Inspection·May 25, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct, respond to, and file grievance investigations for residents reporting concerns to the facility. This applies to 4 of 5 residents (R1, R2, R7 and R10) reviewed for facility communication in a sample of 10. The findings include: 1. On 5/22/23 at 2:53 PM, V3 (Family) stated they left V1 (Administrator) phone messages on 5/20/23 and 5/21/23 regarding concerns about R1's care they witnessed on R1's in-room camera. V3 stated V4 (Family) had also left messages with V1 and had not received any call backs. V3 stated they frequently leave messages with concerns at the facility and do not receive any communication back from V1 or the facility regarding their concerns. V3 stated she did not know what a grievance was or what the process was. On 5/23/23 at 11:47 AM with V2, V1 stated she had just picked up phone messages on her office phone from the weekend from R1's family regarding their concerns with care. V1 stated V3 expressed a concern that R1 was not changed for approximately eight hours on 5/20/23. Review of facility Complaint/Concern forms as of 5/24/23 at 4:00 PM showed no Form was initiated at the facility regarding R1's family grievance. V2 stated there was only one in process Complaint/Concern Form being investigated at the facility at that time which was for R6. On 5/25/23 at 4:19 PM, V1 (Administrator) stated there was no actual time frame in which grievances were expected to be investigated and responses were to be provided. V1 stated the time frame depended on the nature of the grievance. Facility document How to File a Grievance Grievance Official, undated, shows, You or your advocate may file a complaint orally or in writing Our staff members are trained to assist residents and their advocates infilling out a Concern Form Facility Grievance Policy/Procedure, revised 7/28/21, shows, 1. The facility will establish a Grievance Policy that will be made available to the resident upon request. 2. The facility will notify the resident individually or through postings in prominent location of the facility the right to file grievance orally, in writing or anonymously. 3. The notification will include the name, address and phone number of the grievance official, a reasonable time frame to investigate the grievance, and the resident's right to obtain a written copy of the grievance investigation if requested 7. All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. 8. If grievance is confirmed, the facility will take appropriate corrective action. 9. The facility will maintain results of grievances for three years. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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 0585 2. MDS (Minimum Data Set), dated 5/6/23, showed R7's cognitive status was intact. Level of Harm - Minimal harm or potential for actual harm On 5/24/23 at 1:56 PM, R7 stated he had concerns about his care from staff over the past weekend including long call light waits and lack of nursing/CNA (Certified Nursing Staff) staff. R7 stated he spoke to V1 and V2 on 5/22/23 regarding his concerns about the weekend. R7 stated approximately two weeks prior he called and left several messages for V1 (Administrator) regarding concerns a staff bumped his injured leg on a dresser but V1 did not return his calls. R7 stated he became frustrated he could not reach V1 after several attempts and messages so he wheeled to the receptionist and asked her to call V1 but was unsuccessful in reaching her. R7 stated he then left out of the front door of the facility after being told by receptionist not to leave and R7 said that moments later V1 was following him in the parking lot. R7 stated he expressed his concerns about waiting too long to receive help toileting, his concerns about lack of staff, and other concerns. R7 stated he asked V1 why she had not responded to the several messages he left her and R7 stated V1 responded, I don't listen to messages. R7 stated he spoke to V1 as recently as 5/22/23 about his concerns about lack of staff and not having assistance. R7 stated V1 told R7 she would investigate and get back to R1 however V1 was unable to provide a timeframe in which he could expect a response. Residents Affected - Some Review of facility Complaint/Concern forms as of 5/24/23 at 4:00 PM showed no Complaint Concern Form was initiated at the facility regarding R7's grievance. V2 stated there was only one in process Complaint/Concern Form being investigated at the facility which was for R7. 3. MDS, dated [DATE], shows R10 was cognitively intact. On 5/23/23 at 10:16 AM, R10 stated she had concerns about her nurse not providing her insulin on 5/21/23. On 5/23/23 at 2:15 PM, V2 stated he was aware of R10's concerns about not receiving insulin and he was investigating her concerns. Review of facility Complaint/Concern forms as of 5/24/23 at 4:00 PM showed no Complaint Concern Form was initiated at the facility regarding R10's grievance. V2 stated there was only one in process Complaint/Concern Form being investigated at the facility which was for R6. 