Health inspection·January 14, 2025

F 0729 Level of Harm - Minimal harm or potential for actual harm Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on observation, interview and record review the facility failed to ensure nursing assistants were certified after completing the training program. This applies to all 114 residents residing in the facility. Residents Affected - Many Findings include: The facility Data Sheet dated 01/14/25 shows 114 residents residing in the facility. On 01/14/25 at 10:43 AM, V7 (Certified Nursing Assistant-in training) was observed working on the 2nd floor. She was leaving a resident's room. Her name tag stated CNA. V7 said she's been working at the facility for about 1.5 years and floats throughout the facility. She said she went to school for her CNA training and she's is a CNA. She said she completed the training a 2nd time about three months ago. V7 said she has her own resident assignment. On 01/14/25 at 11:52 AM, V2 (Director of Nursing) said we do not employ staff that are not licensed, there is window once a CNA has completed the training and have 120 days to take their test and pass. If they don't, they are removed from the schedule. V2 said there is one male staff who has completed the training and is schedule to take his test. She is not aware of any other staff who have not tested and who are not certified. On 01/14/24 at 11:58 AM, V6 (Human Resources) said staff who are in the CNA program have 120 days to pass their test after their class is completed. They can do all the duties as a CNA under the supervision of the nurse and have their own patient assignment. V7 did not pass her test and is taking the test again, V8 (CNA) just passed her test and is certified. On 01/14/25 at 2:00 PM, V1 (Administrator) and V2 (DON) confirmed V8's start date of 8/14/23 and V9's start date of 8/15/23. V2 said she was not aware of V8 not passing her test and confirmed she was aware of V9 not passing her test and was placed as activity aide until she passed her test. V8's Basic Nursing Assistant Training Program certificate dated October 7, 2024, to November 9, 2024. V8's undated Health Care Worker Registry showed Certification Program Information: Date training successfully completed 8/12/23 and 11/9/24. Date of Competency Evaluation: 12/11/23 (F-Fail), 01/06/25F2. The registry shows V8 as unlicensed Health Care-Certified Nurse Aide. V9's Basic Nursing Assistant Training Program certificate dated October 7, 2024, to November 9, Page 1 of 2 145593 145593 01/14/2025 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

F 0729 2024. Level of Harm - Minimal harm or potential for actual harm V9's undated Health Care Worker Registry showed Certification Program Information: Date training successfully completed. 05/6/23 and 11/9/24. Date of Competency Evaluation: 7/05/23 (F1), 12/10/23 (NS) and 12/16/24 (P). Residents Affected - Many There was no evidence provided of V9's schedule regarding the timeframe when she was pulled from direct care. The facility's schedule from 01/01/25 to 01/14/25 showed V8 worked as a CNA 11 out of 14 days. The facility did not provide a policy on Health Care Worker Registry Check. 145593 Page 2 of 2