Health inspection·September 20, 2022

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide supervision, investigate falls thoroughly to develop a root cause and analysis and implement progressive interventions to prevent falls for 2 of 5 residents (R1, R31) reviewed for falls. This failure resulted with R1 dislocating his shoulder multiple times, receiving 2 staples for a head laceration and hematomas. Findings include: 1. R1's admission Profile, undated, documents R1 was admitted on [DATE]. R1's September 2022 Physician Orders documents that R1 has diagnoses of Depression, Anxiety, and unspecified neuro cognitive disorder. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has moderately impaired cognition and is totally dependent on one staff member for locomotion on the unit using a wheelchair. R1's Care Plan, with start date of 2/18/22 documents Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. (Consider medical conditions, sensory altercations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medication, restrictions, restraints. Risk factors include poor safety awareness, dementia, agitation, anxiety, weakness as evidence by related diagnoses/ condition/history. R1's Goal for this problem documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. The following are R1's Care Plan Approaches/Interventions all dated 2/18/22: Review quarterly and prn (as needed) resident's ADL (activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary team) review of changes and needs with Resident and/or responsible party (when choose to attend) during care plan. Discuss fall related (information to review and revise plan as needed; Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues as needed to gain resident participation in minimizing risk factor and injury, encourage and assist placement of proper non-skin footwear; Attempt to anticipate needs-toileting, hydration, hunger and provide care before resident attempt to fulfill on own; observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed; Fall risk assessment quarterly and as needed with change in condition or falls status; IDTG review of ADL status and fall potential changes in condition or fall status. Report significant finding to MD for follow up; Monitor for changes in condition such as appetite, sleep patterns, balance, ADL assist level, swelling, muscle weakness, less socialization. Report to nurse for follow up assessment and MD notification. An intervention, dated 2/11/22 documents Low bed. Page 1 of 10 145411 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0689 R1's Nurse's Note, dated 4/4/22 at 11:30 PM, documents, Res (Resident) fell in living room with injuries noted to Lt (left) temporal area and shoulder deformity. Sent to ER (Emergency Room). Level of Harm - Actual harm Residents Affected - Few R1's Nurse's Note, dated 4/4/22 at 12:45 PM, documents, Res returned from ER (Emergency Room) with dx (diagnosis) of Anterior Dislocated of L shoulder, contusion to face, COVID 19, Broken collarbone. R1's emergency room documentation, dated 4/4/22, documents, Assessment/Plan: 1. Anterior dislocation of left shoulder. 2. Clavicle fracture. 3 Head contusion. 4. Neck Strain. Procedure: Attempted to reduce left shoulder dislocation multiple times without any success. Transfer to (regional) hospital. On 9/15/22 at 1:48 PM, surveyors were unable to view the fall investigations independently. At that time, V2 Regional Nurse, reviewed the investigation from 4/4/22 with the surveyor and stated, (R1) got up from his recliner. He had fallen asleep, and the aide went to clean the dining room. (R1's) alarm sounded and by the time the aide got to him he was on the floor. The emergency room could not do a closed reduction. He came back with both of his arms in a sling and a follow up appointment to the orthopedic doctor. (R1's) investigation showed that he woke up and was disorientated and tried to self-transfer and he fell. (R1's) new intervention was to not leave (R1) asleep in the lounge unattended. R1's Care Plan was reviewed and there was no documentation that this intervention was implemented to prevent R1 from future falls. R1's Nurse's Note, dated 4/5/22 at 1:30 PM, documents, Res is alert with confusion noted. Res constantly trying to get up on his own. R1's Nurse's Note, dated 4/5/22 at 7:30 PM, documents, Res (resident) observed on floor in room [ROOM NUMBER]. Res laying on abdomen with arms outstretched and legs outstretched. Res noted to have large s/t (skin tear) to lt (left) arm probably from ER (Emergency Room) visit from previous night. Res has laceration on Rt (right) brow with some slow to respond answers to questions. Res appears to be confused beyond his norm (normal). sent out to ER. R1's ED (Emergency Department) Physician note, dated 4/5/22, documents, History of Present Illness: [AGE] year-old man with a history of dementia brought to the emergency department after a fall in which he injured his head and his left shoulder per EMS (Emergency Medical