4. On 5/23/23, V13 (Family) and V14 (Family) stated on 5/20/23 while they were in the room with R2 visiting, R2 sat in his bed from 11:00 AM to 6:00 PM and no staff checked/changed his incontinence brief. V13 stated at 6:00 PM she had to leave the facility and asked a staff to check/change his incontinence brief. On 5/23/23 at 1:53 PM, V13 and V14's lack of ADL assistance concerns for R2 were reported to V1. Review of facility Complaint/Concern forms as of 5/24/23 at 4:00 PM showed no Complaint Concern Form was initiated at the facility regarding R2's family grievance. V2 stated there was only one in process Complaint/Concern Form being investigated at the facility which was for R6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide ADL (Activities of Daily Living) care to residents who required staff assistance for toileting and repositioning. Residents Affected - Some This applies to 5 of 5 residents (R1-R4, R7) reviewed for ADL care in a sample of 9. The findings include: 1. Face sheet, dated 5/23/23, shows R1's diagnoses included urinary tract infection, hematuria, hemiplegia and hemiparesis following cerebral infarction affecting her left non-dominant side, malignant neoplasm of brain, non-traumatic intracerebral hemorrhage, unspecified psychosis, anxiety, depression, and adult failure to thrive. MDS (Minimum Data Set), dated 2/22/23, shows R1's cognition was severely impaired, R1 required the extensive assistance from two staff for bed mobility/toileting, and R1 was always incontinent of bowel/bladder Review of R1's care plan showed R1 required two staff assistance with ADLs such as toileting and repositioning, and R1 was incontinent. The care plan showed staff were to monitor for incontinence every two hours and as needed. On 5/23/23 at 9:50 AM, R1 was lying on her back in her bed with her head of bed elevated approximately 45 degrees. On 5/23/23 during continuous observation between 9:50 AM and 1:12 PM, R1 remained in the same position and no staff attempted to check/change R1's incontinence brief or reposition R1 in her bed. On 5/23/23 at 11:58 AM, V5 (CNA-Certified Nursing Assistant) stated she last changed R1's incontinence brief that morning at approximately 9:00 AM. At 12:40 PM, V5 stated she had not gone into R1's room or repositioned R1 since she repositioned R1 around/before 10:00 AM that morning. On 5/22/23 at 2:53 PM, V3 (Family) stated the family placed a camera in R1's room and on 5/22/23 they witnessed R1 remain in her bed for almost eight hours (between 5:00 AM and 12:30 PM) without staff checking or changing her brief. V3 stated the video camera showed on both 5/19/23 and 5/20/23 R1's incontinence brief was not checked/changed for 7.5 hours. V3 stated on 5/21/23 R1 waited 12 hours for staff to change her incontinence brief. On 5/23/23 at 11:58 AM, V5 stated she worked with R1 on 5/21/23 and V5 stated she checked/changed R1's incontinence brief twice during her shift - at approximately 9:30 AM and then again at approximately 1:30-2:00 PM. On 5/23/23 at 2:15 PM, V2 (Director of Nursing) stated it was his expectation for staff to round every two hours or as needed on residents which included repositioning the residents and checking/changing incontinence briefs. Facility General Care policy, revised 7/28/22, shows, It is the facility's policy to provide care for every resident to meet their needs 2. The facility will assist the resident to meet these needs 2. Face sheet, dated 5/23/23, shows R3's diagnoses included dementia, anorexia, heart failure, malnutrition, and depression/anxiety. MDS, dated [DATE], shows R3's cognition was severely compromised, R3 required the extensive assistance of staff for bed mobility, transfers, eating, toileting and personal hygiene, and R3 was always incontinent of bowel and bladder. Review of R3's care plan showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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 R3 had impaired cognitive function/dementia, required staff assistance for toileting and turning and repositioning as needed. On 5/23/23 R3 was lying on her back in her bed with her head of bed raised at approximately 45 degrees. On 5/23/23 during continuous observation between 9:51 AM and 1:31 PM, R1 remained in the same position in her bed with no staff checking/changing her incontinence brief or repositioning her. On 5/23/23 at 12:49 PM, V5 (CNA) stated she last checked/changed R3's incontinence brief and repositioned R3 in bed was at approximately 9:30 AM. 3. Face sheet, dated 5/23/23, shows R4's diagnoses included fracture of right humerous, malignant neoplasm, urinary incontinence, colitis and gastroenteritis, depression and anxiety. MDS, dated [DATE], shows R4's cognition was moderately