Health inspection·January 20, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review the facility failed to employ and schedule sufficient maintenance, custodial, laundry, and housekeeping staff to ensure the facility was kept clean and free of odors, to ensure the facility had a sufficient amount of clean linens, mechanical lifts, mechanical lift slings, to ensure the facility's clean utility rooms and all resident rooms were cleaned at least daily, and to ensure the facility's walls, floors, mechanical lifts, lights, window coverings, and toilets were kept maintained and in good repair. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff Type-support staff including plant operations, custodians, housekeeping, and maintenance staff. Staffing Plan- Enter number of staff needed or average or range: Staff other (department heads, nurse educator, quality assurance, ancillary staff, housekeeping, dietary, laundry): Refer to facility assessment addendum. This same Facility Assessment does not include an addendum to provide the facility with the staffing plan and number of staff needed to perform maintenance services, housekeeping services, and laundry services.The Maintenance Director Job Description dated 03/2025 documents, The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current, federal, state, and local standards, guidelines, and regulations governing our facility. Essential duties and responsibilities: Repair facility/resident property as necessary. Inspect storage rooms, workrooms, utility/janitorial closets, etc. (etcetera), for upkeep and supply control. Ensure that supplies, equipment, etc. are maintained to provide safe and comfortable environment. Ensure that maintenance policies and procedures identify appropriate safety precautions and equipment to use when performing tasks that could result in bodily injury. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Place orders for equipment and supplies as necessary or as may be required.The Housekeeper Job Description dated 7/24 documents, The primary purpose of the housekeeper is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility. Essential Duties and Responsibilities: Ensure that work/cleaning schedules are followed as closely as practical. Clean, wash, sanitized, and/or polish fixtures, ledges, room heating/cooling units, bathrooms fixtures, etc. Clean floors including sweeping, dusting, damp/wet mopping, Page 1 of 7 145774 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stripping, waxing, buffing, disinfecting, etc. Discard waste/trash into proper containers and reline trash receptacle with plastic liner.The Laundry Aide Job Description dated 07/2024 documents, The primary purpose of the Laundry Aide position is to perform the day-to-day laundry department functions, to assure that quality services are provided on a daily basis, to safeguard the health, safety and welfare of all residents of the facility, and to assure the facility laundry is maintained in a clean, safe, and sanitary manner.The Residents' Rights Illinois-Long Term Care Ombudsman Program dated 11/2018 documents, Your facility must be safe, clean, comfortable, and homelike.The Mechanical Lift's Manufacturer's Manual dated 2015 documents, When battery power goes below 50% (percent), the controller has an audible beep warning. When the low battery warning is heard, charge the battery immediately. Please note that a lifted patient cannot be lowered down when battery is out of power. Push the emergency red button if the control unit system is not functioning properly. In the event of a power failure, a person can be lowered by pulling up on the red quick release lever.On 1/15/26 at 1:45 PM V2 (Director of Nursing) provided a list of residents who use a mechanical lift and sling for transfers. This list included R2, R6, R8, R9, R11, R12, R13, R14, R15, and R17.The facility's Housekeeping/Laundry Schedule dated 1/1/26 through 1/15/26 was reviewed and documents there was only one laundry aide working eight hours total on 12 days out of the 15 days.The facility's Housekeeping/Laundry Schedule dated 1/1/26 through 1/15/26 was reviewed and documents there was only one housekeeper working eight hours total on seven days out of the 15 days.A Concern Form dated 1/7/26 documents, Staff member making report: (V5/CNA/Certified Nursing Assistant). Nature of concern: 1/3/26 there were no slings (mechanical lift) during the AM (morning shift) and nine showers to give. 1/5/26 AM shift no slings. Staff had to dig through dirty laundry to find the least dirty one (sling). 