hours for the PBJ reporting and the management staff have not been doing this, so their hours worked are not being counted. On 11/8/24 at 11:00 am, V3 VP of Clinical Operations provided facility timecard reports and Agency staff hours worked for the weekends of 10/12/24, 10/13/24, 10/19/24, and 10/20/24 and stated V24 Former Administrator was not including the Agency Nurses and CNAs in the total hours when submitting the hours for the PBJ staffing information. V3 VP of Clinical Operations reviewed hours with this writer and stated the facility had greater totals of staff than what was reported. V3 stated the staffing hours will be reported correctly from here on out and the next quarter will reflect accurate information for the facility's PBJ report. 145319 Page 3 of 3