Inspection·January 30, 2026

F 0677 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete from 9:00 AM to 11:50 AM. V7 did not return back to R4's room. R4 turned back on his call light at 11:45 AM, V37 [Certified Nurse Assistant] answered the call light. V37 exited R4's room at 11:50AM, and V37 returned with supplies and initiated ADL incontinence care to R4 three hours later [9:00AM to 12:00PM R4 was soiled with feces]. On 1/27/26 at 12:24PM, V7 [Certified Nurse Assistant] stated, I answered R4's light he reported he needed to be cleaned up after having a bowel movement, I did tell him I would be back, but I forgot. I was so busy with my own assigned residents. There are only two of us on this floor with approximately forty or more residents that need assistance. I am not sure why they sent V8 out on a medical appointment. Staffing has been an issue working short for over two months. On 1/27/26 at 10:20AM, during surveillance of R4's room, a couple rooms down from R4's room, surveyor heard someone yelling out for help. R5 was in bed, stated, I am wet and need help. I been wet a long time.Surveyor turned on R5's call light. 10:22AM. V9 [Licensed Practical Nuse] turned off the call light and came out the room and went back to the nursing station. At 11:10AM, surveyor asked R5 was she still wet. R5 stated, Yes, I am still wet. The lady said she will be back. On 1/27/26 at 11:30 AM, surveyor asked V9 what did R5 requested, when she answered the call light. V9 stated, R5 needs to be cleaned up. I told one of the aides, I don't remember which one. I have an admission coming and need to get report. Staffing has been an issue for a while; we work together to do the best we can. Someone will help R5 soon as possible. On 1/27/29 at 11:58 AM, V8 [Certified Nurse Assistant] retuned back to unit from escorting a resident to medical appointment. At 12:15PM, surveyor asked V8 if she could provide ADL incontinence care to R5. V8 stated, I was sent out to go with a resident to their medical appointment. There are other aides that could have gone instead of me. There are restorative certified nurse assistants, and a wound care certified nurse assistant. They are not assigned to residents.V8 went to R5's room and provided care. R5 was wet from 10:22AM to 12:15PM [two hours]. On 1/27/26 R17, said the staffing is not sufficient and they have to wait a long time for assistance. They all said the facility needs more certified nurse assistants. On 1/27/26 at 3:05 PM V3 [Acting Director of Nursing/Nurse Consultant] stated, I became the acting director of nursing on 1/13/26. I was not made aware V8 [Certified Nurse Assistant] was sent out on a medical appointment. I rather had sent another certified nurse assistant such as restorative, or wound care aide. My expectation related to ADL incontinence care is that care is provided as soon as possible. For a resident to wait three hours for assistance is not acceptable. If a resident is left wet or soiled for two to three hours, it could potentially cause infection, skin breakdown, pain or feelings of sadness and/or dignity issues. Policy in part:Certified Nurse Assistant Job Description:Provide residents with daily nursing care in accordance with current federal, state and local standards, guidelines, and regulations.Provide ADL assistants to a specific number of residents and or directed by nursing staff. 483.24(a)(2) ADL Care Provided for Dependent ResidentsS483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain goodnutrition, grooming, and personal and oral hygiene. Event ID: Facility ID: 145450 If continuation sheet Page 2 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 a.) ensure two (R8, R9) resident's oxygen was on the correct setting b.) failed to ensure respiratory equipment was labeled and stored to prevent contamination for two (R8, R9) residents and c.) failed to ensure one (R13) resident had a physician order for oxygen. These failures have the potential to affect 5 residents reviewed for oxygen use.Findings Include: R8 has diagnosis not limited to Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Chronic Respiratory Failure with Hypoxia, Bipolar Disorder, Specified Depressive Episodes, Dependence on Supplemental Oxygen and Pulmonary Hypertension. R8's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R8's Care Plan document in part: Focus: R8 is at risk for falls due to weakness, Respiratory failure, dependency on oxygen and asthma. Focus: R8 has potential for shortness of breath, anxiety and/or fatigue due to