1/7/26 AM shift no clean slings at all for showers again. Nine showers to give and six of them are (mechanical lift) showers. This same concern form has no follow-up of pertinent findings or corrective actions taken to address this concern.A Concern Form dated 1/12/26 documents, Person Relating concerns: (R2). Nature of Concern: 95 percent of laundry comes to (R2) stinking, dirty, or badly stained.A Concern Form dated 1/12/26 documents, Person Relating concerns: (V20/R1's Friend). Nature of Concern: Sheets hanging on dining room windows. Very tacky. No pictures on walls. Very plain.R9 and R17's Shower Reports dated 1/13/26 and signed by V7 (CNA) and V9 (LPN) documents R9 and R17's scheduled showers were not given on 1/13/26 due to the facility not having mechanical lift slings or linens (washcloths and towels).On 1/15/26 from 8:55 AM through 10:00 AM and 1/16/25 from 2:00 AM through 3:00 AM tours were conducted throughout the facility. During these tours there were four hallways (A, B, C, and D) with residents residing. One hallway consisted of a special memory care unit that had closed alarmed doors. On the special memory care unit, the dining room had two windows that did not have blinds or curtains and there were two see-through bed sheets tacked up unevenly covering a quarter of the windows. The A, B, and C Hallways clean linen storage room contained a three-tier cart with an ice water cooler on the top tier. The second and third tiers of this three-tier cart were covered in chunky brown debris and brown stains. The sink in this clean linen storage room was covered in a rusty substance, all the walls in this room had holes and exposed, unpainted drywall patches, and the floor had brown staining on all floor tiles and trash and debris throughout. There were no clean bed pads or washcloths in this linen storage room. All other linens, including towels and sheets, within this storage room were stained a light brown color and smelled of feces. R3 and R4's bathroom wall had missing chunks of drywall and numerous areas of exposed, unpainted drywall and the bathroom floor had scattered debris. R3's cubicle curtain had multiple brown stains and the wall behind R3's bed headboard has missing chunks of drywall. R8's floor had scattered debris and R8's trashcan was 145774 Page 2 of 7 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many overflowing onto the floor. R2 and R7's floors had scattered debris. R13 and R19's wall above the heating/cooling unit had cracking and bulging drywall.On 1/15/26 at 12:00 PM V8 (Maintenance Supervisor) demonstrated using the mechanical lift machine. The mechanical lift emergency button was missing from the machine and the machine's legs were completely covered in debris and brown stains. V8 stated, I did not realize the emergency button was missing. V8 confirmed the emergency button is the only means to lower a resident whenever the mechanical lift battery runs dead. V8 also stated he was unaware of who is responsible for cleaning the mechanical lift and stated, The (mechanical lift) is extremely dirty.On 1/15/26 at 12:55 PM The C and D Hallways clean linen storage room had four missing floor tiles, a trashcan that was full and overflowing onto the floor, scattered debris on the floor, and a white buildup of debris in the sink and around the sink handles. There were no clean wash clothes within this clean linen storage room.On 1/15/26 at 2:20 PM R16's window had a bedspread draped over the curtain rod. R16 stated at this time, I have never had curtains, so I hung my bedspread up over the window to block the sun from beating through the window.On 1/16/26 at 2:55 AM R15 was lying in bed sleeping. R15's above the bed light was flicking on and off continuously.On 1/17/26 at 12:15 PM R2 was lying in bed. R2's top sheet was stained and smelled of feces. R2 stated, My sheets always stink like feces. I bought myself my own washcloths because I refuse to let the staff use the facility's dirty washcloths on me. I have not had a housekeeper clean my room since January third. A few weeks ago, my toilet was overflowing every day, and I would have water and turds overflowing into my room. How would you like to have turds all over your floor? This place is gross.On 1/15/26 at 8:40 AM V4 (CNA/Certified Nursing Assistant) stated, There are not enough housekeepers to clean the entire facility daily.On 1/15/26 at 8:50 AM V5 (CNA) stated, I have never seen the (A, B, C) hallway linen closet cleaned by housekeepers. We (facility staff) never have enough wash clothes or bed pads. This morning, I had to use towels to wash the residents up. We also do not have enough clean (mechanical lift) slings to get all the residents up. I have had to go to laundry on multiple occasions and pull out a dirty sling to use to get the residents up. There is one first shift staff doing laundry every day. There is no staff doing laundry on second or third shifts, therefore there is no clean linens or (mechanical lift) slings to use in the mornings when we are getting the residents up. I filled out a grievance, and nothing has been done that I am aware of. (R2 and R7's) toilet overflows constantly into R2 and R7's rooms and had been overflowing