Services). Witnessed fall from a standing position. No loss of consciousness. Patient was seen yesterday for a similar presentation and found to have a right clavicle fracture, left anterior shoulder dislocation and scalp contusions. Transferred to (regional) hospital for shoulder dislocation after several unsuccessful attempts were made here. There were abrasions and contusions on his face and forehead on the right last night. There are 2 new contusions today. R1's Nurses Note, dated 4/6/22 at 2:30 AM, documents, Res returned to via transport. Orders to see ortho r/t dislocation of lt. (left) shoulder from fall on 4/4/22. On 9/19/22 at 11:00 AM, V2, stated that she was unaware of this fall. There was no fall investigation for the fall on 4/5/22 for review. R1's Care Plan was not revised after this fall on 4/5/22, with progressive interventions to prevent him from future falls. 145411 Page 2 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0689 R1's Nurse's Note, dated 4/27/22 at 8:00 PM, documents, Res fell in LR (living room) with gash to Rt side of head. Unable to assess fully r/t (related to) sending res out with head trauma. Level of Harm - Actual harm Residents Affected - Few R1's Nurses Note, dated 4/27/22 at 10:00 PM, documents, ER called and sending res back res has 2 staples to Rt (right) side of head no other injuries. R1's ED (Emergency Department), dated 4/27/22, documents, Procedure: Scalp laceration right forehead 2 cm (centimeter) x (by) 0.5 cm no active bleeding local lidocaine 1% 5 cc (cubic centimeters) stapled with 2 closed the wound. On 9/15/22 at 2:15 PM, V2, reviewed the investigation and stated that R1 was resting in the recliner. V2 stated R1 tried to stand, and he fell. V2 stated that the new fall intervention is to always wear shoes because he only had on gripper socks. R1's Care Plan was not revised after this fall to prevent R1 from future falls. R1's Nurse's Note, dated 4/29/22 at 2330, documents, Resident was in low bed, alarm on alarm was sounding, resident on floor by bed. hematoma above L eye noted. On 9/19/22 at 11:55 AM, V2, Regional Nurse, stated, (R1) got out of bed and bumped head on foreign object. (R1's) intervention is to ensure to continue use of low bed. R1's Nurse's Note, dated 5/2/22 at 12:25 PM, Resident in w/c (wheelchair) in dining area. Resident attempted to stand out of w/c and fell to floor on L side. Hitting left side of head on floor 3 x 2 cm (centimeter) s/t noted to LFA (left forearm). Cleansed with (wound cleanser) dry dressing applied scant amount of serosanguinous drainage noted to L forehead. On 9/15/22 at 2:35 PM, V2, stated, (R1's) root cause for the fall on 5/2/22 was he attempted to self-transfer and 15-minute checks were initiated. R1's Care Plan was not revised after his fall on 5/2/22 with progressive interventions to prevent him from future falls. R1's MDS, dated [DATE], documents, R1 is moderately cognitively impaired and requires supervision of 1 staff member for ambulation and transfers. R1's Nurse's Note, dated 8/12/22 at 12:35 AM, documents, Writer called to resident room. Res is sitting in floor 1 cm skin tear noted to R elbow unable to reapproximate. area cleansed with (wound cleanser) steri-strips applied, thumb swollen and purple in color. Res c/o (complaint of) pain to Left finger and LFA, unable to perform pronation / supination to L arm. no other injuries apparent. Res sitting in chair at this time. R1's Nurses Note, dated 8/12/22 at 11:45 AM, Res returned to facility per facility van. L shoulder back in place. L thumb severely fractured and L pinky fx. (fracture) Splint in place to L hand and arm and ace wrap. R1's Hospital Emergency Department Discharge Instruction, dated 8/12/22, documents, Diagnosis: 1. Anterior dislocation of left shoulder. 2. Fracture of fifth metacarpal bone of left hand. 145411 Page 3 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0689 Level of Harm - Actual harm On 9/15/22 at 2:36 PM, V2, stated, On 8/12/22 (R1) was found on the floor at 12:35 AM, just prior to this he was walking in the hallway to go back to his room. He stated that he got his foot caught on an extra cover and he fell. The new intervention for this fall is to ensure that blankets are not touching the ground and extra blankets are taken off the bed. Residents Affected - Few On 9/19/22 at 12:15 PM, V20, Medical Director, was questioned about all R1's falls. V20 stated, It is obvious (R1) should be on one to ones (supervision). The facility made me aware of all of the fractures, but I was never made aware of the big picture that he had fallen that many times. On 9/19/22 at 3:10 PM, V8, Licensed Practical Nurse, stated, I am not sure what was going on with (R1) when he kept falling. They were using a wheelchair for him, and he just kept standing up and trying to walk. He then went out to (Behavioral Health) and when he came back, they just let him walk and he has been doing better. 