COPD that require respiratory treatments. Interventions: Administer oxygen as ordered.R8's Order Summary Report document in part: Focus: Respiratory: Oxygen Per Nasal Cannula @ _1-5_Liters Per Minute Continuous Every Shift Related to Unspecified Asthma. Focus: DuoNeb Solution 0.5-2.5 (3) MG/3ML (milliliter) (Ipratropium-Albuterol) 3 ml inhale orally via nebulizer every 12 hours for COPD (Chronic Obstructive Pulmonary Disease).On 01/27/26 at 11:12 AM R8 was observed lying in bed on a low air loss mattress with oxygen at 3 liter per nasal cannula in use. The wall oxygen flow meter was observed at 3 liters. R8's nebulizer mask was observed laying on a table on the left side of the bed unlabeled and not in bag. R8 stated I always use oxygen.R9 has diagnosis not limited to Primary Pulmonary Hypertension, Acute and Chronic Respiratory Failure with Hypoxia and Chronic Systolic (Congestive) Heart Failure. R9's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response.R9's Care Plan document in part: Focus: R9 requires oxygen therapy PRN (as needed) related to history of Chronic Respiratory Failure. Interventions: Administer oxygen per MD (medical doctor) orders. Focus: R9 has the potential for shortness of breath, anxiety and/or fatigue due to breathing problems that require respiratory treatments. Interventions: Administer oxygen as ordered.On 01/27/26 at 11:32 AM R9 was observed lying in bed with a nasal cannula in place and the oxygen flow meter off. An oxygen tank was observed on R9's wheelchair with a nasal cannula connected to the oxygen tank undated with no storage bag. R9 stated I use oxygen sometimes when I need it. This surveyor asked R9 how many liters of oxygen he uses. R9 responded 2 liters. Surveyor observed the oxygen flow meter set at zero. R9 took the nasal cannula off, placed it near his face and said, I can't feel any oxygen.On 01/27/26 at 10:38 AM V12 (Licensed Practical Nurse) stated If a resident is on oxygen and has a nasal cannula nasal cannula, we make sure they have the humidifier, the apparatus changed weekly, and the humidifier is changed as need and make sure the oxygen is on the correct setting. If they are on oxygen the tubing should be labeled when changed. On 01/2/26 at11:35 AM V12 (Licensed Practical Nurse) stated R9's oxygen order is for 2 liters, but it does not say continuous.On 01/27/26 at 11:39 AM surveyor asked V12 to check R9's pulse oximetry. V12 entered R9's room and checked the pulse oximetry with a reading. Surveyor then asked V12 the setting on R9's oxygen flow meter. V1 responded, it is on zero. V12 then adjusted the oxygen flow meter to 2 liters. R9 said now I can feel the oxygen.R13 has diagnosis not limited to Pleural Effusion, Chronic Pulmonary Edema, Pneumonia, Acute Metabolic Acidosis and Acute and Chronic Respiratory Failure with Hypoxia.R13 was admitted to the facility on [DATE] and there was no physician order for oxygen in R13's electronic medical records when reviewing R13's Order Summary Report. There was no Care Plan for R13's oxygen use.On 01/27/26 at 10:57 AM R13's oxygen concentrator was observed at 1 liter per nasal cannula in use. R13 stated I have been using oxygen Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145450 If continuation sheet Page 3 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete since I have been here.On 01/28/26 at 12:12 PM V2 (Acting Director of Nursing/Nurse Consultant) stated there should be an order for the oxygen, the care plan that addresses it, typically the oxygen is documented how often the titration is checked, make sure they have the appropriate setting, equipment and humidity. The staff should make sure they have a physician order for the oxygen unless it is an emergency. If someone is in respiratory distress the doctor will be notified but oxygen can be administered as lifesaving interventions. The nasal cannula when not in use and nebulizer mask should be stored in a clean bag at the resident beside for infection control purposes. The nasal cannula should have the date it was changed. The nurse should do a daily assessment and if the nasal cannula does not have a date or is stored in a bag it should be discarded and replaced. The wall oxygen flow rate adjusters are called oxygen flow meter with the connector. If a resident does not have an order for oxygen it should not be in their room. If the oxygen is not on the correct setting the resident may not get enough oxygen or if the oxygen rate is to high the resident can end up with hypercapnia. If the nebulizer mask is not in a bag there is an issue of infection control. It the oxygen flow meter is off it is possible that R9 was not getting enough oxygen.Policy:Titled Oxygen Concentrator dated 09/20 document in part: Residents will be administered Oxygen via oxygen concentrator upon Physician's orders by an RN (Registered Nurse), LPN (Licensed Practical Nurse or RT (Respiratory Therapist). e. set the flow dial to LPM (Liter per Minute) prescribed by physician. 