impaired, required extensive assistance from staff for bed mobility, toileting and personal hygiene, and was always incontinent of bowel/bladder. Care plan shows R4 required assistance with ADLs including toileting. On 5/23/23 at 12:40 PM, R4 was lying in bed. V5 stated the last time she checked/changed R4's incontinence brief was approximately 9:00 AM. V5 stated R4 was incontinent of urine but may call her to be changed if she had a bowel movement. V5 stated she would change R4 after lunch service was finished. As of 1:23 PM, R4 had not had her incontinence brief changed since 9:00 AM. 4. Face sheet, dated 5/23/23, shows R2's diagnoses included Parkinson's disease, neurocognitive disorder with lewy bodies, altered mental status, cognitive communication deficit, and low back pain. MDS, dated [DATE], shows R2 was severely cognitively impaired, required total dependence on staff for transfers/toileting, extensive assistance for bed mobility/dressing/personal hygiene and R2 was always incontinent of bowel/bladder. On 5/23/23, V13 (Family) and V14 (Family) stated on 5/20/23 while they were in the room with R2 visiting, R2 sat in his bed from 11:00 AM to 6:00 PM and no staff checked/changed his incontinence brief. V13 stated at 6:00 PM she had to leave the facility and asked a staff to check/change his incontinence brief. 5. Face sheet, dated 5/25/23, shows R7's diagnoses included displaced bicondylar fracture of left tibia, depression, and autonomic neuropathy. MDS, dated [DATE], shows R7 was cognitively intact, was totally dependent on two staff for transfers, required extensive assistance for toileting/dressing, and was assessed as occasionally incontinent of urine and frequently incontinent of bowel. On 5/24/23 at 1:56 PM, R7 stated on the evening of 5/19/23 or 5/20/23, he had his call light on to be toileted because he had a brace on his leg and could not go to the bathroom by himself. R7 stated a CNA walked in and stated he needed another staff to help him and he would be right back. R7 stated he waited one and a half hours for the CNA to return. R7 stated he yelled at the CNA and told the CNA he had already urinated in his pants. R7 stated the CNA told R7 next time to just ring the bell and he would be there quickly. R7 stated he later had to urinate again, he put his call light on, and R7 waited one hour and forty five minutes and no staff assisted him. R7 stated he had to wheel out in the hall and yell for his CNA. R7 stated he CNA came out of the room next door to R7's and the CNA stated he was working with another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient staffing to care for residents who required staff assistance for toileting and repositioning. This applies to 5 of 5 residents (R1-R4, R7) reviewed for staffing in a sample of 9. The findings include: 1. Face sheet, dated 5/25/23, shows R7's diagnoses included displaced bicondylar fracture of left tibia, depression, and autonomic neuropathy. MDS, dated [DATE], shows R7 was cognitively intact, was totally dependent on two staff for transfers, required extensive assistance for toileting/dressing, and was assessed as occasionally incontinent of urine and frequently incontinent of bowel. On 5/24/23 at 1:56 PM, R7 stated This place is severely understaffed! R7 stated on the evening of 5/19/23 or 5/20/23, he had his call light on to be toileted because he had a brace on his leg and could not go to the bathroom by himself. R7 stated a CNA walked in and stated he needed another staff to help him and he would be right back. R7 stated he waited one and a half hours for the CNA to return. R7 stated he yelled at the CNA and told the CNA he had already urinated in his pants. R7 stated the CNA told R7 next time to just ring the bell and he would be there quickly. R7 stated he later had to urinate again, he put his call light on, and R7 waited one hour and forty five minutes and no staff assisted him. R7 stated he had to wheel out in the hall and yell for his CNA. R7 stated he CNA came out of the room next door to R7's and the CNA stated he was working with another resident. On 5/23/23 at 2:15 PM, V2 (Director of Nursing) stated it was his expectation for staff to round every two hours or as needed on residents which included repositioning the residents and checking/changing incontinence briefs. On 5/23/23 at 1:53 PM, V1 (Administrator) stated her expectations for staffing the facility at an average census of 95-96 was seven CNAs on the AM and PM shifts and five CNAs on the night shifts. On 5/23/23 V1 (Administrator) provided an updated Facility Assessment Plan, dated 5/23/23, which showed the average daily census at the facility was 96 residents. The Plan showed CNA staffing ratios for AM/PM shifts were expected to be 1:13 and Night ratios to be 1:19. On 5/24/23 at 10:00 AM during review of the facility's schedule, V1 stated the facility assessment tool again needed to be updated and V1 hand wrote in new staffing ratios the Facility Assessment. The new, handwritten CNA to resident ratios showed 1:14 on Day/Evening shifts and 1:20 on Night shifts. Review of facility schedules, dated 4/25/23 to 5/23/23, show 21 of 78 shifts were short staffed at the facility when assessed using the Facility Assessment and V1's verbalized staffing expectations. 