2. R31's admission Sheet documented R31 was admitted to the facility on [DATE]. R31's Nurse's Note documented Res (Resident) arrived @ (at) facility per facility van into room (Room #)-see assessment. R31's Nursing admission Assessment, dated 6/2/22, documented R31's admitting diagnosis was brain hemorrhage. R31's Fall risk assessment, dated 06/02/2022, documented that she was a high risk for falls. R31's Baseline Care Plan, dated 06/02/2022, documented, High Risk Fall Assessment, Poor Safety awareness, Fall history and 15 (minute check). R31's 15 Minute Observation checklist, dated 06/02/2022 from 5:30 PM until 7:30 PM, documented that R31 was in her room, sitting in a chair and was anxious. No interventions for R31's anxiousness was documented. There was nothing in R31's Nurse's Notes regarding R31s anxious behaviors and what staff were doing to address her anxious behaviors while she was alone in her room. R31's Nurse's Note, dated 06/02/2022 at 7:30 PM, documented, (Resident) attempted to get up (without) assistance (and) was alerted to staff per call light. Staff found her on the floor (at) foot of bed, sitting on bottom. Top of head was rested up against the foot board, blood all over head (and) hands. (Small) pool of blood on the floor (and) (resident) states I fell headfirst. Able to answer all nurses questions correctly but due to recent bleeding in brain (resident) will be sent to (local hospital Emergency Room) for (evaluation) (and) (treatment). Administrator and (V18, Care Plan and MDS) aware. (Power of Attorney) (phone number) is not in chart. (Regional Hospital) was called (and) they would not give nurse any (information). (Administration) notified. R31's Investigation Report for falls, dated 06/02/2022, documented that she was seen at 7:25 PM and that she had a tab alarm in place. On 09/15/2022 at 02:10 PM, V2, Regional Nurse stated that R31's tab alarm was not sounding because it was in her hand when she fell. Report sent to the Illinois Department of Public Health, dated 06/09/2022, documented, .Tabs monitor was in resident's right hand. 145411 Page 4 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0689 R31's Minimum Data Set (MDS), dated [DATE], documented that R31 required extensive assistance with transferring, frequently incontinent of bladder and occasionally incontinent of her bowels. Level of Harm - Actual harm Residents Affected - Few R31's History of Present Illness from Trauma Center, dated 06/03/2022, documented, (R31) is a [AGE] year old female brought in by (Emergency Medical Service), ground transfer from outlying facility and was in cervical collar and boarded on presentation. The patient was involved in a fall from standing. Per report, (R31) was discharged earlier today after being admitted from 2/18 to 6/2/2022, patient was discharged to a nursing home. Patient was admitted for an intracranial hemorrhage, (Urinary Tract Infection) Hypertensive emergency, metabolic encephalopathy, and A-fib who was on coumadin which was stopped at time of discharge. Upon being discharged and admitted to the nursing home, patient was reported to be found lying on the floor on her back after an unwitnessed fall. It continues, At the (Outside Service Hospital), patient was reported confused and moaning. Imaging reported at the (Outside Service Hospital) found a C1-C2 fracture. Upon arrival to the trauma center, there was no (Outside Service Hospital) records to review. Patient is noted to have a small scalp laceration and surrounding hematoma. R31's Trauma CT Cervical Spine report, dated 06/03/2022, documented, Findings: Acute, mildly displaced type 3 fracture of the odontoid process. Mild dorsal subluxation of the lateral masses of C1 relative to C2. Moderate multilevel cervical spondylosis . It continues, Impression: Acute type 3 fracture of the odontoid process. On 09/14/2022 at 1:30 PM, V17, Assistant Director of Nurses (ADON), stated that when a resident falls, the nurses fill out the form and then the Interdisciplinary team (IDT) will meet and discuss the fall and then they will fill out the rest of Quality Care Reporting Form, the investigation. On 09/14/2022 at 2:00 PM V18, Minimum Data Set/Care Plan Coordinator, stated that R31 had a baseline care plan and it addressed her being a high risk for falls and that she should have been on 15-minute checks. On 09/15/2022 at 2:10PM, V2, Regional Nurse stated that she would expect the nurses and CNAs to do the 15-minute checks if it was on the care plan. She continued to state that the Investigation Report for Falls was an internal document, and that the facility would not give a copy to the state surveyor but was able to review the document. The Fall Prevention Policy, dated 11/10/18, documents, Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. It continues, Report all falls during morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. 