2. a. No smoking or use of any other open flame in resident's room while equipment is in operation. Equipment: 5. Oxygen In-Use sign placed in the lobby.Titled Oxygen Therapy Devices - Nasal Cannula dated 09/20 document in part. Procedure: 1. Verify physician's order. Equipment: 1. Oxygen source. 4. Oxygen In-Use sign placed in the lobby area.Titled Equipment Change Schedule dated 10/25 document in part: Equipment will be changed following established schedules to prevent cross contamination. 6. Nebulizers: a. Nebulizer tubing shall be stored appropriately in a bag when not in use. c. Nebulizer set-ups for bronchodilator therapy changed weekly and prn (as needed). Event ID: Facility ID: 145450 If continuation sheet Page 4 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, interviews and record reviews, the facility failed to have adequate staffing to ensure two (R4, R5) out of eight residents reviewed for ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all residents residing on the second floor and third floors. On 1/27/26 at 8:15 AM, V30 [R3's Family Member] stated, On 12/25/25 around 5PM, I noticed the nurse earlier was not there. A certified nurse assistant reported the nurse from 7AM to 3PM was gone and there was one nurse on the other side. I walked to the other end of the third floor and spoke to V33 [Registered Nurse]. V33 reported the 3PM to 11PM nurse called off. V33 said she was not liable for all fifty residents on the entire floor. I went to the front desk and asked V36 [Facility Receptionist] to call the administrator [V1]. I heard V36 explain to V1 my concerns, V36 replied V1 would get coverage. There is always a staffing issue at the facility. There were several times R3's under brief was entirely wet and soiled with feces stuck to her body. R3 is no longer at the facility, I moved her to another nursing facility. On 1/27/26 during facility tour at 9:00AM, across from the nursing station surveyor observed a room with call light activated. R4 resting in bed, alert and oriented x3. Surveyor noted a strong odor of feces. R4 stated, I'm doing alright. After breakfast I had a bowel movement, and I need to be changed I just turned on the call light. The staffing is terrible. I always wait a long time sometimes for hours before I get changed and cleaned up. I use my urinal. I just need assistant when I have a bowel movement. On 1/27/26 at 10:00AM, Surveyor observed V7 entered R4's room, turned off the call light and exited the room. R4 tuned the call light back on. On 1/27/26, Surveyor conducted surveillance of R4's room on 1/27/26 from 9:00 AM to 11:50 AM. At 11:45 AM, V37 [Certified Nurse Assistant] answered the call light. V37 exited R4's room at 11:50AM, and V37 returned with supplies and initiated ADL incontinence care to R4 three hours later [9:00AM to 12:00PM R4 was soiled with feces]. On 1/27/26 at 12:24PM, V7 [Certified Nurse Assistant] stated, I answered R4's light he reported he needed to be cleaned up after having a bowel movement, I did tell him I would be back, but I forgot. I was so busy with my own assigned residents. There are only two of us on this floor with approximately forty or more residents that need assistance. I am not sure why they sent V8 out on a medical appointment. Staffing has been an issue working short for over two months. On 1/27/26 at 10:20AM, Surveyor heard someone yelling out for help. R5 was in bed, stated, I am wet and need help. I been wet a long time. Surveyor turned on R5's call light. 