Inspection·December 13, 2023

F 0677 required to fill out a shower sheet documenting the staff offered, and the resident refused, the shower. Level of Harm - Minimal harm or potential for actual harm On 12/13/23 at 1:17 PM, V16 (CNA) stated every time she gives a resident a shower, she fills out a shower sheet for each resident. V16 stated she may document in the electronic clinical record she gave a resident a shower, there would be a shower sheet she filled out for every shower documented. Residents Affected - Some On 12/11/23 at 11:20 AM, V14 (Wound Nurse) stated she collects all unit shower sheets every week and places the shower sheets in a binder for review of skin concerns. On 12/11/23 at 11:15 PM, V1 (Administrator) stated all residents were to be offered one shower/bed bath a week or per the resident preference and all showers were to be documented on shower sheets. V1 stated residents in the facility were scheduled once a week on the shower schedule for a shower/bath per the facility policy. V1 stated if a resident refused a shower/bath offered, the refusal should be documented on a shower sheet and the nurse on duty was to be made aware. V1 reviewed the shower sheets available at the facility from 11/1/23 to 12/7/23 and stated the were no further shower sheets for the reviewed residents. On 12/13/23 at 12:31 PM, V1 (Administrator) initially stated the staff were only required to document if a shower/bath was given in the clinical record but not fill out a shower sheet. After reviewing the facility policy, V1 stated, the staff technically should do a shower sheet when giving a shower to document a skin assessment. Facility Shower Schedules 1-300 (updated 11/9/23) and 4-600 (updated 11/9/23) both show, All showers, including bed baths, MUST have a shower sheet filled out and turned in to the nurse before the end of the shift. If a shower sheet is not filled out, the shower never happened Note: If [resident] refuses shower, write down explanation to why [resident] is refusing shower, make sure to notify your NOD (Nurse on Duty) as soon as it happens so NOD can notify family and write progress note. Shower and Hygiene policy, revised 7/28/23, shows residents were to be administered a shower once weekly and/or as often as necessary. The policy shows shower refusals by the resident shall be relayed by the assigned CNA to the charge nurse. The policy shows the staff were to document date/shift of the shower/bath, name/title of nursing staff who administered the shower, assessment data of skin, and if a resident reviewed the shower/bath and if interventions were taken. 2. MDS, dated [DATE], shows R4 was cognitively intact and R4 required partial/moderate assistance for showering/bathing. On 12/7/23 at 1:45 PM, R4 stated he was not sure when his last shower was given at the facility. Facility shower schedule 4-600, updated 11/9/23, shows R4 was to receive showers every Sunday on the PM shift. Review of shower sheets, dated 11/1/23 to 12/7/23, show R4 only received two of his six scheduled showers (11/12/23 and 11/26/23.) Review of R4's electronic task record on 12/11/23 showed R4 had no documented showers in the electronic clinical record between 11/1/23 and 12/7/23. Follow up report, printed 12/13/23 by V1, shows R4 had only two showers (11/12/23 and 11/26/23 refused) documented in the electronic clinical record between 11/1/23 and 12/7/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 3. Face sheet, dated 12/12/23, shows R8 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm MDS, dated [DATE], shows R8's cognitive status was moderately impaired and R8 required substantial/maximal assistance from staff for showering/bathing. Residents Affected - Some On 12/7/23 at 12:09 PM, R8 stated he had not had a shower since admitted to the facility. R8 stated the staff provide a bed bath with basic clean up every so often, but no showers were offered. Review of shower sheets, dated 11/25/23 to 12/7/23, show R8 received zero showers/baths during the time frame. Review of R8's electronic task record on 12/11/23 showed R8 had only one documented shower (11/29/23) in the electronic record but no shower sheet was located by the facility. Follow up question report, printed 12/13/23 by V1, shows R8 had no shower/bath/bed baths marked as completed from 11/26/23 to 12/13/23 in the clinical record. 4. MDS, dated [DATE], sows R2's cognitive status was intact, R2 required substantial/maximal assistance from staff for toileting hygiene, showers/baths, and personal hygiene. The care plan shows R2 was occasionally continent of both bowel and urine. On 12/7/23 at 12:13 PM, R2 was lying in his bed in his room with a urinal half full of urine hanging on his bed rails. R2's room had a strong smell of urine. R2 stated, They don't empty [the urinal] as much as they should. That's the first thing they should look at - to see if it needs emptying. That don't happen. R2 stated he had not had any showers or baths recently. Facility shower schedule 1-300, updated 11/9/23, shows R2 was to receive showers every Tuesday on the AM shift. Review of shower sheets, dated 11/1/23 to 12/7/23, show R2 had not received any showers during the time frame. Review of R2's electronic task record on 12/11/23 showed R2 had no documented showers/baths in the electronic clinical record between 11/1/23 and 12/7/23. Follow up question report, printed 12/13/23, shows R2 had only one shower (12/5/23) documented in the electronic clinical record between 11/1/23 and 12/7/23. 5. MDS, dated [DATE], shows R3's cognitive status was moderately impaired and R3 was dependent on facility staff for personal hygiene, showers/baths, toileting hygiene, and R3 was always incontinent of bowel and bladder. On 12/7/23 at 1:10 PM, R3 stated if she pushes her call light at approximately 1:50 PM to call staff to change her brief, the staff sometimes do not respond for two hours. Facility shower schedule 1-300, updated 11/9/23, shows R3 was to receive showers every Wednesday on the AM shift. Review of shower sheets, dated 11/1/23 to 12/7/23, show R3 received no showers during the time frame. Review of R3's electronic task record on 12/11/23 sowed R3 had no documented showers/baths in the electronic clinical record between 11/1/23 and 12/7/23. Follow up question report, printed 12/13/23 by V1, shows R3 had only two documented shower/bath/bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove of St Charles 611 Allen Lane Saint Charles, IL 60174 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some baths (11/7/23 and 11/22/23) in the electronic clinical record between 11/1/23 and 12/7/23. with no corresponding shower sheet documentation available. 6. MDS, dated [DATE], shows R11 was cognitively intact, R11 required substantial/maximal assistance for showering and personal hygiene, was dependent on staff for toileting hygiene, and R11 was always incontinent of bowel and bladder. Facility shower schedule 1-300, updated 11/9/23, shows R11 was to receive a shower every Friday during the PM shift. Review of shower sheets, dated 11/1/23 to 12/7/23, show R11 received only three of her six scheduled showers (11/17/23, 11/24/23, and 12/1/23.) Review of R11's clinical task record on 12/11/23 showed R11 had no documented showers in the electronic record since 11/1/23. Follow up report, printed 12/13/23 by V1, shows R11 was marked in the clinical record as receiving shower/bath/bed baths completed on 11/1, 11/3, 11/8, 11/9, 11/10. 11/11. 11/13. 11/15, 11/16, 11/17 (twice), 11/21 (twice), 11/22, 11/27, 11/28, 11/29, 12/1, 12/4, 12/5, 12/11, 12/12, and 12/13/23. Corresponding shower sheets were located for showers provided to R11 on 11/17/23 and 12/1/23, however there were no further shower sheets located to match the electronic clinical record documentation. Additionally, the electronic clinical record showed R11 did not receive a bath on 11/24/23 for which there was a hand written shower sheet located for that date documenting a shower was given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145433 If continuation sheet Page 4 of 4