for over two weeks before somebody finally fixed it. Usually there is only one housekeeper, and all the resident rooms do not get cleaned daily.On 1/15/26 at 9:05 AM R19 stated, My wall has always been cracked around the heater and the housekeepers are not able to clean my room every day. My trash is always full.On 1/15/26 at 9:50 AM R3 stated, My walls and floors are always dirty. I would like my room to be cleaned daily. My toilet overflowed into my room for two weeks (around a month ago) before somebody fixed it. I had turds on my floor.On 1/15/26 at 10:10 AM V6 (Housekeeper) stated, There are a lot of days when we only have one housekeeper working for the entire day. There is no way to get all the housekeeping done with one person. All the residents' rooms do not get cleaned daily and I do not have time to wash all the surfaces when there is only one housekeeper. I have to work quickly and just get the basics done like taking out the trash and sweeping/mopping some of the rooms. It is very stressful. We also do not have any floor staff or janitors.On 1/15/26 at 10:20 AM V7 (CNA) stated, We never have enough clean linens or (mechanical lift) slings. Resident showers do not get done when we don't have slings or clean linens. The linens we do have are dingy and stink. When we don't have washcloths, we have to use towels to wash the residents. The C-Hallway is the hallway I work on, and I have not seen it get cleaned one day this week. The clean linen rooms are always dirty and do not get touched by housekeeping. 145774 Page 3 of 7 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The mechanical lift does not have an emergency release button and there are not enough batteries to keep the mechanical lift going. Residents get stuck up in the air because the batteries die and there is no emergency release. I have told (V2/Director of Nursing) about the emergency release being broken several times and maintenance is aware that the mechanical lift batteries are junk and do not keep the lift charged. (R2, R3, R4, and R7's) were overflowing for weeks before maintenance ever fixed them. We have also been told we cannot use the hopper to clean dirty washcloths and linens, so now we are sending linens covered in feces to laundry. It is just disgusting.On 1/15/26 at 11:30 AM V10 (Laundry Aide) stated, We have been down a second shift laundry aide for over two weeks. When I come in in the mornings all the laundry barrels are overflowing with dirty laundry and the staff do not have clean slings, washcloths, or bed pads. It usually takes me until around 10:00 AM daily to get one load of clean slings, washcloths, and bed pads out to the clean storage rooms and that is still not enough to take care of all the residents. I have spoken with (V8/Maintenance Supervisor) numerous times about not being able to keep up with the laundry.On 1/15/26 at 11:40 AM V11 (RN/Registered Nurse) stated, We do not have clean washcloths, towels, slings, or bed pads daily. The residents do not get their showers or cleaned up because of it. There is usually only one housekeeper working a day. One housekeeper cannot clean this entire facility. The facility is always dirty.On 1/15/26 at 12:50 PM V16 (CNA) stated, We run out of linens daily. We usually do not have washcloths or bed pads. We also do not have enough (mechanical lift) slings. The trash in all the rooms is usually overflowing and there are usually no housekeepers working on second shift.On 1/15/26 at 2:20 PM V8 (Maintenance Supervisor) stated, We (the facility) did have two full mechanical lifts, but one of the lifts broke about a month ago. We have only had one lift that has been working for the last month. I am the laundry/maintenance supervisor. I am told I can have three and a half full-time staff daily to do laundry and housekeeping. I am aware that I have not had enough staff working in housekeeping and laundry for the last two weeks and have been told there are not enough clean linens.On 1/16/26 at 2:50 AM V21 (CNA) stated, I work third shift. We never have clean washcloths or bed pads. There is no laundry staff here on second or third shift and the CNAs do not have time to do laundry. (R15's) above the bed light has flickered like a strobe light for weeks and I know (R15's) family has told maintenance. It still has not been fixed and I am always worried it will cause (R15) to have seizures.On 1/16/26 at 3:00 AM V22 (LPN) stated the facility never has clean linens.On 1/16/26 at 3:15 AM V23 (CNA) stated, We never have clean linens and there are no laundry staff working on second or third shift.On 1/16/26 at 3:30 AM V24 (LPN) stated the facility has not had clean linens or second shift laundry staff for the past two weeks. V24 stated the linens they do have are stained.On 1/17/26 at 7:10 AM V14 (RN) stated, The linens smell like feces and are all stained. There are no clean