10:22AM. V9 [Licensed Practical Nuse] turned off the call light and came out the room and went back to the nursing station. At 11:10AM, surveyor asked R5 was she still wet. R5 stated, Yes, I am still wet. The lady said she will be back. On 1/27/26 at 11:30 AM, surveyor asked V9 what did R5 requested, when she answered the call light. V9 stated, R5 needs to be cleaned up. I told one of the aides, I don't remember which one. I have an admission coming and need to get report. Staffing has been an issue for a while; we work together to do the best we can. Someone will help R5 soon as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145450 If continuation sheet Page 5 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0725 Level of Harm - Minimal harm or potential for actual harm On 1/27/29 at 11:58 AM, V8 [Certified Nurse Assistant] retuned back to unit from escorting a resident to medical appointment. At 12:15PM, surveyor asked V8 if she could provide ADL incontinence care to R5. V8 stated, I was sent out to go with a resident to their medical appointment. There are other aides that could have gone instead of me. There are restorative certified nurse assistants, and a wound care certified nurse assistant. They are not assigned to residents. Residents Affected - Some V8 went to R5's room and provided care. R5 was wet from 10:22AM to 12:15PM [two hours]. On 1/27/26 R6, R9, R14, R15, R17, and R18 all said the staffing is not sufficient and they have to wait a long time for assistance. They all said the facility needs more certified nurse assistants. On 1/27/26 at 1:10 PM V10 [Nurse Scheduler/Certified Nurse Assistant] stated, The staffing requirements on 12/25/25 are: Second- floor is rehab and dialysis residents. The census is around 45 residents. I staff three certified nurse assistants and two nurses for first [7AM- 7PM] and second shift [7PM to 7AM], and two nurse assistants for third shift. On the third-floor west unit is resident that requires respiratory care. There are about thirty-two residents. The first shift 7Am-3PM and second shift 3PM-11PM requires two nurses and three certified nurse assistants. Third shift, 11PM- 7AM, requires two nurses and two certified nurse assistants. On the third-floor vent unit the first shift from 7AM to 7PM and 7PM-7AM shift requires two nurses and three certified nurse assistants. On the fourth floor there are more independent residents, about seventy residents. I will try to staff three nurses for first shift 7AM-3PM and second shift 3PM-11PM. Third shift 11PM-7AM requires two nurses and four certified nurse assistants. On 12/25/25, three nurses called off work. A nurse called off for the second floor 3PM-11PM shift, nurse called off from 7PM to 7AM on the third-floor vent and trach unit, a nurse called off the fourth floor for 11PM to 7AM shift. I could not find nurse replacements for the vacancies. I texted V34 [Former Director of Nursing], V28 and V9 both assistant director of nursing, and V1 [Administrator] of the call offs and there was no replacement located. On 12/25/25, The staffing was as follows: On the second floor there was one nurse for the second shift [3PM-11PM], two nurses are needed. The third-floor vent unit 7AM-7PM there was one nurse, two nurses are needed. The one nurse on the vent unit was alone for the vent unit and the west unit from 3PM to 9PM. The fourth floor was managed well, the residents on the fourth floor are independent. On 1/28/26 at 10:27 AM V25 [Registered Nurse] stated, On 12/25/25, I was the only nurse working on the second-floor form 7AM -7PM. There are normally two nurses. I notified V34 [Former Director of Nursing]. V34 told me I was reasonable for all the residents. The facility is always short-staffed. I resigned from working there on 12/28/25 due to the staff shortage it was not safe working there. On 1/28/26 at 10:50 AM, V29 [Assistant Director of Nursing] stated, I was off work on vacation with approved time off. I was not made aware of the nursing shortage on 12/25/25, due to my cell phone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145450 If continuation sheet Page 6 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0725 was broke. Level of Harm - Minimal harm or potential for actual harm On 1/28/26 at 11:20 AM V28 [Assistant Director of Nursing] stated, The facility staffing is good we are never short staffed. The Second floor is good for working with one nurse. The third floor is good to have only one nurse for the vent unit and the three-west unit. I did not receive any communication from V1 or anyone else about any staffing issues on 12/25/25. Today when the aide was sent out on an appointment. The second-floor staff was good with two nurse assistants working with forty-five residents, there was nothing wrong with that at all. A resident should not wait for three hours to be cleaned. It was not a staff issue. Residents Affected - Some On 1/27/26 at 3:05 PM V3 [Acting Director of Nursing/Nurse Consultant] stated, I became the acting director of nursing on 1/13/26. I was not made aware V8 [Certified Nurse Assistant] was sent out on a