145411 Page 5 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review the facility failed to employ a Registered Nurse (RN) in the facility for 8 hours a day, 7 days a week, or a Director of Nursing since May 2022. This has the potential to affect all 39 residents in the facility. Findings include: On 9/12/2022 at 10:00 AM there was no Director of Nursing (DON) or RN present at the facility, or throughout survey. On 9/14/2022 at 11:45 AM V17, Assistant Director of Nursing (ADON) stated the facility has not had a Director of Nursing since May2022. On 9/15/2022 at 2:15 PM V2, Regional Nurse, stated she is not the acting director of nursing. V2 stated she supervises nurses to make sure everything gets done. She stated she does not provide RN coverage The facility daily staffing report documents there was no RN scheduled 8 hours a day seven days a week from 8/13/2022- 9/11/2022. On 9/19/2022 at 1:43 PM V1, Administrator stated she would expect the facility to have a full time DON and provide RN coverage 8 hours a day 7 days a week. The facility policy nurse staffing, undated, documents It is the policy of facility to provide sufficient licensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. The Resident Census and Conditions of Residents, CMS 672, dated 09/12/2022, documents that the facility has 39 residents living in the facility. 145411 Page 6 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview, observation and record review, the facility failed to wash hands, wear a hair net properly and store dry goods in a sanitary manner. This failure has the potential to affect all 39 residents living in the facility. Findings include: On 9/12/22 at 11:37 AM, V5, cook, entered the kitchen to check steam table temperatures. V5 donned gloves without hand hygiene and then started to take the temperatures. At 11:42 AM, V5, adjusted her face mask by touching the middle of the mask and adjusting with her gloved hand. V5 failed to change gloves and wash her hands. V7 kitchen aide, was preparing drinks for lunch. V7 is wearing a hair net which only covers the back portion of her hair, her bangs and sides of hair are visible. At 11:45 AM, V5, changed gloves without washing hands and began to serve the noon meal from the steam table. V5 adjusted her mask with her gloved hand 5 times while serving the noon meal. On 9/12/22 at 12:00 PM, the dry storage room was toured. A large bin of oatmeal has a scoop in it with the handle lying on the oatmeal. A large bin of flour has a scoop in it with the handle lying on the flour. There is a cardboard full box of orange juice base on the floor, a cardboard box of full elbow macaroni on the floor, a 25 pound bag of instant nonfat milk which is open and on the floor and a large bag of spiral noodles which was open. On 9/13/22 at 10:15 AM, V1, Administrator, stated, The kitchen staff should always wash their hands before putting on gloves, after touching their mask and when they enter the kitchen. The food scoops should not be left in the food storage bin and food should not be stored on the floor on the floor in the dry storage area. The kitchen storage policy, dated 10/20, documents, 6. When using only part of the product, the remaining product should be in the original package or air tight contained and labeled and dated. The hand washing policy, dated 10/09, documents, Hand washing is to be done: Before starting work. Before putting on gloves. After removal of gloves. During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks. The Resident Census and Census and Conditions of Residents, CMS 672, dated 9/12/22, documents that the facility has 39 residents living in the facility. 145411 Page 7 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 6. On 9/12/2022 at 12:13PM, V21, Administrator in training, walked around in the dining room with surgical mask on below her nose. Residents Affected - Many On 9/12/2022 at 12:13PM, V22, social services, was cutting up residents' meat in the dining room with a surgical mask below nose. On 9/19/2022 at 10:41AM, V1, Administrator, stated she would expect staff to wear face mask covering the nose. 7. On 09/19/22 at 09:48 AM during incontinent care, V15, CNA, donned gloves and did not sanitize hands prior to donning gloves. V15 and V16, CNA, then provided incontinent care to R6. After completing incontinent care, neither V15 nor V16 doffed gloves and sanitized hands prior to touching R6's clothing and touching the mechanical lift. The facility policy hand hygiene dated, revised 12/7/18 documents all staff will wash hands as promptly and thoroughly as possible after resident contact with blood, body fluids, secretions, excretions and equipment or articles contaminated by them. On 9/19/2022 at 10:38AM, V1, Administrator, stated she would expect staff to cleanse hands prior to donning and after doffing gloves. The CDC COVID tracker documents the county transmission rate, for the county where the facility was located, dated week of 09/02/22 to 09/08/2022, was high. The facility policy, Hand Hygiene, dated 12/07/2018, documented, All staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. The facility policy Covid-19 control measures dated revised 3/25/2022 documents for facilities in a county where the community transmission rate level is substantial or high, employees providing services to residents must wear a facemask and eye protection. The Resident Census and Census and Conditions of Residents, CMS 672, dated 9/12/22, documents that the facility has 39 residents living in the facility. Based on interview, observation and record review, the facility failed to perform hand hygiene, wear protective eyewear, and wear mask correctly to prevent/control the spread of COVID-19 and other infections. This failure has the potential to affect all 39 residents living in the facility. Findings include: 1. During the survey, V12, Certified Nurse Aide (CNA) and V13, CNA, both were observed caring for resident without eye protection. 