slings, washcloths, or bed pads every morning. A few days ago, I went to use a clean washcloth, and it smelled of feces so bad. I took it into (V1's/Administrator's) office and the department heads were having a meeting. I asked all of them if they would like to use this washcloth on their faces. The linens here are so disgusting and there are not enough housekeepers or laundry staff to keep up.On 1/17/26 at 11:00 AM V25 (CNA) stated, We are always out of slings and washcloths in the morning and cannot get the residents up because of it. For some reason we were told we can no longer use the hopper to clean out the linens, so now we take poopy linens down to the laundry room. It is gross. A couple days ago, I went to wash up a resident with a clean washcloth and when I opened the washcloth up to use it, it had feces stuck to it. The linens are stained and smell of poop. 145774 Page 4 of 7 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure the facility assessment included the amount of direct care staff required daily to meet the needs of the residents, ensure there were an adequate amount of direct care staff to perform daily ADLs (Activities of Daily Living) to the residents, ensure residents received fresh ice water every shift, and ensure call lights were answered timely. These failures have the potential to affect all 58 residents residing within the facility.Findings include:The Facility's Daily Census Log dated 1/15/26 documents there are 58 residents currently residing within the facility.The Facility's Assessment Tool dated 11/25 through 11/26 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually, per the above requirement. Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff Type-support staff including plant operations, custodians, housekeeping, and maintenance staff. Staffing Plan- Enter number of staff needed or average or range. Direct Care Staff: Refer to facility assessment addendum. This same Facility Assessment does not include an addendum to provide the facility with the staffing plan and number of direct staff needed daily to meet the needs of the residents.The Residents' Rights Illinois-Long Term Care Ombudsman Program dated 11/2018 documents, Your facility must provide services to keep our physical and mental health at their highest practical levels. You should receive the services and/or times included in the plan of care.The Bathing-Shower and Tub Bath Policy dated 8/26 documents, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be offered according to resident's preferences, no less than once per week or according to the resident's preferred frequency and as needed or requested.The facility's Water Pass-Hydration Policy dated 7/26 documents, Purpose: To provide fresh drinking water to residents in a clean and sanitary manner to meet hydration needs. Fresh cold ice water will be provided to each resident a minimum of three times each day, unless contraindicated.R2's current Care Plan documents R2 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.The facility's Shower Schedule documents R2 is to receive showers every Tuesday and Friday during day shift.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is dependent on staff for personal hygiene and showers.A Concern Form dated 1/12/26 documents, Person Relating concerns: (R2). Nature of Concern: Not getting showers. It's been another whole week without a shower.R2's Shower Reports and Shower Tasks dated 1/1/26 through 1/17/26 do not include evidence of R2 receiving his scheduled shower on 1/9/26 (Tuesday).R7's current Care Plan documents R7 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed. This same Care Plan documents R7 has a decreased oral fluid intake related to cognitive impairments and is at risk for dehydration and staff should offer fluids in an easy-to-handle container and offer small sips throughout the day reminding R7 to drink as cognitive impairment may cause R7 to forget.R7's MDS dated [DATE] documents R7 is dependent on staff for showers, personal hygiene, and toileting.R8's current Care Plan documents R8 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R9's current Care Plan documents R9 has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R9's MDS assessment dated [DATE] 145774 Page 5 of 7 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many documents R9 is dependent on staff for personal hygiene and showers.The facility's Shower Schedule documents R9 is to receive showers every Tuesday and Friday during day shift.R9 Shower Report dated 1/13/26 and signed by V7 (CNA/Certified Nursing Assistant) and V9 (LPN/Licensed Practical Nurse) documents R9's scheduled shower was not given on 1/13/26 due to the facility not having enough staff.R17's MDS assessment dated [DATE] documents R17 is cognitively intact and is dependent on staff for personal hygiene and showers.R17's Current Care Plan documents R17 prefers