medical appointment. I rather had sent another certified nurse assistant such as restorative, or wound care aide. My expectation related to ADL incontinence care is that care is provided as soon as possible. For a resident to wait three hours for assistance is not acceptable. The second floor should have two nurses. The third-floor vent unit needs its own nurse, and the west unit needs a nurse designated to that unit to provide adequate care. The facility does not have a staffing policy. On 1/28/26 at 3:24 PM, V1 [Administrator] stated, I was notified by V10 [Nurse Scheduler] on 12/25/25, there was a staffing issues with nurses calling off work. I called V34[Former Director of Nursing] and he reported he was not the on call nursing manager for 12/25/25. After that communication, V34 did not respond anymore. I contacted the two Assistant Director of Nursing V28 and V29. V29 did not respond, later I found out her phone was broken. V28 did not respond. I called staff nurses offering a bonus and I phoned the nursing agency, but no one was available to work. I did not mandate any nurse managers to come into work. I did not find any nursing coverage. The staff worked short on 12/25/25. The facility does not have a staffing policy. Policy in part:Certified Nurse Assistant Job Description: Provide residents with daily nursing care in accordance with current federal, state and local standards, guidelines, and regulations. Provide ADL assistants to a specific number of residents and or directed by nursing staff. Facility Assessment Statement: Extra and relief staffing will be provided by other sister facilities and the over 200 corporate employees stationed and living throughout our service area. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145450 If continuation sheet Page 7 of 8 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 145450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alden Lakeland Rehab & Hcc 820 West Lawrence Chicago, IL 60640 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 0725 483.35(a) Sufficient Staff. Level of Harm - Minimal harm or potential for actual harm 483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all Residents Affected - Some residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides.483.35 Nursing Services Findings include: Daily Schedule for Tuesday, 1/27/2026, documents in part one nurse, V14, for 7:00 AM to 7:00 PM shift on the vent unit. Second nurse slot was blank. There were two CNAs (Certified Nurse Aides), V15 and V16 for the unit. The third CNA slot was blank. On 01/27/2026 at 10:49 AM, V16 (CNA) stated the vent unit should have two nurses and three CNAs but there's only one nurse and two CNAs for today. V16 stated when the unit is short staffed, the workload increases. V16 stated most of the residents on the unit are bed bound and total assist, so it makes it difficult to take care of everyone properly. V16 stated residents will complain and there's only so much the staff can do when they're short staffed. V16 stated residents would complain about the staff not coming right away to change them or would complain that the call lights were on for a while. V16 stated the residents will also complain about the food being cold if there's not enough staff to pass the food trays right away. On 01/27/2026 at 11:33 AM, R15 stated there are not enough CNAs. When the facility is short staffed, the CNAs are slow to change people because they're spread short taking care of a lot of dependent and heavy residents. On 01/27/2026 at 11:58 AM, R16 stated there's not enough nurses and CNAs for the third floor. R16 stated most of the time, the floor has three nurses when it's supposed to have four. R16 stated last month there was a day when there were only two nurses in the unit because staff called off and facility did not find replacements. R16 also stated the floor does not have enough CNAs. R16 stated needing staff assistance with bowel movements. R16 stated staff are supposed to change R16 right away but would wait for hours to get it done when short staffed. R16 stated short staffing occurs most during the weekends and holidays. On 01/27/2026 at 12:14 PM, V15 (CNA) stated we need more help. V15 stated there should be two nurses and three CNAs on the vent unit but it's short one nurse and one CNA today. V15 stated the facility had to redo the assignments and split the 3 [NAME] staff to help cover the workload on the vent unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145450 If continuation sheet Page 8 of 8