2. On 9/13/22 at 3:15 PM, V14, CNA, took R24 to the restroom. V14 assisted R24 with pulling down her pants and soiled depends and sitting on the toilet. V14 failed to don gloves. V14 then got a pair 145411 Page 8 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0880 of gloves and donned them without hand hygiene. Level of Harm - Minimal harm or potential for actual harm 3. On 9/13/22 at 3:00 PM, V11, Physical Therapy Assistant, was sitting next to R14. V11 had her face mask pulled down to her chin while talking to the resident. Residents Affected - Many On 9/15/22 at 3:00 PM, V1, Administrator, stated that staff should be wearing eye protection, their mask correctly, wash hands before donning gloves and after removing gloves, and wash hands when you contaminate you gloves. 4. On 9/12/22 during the noon medication pass, V4, Licensed Practical Nurse (LPN), adjusted her face mask multiple times by grabbing the middle of it and pulling it up and afterward failed to perform hand hygiene. 5. On 09/13/22 at 11:11 AM , V8, LPN, entered R140's room to perform a blood glucose check. V8 failed to perform hand hygiene before donning gloves. 145411 Page 9 of 10 145411 09/20/2022 Rose Garden of Pana 900 South Chestnut Pana, IL 62557

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed perform twice a week COVID19 testing of staff for who are not up to date with their COVID19 vaccinations and staff who have an exemption. This failure had the potential to harm all 39 residents residing in the facility. Residents Affected - Many Findings include: The facility's COVID19 Tracking for testing for the week of 8/29/2022 documented that V28, Certified Nurse Assistant (CNA), who has a non-medical exemption, V29, CNA, who has a non-medical exemption, V30, Unit Assistant (UA), who has a non-medical exemption, V31, CNA, who has a non-medical exemption, V32, Licensed Practical Nurse, who has a non-medical exemption, and V33, UA, who has a non-medical exemption, V23, Laundry, who was not up to date with COVID vaccinations, V24, Housekeeping, who was not up to date with COVID vaccinations, V25, Business Office Manager, who has a non-medical exemption, and V27, Laundry, who has a non-medical exemption were not tested for COVID19 twice weekly. The facility's COVID19 Tracking for testing, dated for the week of 09/05/2022, documented that V26, CNA, who was not up to date with COVID vaccinations, V29, CNA, who has a non-medical exemption, V30, UA, who has a non-medical exemption, V14, CNA, who was not up to date with COVID vaccinations, V31, CNA, who has a non-medical exemption, V34, CNA, who has a non-medical exemption, and V32, LPN who has a non-medical exemption, were not tested twice weekly for COVID19. On 09/14/2022 at 2:35 PM, V18, Minimum Data Set/Care Plan Coordinator, stated that she keeps up on the COVID19 information. V18 continued to state that the unvaccinated staff are tested twice a week. Vaccinated staff are only tested if they have signs and symptoms of COVID and everyone is tested if there is an outbreak at the facility. On 09/19/2022 at 3:21 PM, V35, Activity Director, stated that they are tested for COVID19 twice a week. On 09/19/2022 at 3:23 PM, V25, CNA stated that she was tested for COVID19 twice a week. On 09/19/2022 at 3:27 PM, V1, Administrator, stated that the staff are tested twice a week for COVID19. On 09/19/2022 11:25 AM, V17, Assistant Director of Nurses (ADON), stated that the documentation of the COVID19 Staff Vaccination Status for Providers, Completely vaccinated means that the staff has had their 1st and 2nd vaccinations and that the Booster dose means that the staff has had the required boosters. The CDC COVID tracker documents the county transmission rate, for the county where the facility was located, dated week of 09/02/22 to 09/08/2022, was high. The facility's policy, Testing of Staff and Residents, dated 03/25/2022, documented, .2. Per executive order 2022-5 and the most recent emergency rules, (Health Care Providers) not up to date with COVID19 vaccination must be tested twice a week, with testing occurring at least 3 days apart. The Resident Census and Conditions of Residents, CMS 672, dated 09/12/2022, documents that the facility has 39 residents living in the facility. 145411 Page 10 of 10