2. Face sheet, dated 5/23/23, shows R2's diagnoses included Parkinson's disease, neurocognitive disorder with lewy bodies, altered mental status, cognitive communication deficit, and low back pain. MDS, dated [DATE], shows R2 was severely cognitively impaired, required total dependence on staff for transfers/toileting, extensive assistance for bed mobility/dressing/personal hygiene and R2 was always incontinent of bowel/bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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 On 5/23/23, V13 (Family) and V14 (Family) stated on 5/20/23 while they were in the room with R2 visiting, R2 sat in his bed from 11:00 AM to 6:00 PM and no staff checked/changed his incontinence brief. V13 stated at 6:00 PM she had to leave the facility and asked a staff to check/change his incontinence brief. V13 and V14 stated the facility seemed understaffed especially on the weekends. 3. Face sheet, dated 5/23/23, shows R3's diagnoses included dementia, anorexia, heart failure, malnutrition, and depression/anxiety. MDS, dated [DATE], shows R3's cognition was severely compromised, R3 required the extensive assistance of staff for bed mobility, transfers, eating, toileting and personal hygiene, and R3 was always incontinent of bowel and bladder. Review of R3's care plan showed R3 had impaired cognitive function/dementia, required staff assistance for toileting and turning and repositioning as needed. On 5/23/23 R3 was lying on her back in her bed with her head of bed raised at approximately 45 degrees. On 5/23/23 during continuous observation between 9:51 AM and 1:31 PM, R1 remained in the same position in her bed with no staff checking/changing her incontinence brief or repositioning her. On 5/23/23 at 12:49 PM, V5 (CNA) stated she last checked/changed R3's incontinence brief and repositioned R3 in bed was at approximately 9:30 AM. 4. MDS (Minimum Data Set), dated 2/22/23, shows R1's cognition was severely impaired, R1 required the extensive assistance from two staff for bed mobility/toileting, and R1 was always incontinent of bowel/bladder. Review of R1's care plan showed R1 required two staff assistance with ADLs such as toileting and repositioning, and R1 was incontinent. The care plan showed staff were to monitor for incontinence every two hours and as needed. On 5/23/23 at 9:50 AM, R1 was lying on her back in her bed with her head of bed elevated approximately 45 degrees. On 5/23/23 during continuous observation between 9:50 AM and 1:12 PM, R1 remained in the same position and no staff attempted to check/change R1's incontinence brief or reposition R1 in her bed. On 5/23/23 at 11:58 AM, V5 (CNA-Certified Nursing Assistant) stated she last changed R1's incontinence brief that morning at approximately 9:00 AM. At 12:40 PM, V5 stated she had not gone into R1's room or repositioned R1 since she repositioned R1 around/before 10:00 AM that morning. On 5/22/23 at 2:53 PM, V3 (Family) stated the family placed a camera in R1's room and on 5/22/23 they witnessed R1 remain in her bed for almost eight hours (between 5:00 AM and 12:30 PM) without staff checking or changing her brief. V3 stated the video camera showed on both 5/19/23 and 5/20/23 R1's incontinence brief was not checked/changed for 7.5 hours. V3 stated on 5/21/23 R1 waited 12 hours for staff to change her incontinence brief. On 5/23/23 at 11:58 AM, V5 stated she worked with R1 on 5/21/23 and V5 stated she checked/changed R1's incontinence brief twice during her shift - at approximately 9:30 AM and then again at approximately 1:30-2:00 PM. 5. Face sheet, dated 5/23/23, shows R4's diagnoses included fracture of right humerous, malignant neoplasm, urinary incontinence, colitis and gastroenteritis, depression and anxiety. MDS, dated [DATE], shows R4's cognition was moderately impaired, required extensive assistance from staff for bed mobility, toileting and personal hygiene, and was always incontinent of bowel/bladder. Care plan shows R4 required assistance with ADLs including toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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 5/23/23 at 12:40 PM, R4 was lying in bed. V5 stated the last time she checked/changed R4's incontinence brief was approximately 9:00 AM. V5 stated R4 was incontinent of urine but may call her to be changed if she had a bowel movement. V5 stated she would change R4 after lunch service was finished. As of 1:23 PM, R4 had not had her incontinence brief changed since 9:00 AM. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 8 of 8