to shower on Tuesdays has an alteration in urinary elimination and staff should encourage oral fluid intake and ensure fresh ice water is at the bedside as needed.R17's Shower Report dated 1/13/26 and signed by V7 (CNA) and V9 (LPN) documents R17's scheduled shower was not given on 1/13/26 due to the facility not having enough staff.R19's MDS assessment dated [DATE] documents R19 is cognitively intact.On 1/15/26 from 8:55 AM through 10:00 AM and 1/16/25 from 2:00 AM through 3:00 AM tours were conducted throughout the facility. During these tours there were four hallways (A, B, C, and D) with residents residing. During this tour, no residents had fresh ice water at the bedside.On 1/15/26 at 8:55 AM R7 was sitting in a wheelchair in his room. R7 had no fresh water at the bedside. R7 stated, It takes hours to get anything around here. There are days my call light is on for over one hour. The staff that are here are good, there is just not enough of them. I would like to get showers more frequently.On 1/15/26 at 9:10 AM R19 was sitting in her room. R19 had no water at the bedside. R19 stated she does not get fresh ice water every shift and it takes a very long time to get her call light answered whenever she needs anything.On 1/15/26 at 9:45 AM R8 stated, There is never enough staff to answer my call light in time to get me off the bed pan. The staff never get me fresh ice water. I went three weeks in November, and I did not get the last two showers on my shower days because there was not enough staff to do them.On 1/16/26 at 6:20 AM R9 was lying in bed. R9 did not have any water at the bedside. R9 stated the staff do not give her showers every Tuesday and if she wants water, she has to bring the water she gets during her meals to her room.On 1/17/26 at 12:15 PM R2 was lying in bed. All R2's fingernails were long, jagged, and had brown debris underneath. R2's water jug was sitting on his over the bed table. R2's water jug was empty. R2 stated, I do not get my showers, or my nails clipped when I am supposed to. I never get fresh ice water. There are not enough staff here to do everything. You never know how long it is going to take to get your call light answered. It takes hours at times.On 1/17/26 at 12:30 PM R17 was sitting in the dining room. R17's fingernails were long and jagged. R17 stated she does not always get her showers and does not get fresh water every shift.On 1/15/26 at 8:40 AM V4 (CNA) stated, There are not enough CNAs to get the scheduled showers done every day and we hardly ever get to pass fresh ice water to the residents. There is never enough help to get everything done for the residents.On 1/15/26 at 8:50 AM V5 (CNA) stated, We are short-staffed almost daily and cannot possibly get everything done for the residents. Ice water does not get passed every day and showers do not get done as scheduled. We hardly ever have six CNAs on day shift and that is what it takes to get everything that needs to be done. We (facility staff) are stressed out almost daily. I have filed numerous complaints with the bosses.On 1/15/26 at 10:20 AM V7 (CNA) stated, We never have enough staff on first shift to get everything done. Resident showers do not get done and ice water does not get passed. I have started documenting on the resident shower sheets whenever their showers cannot get done due to low staffing. We have a lot of residents who require mechanical lifts and two staff for showers and transfers. Those cannot possibly get done when there is only one staff member on the hallway.On 1/15/26 at 11:40 AM V11 (RN/Registered Nurse) stated, We do not have enough staff to take care of the residents. The residents do not get their showers or cleaned up because of it.On 1/15/26 at 12:50 PM V16 (CNA) stated, There are times there are only four CNAs working second 145774 Page 6 of 7 145774 01/20/2026 Arcadia Care Havana 609 North Harpham Street Havana, IL 62644

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many shift and it is impossible to get everything done. I haven't been able to pass fresh ice water to the residents in weeks. Resident showers do not get done and residents are on their call lights for a long time before we can get them answered. I get very stressed out.On 1/15/26 at 12:55 PM V17 (CNA) stated the CNAs do not have time to pass ice water every shift, get showers done, or answer call lights quickly when there are not at least five CNAs working second shift. V17 stated it has been weeks since she was able to pass fresh ice water to the residents.On 1/16/26 at 2:50 AM V21 (CNA) stated, I work third shift. There was one night (unknown date) that I was the only CNA in the entire building. Call lights were going off and there was no way to get them all answered. We do not get time to pass ice water.On 1/16/26 at 3:00 AM V22 (LPN) stated, The facility needs to improve the staffing. I know showers get left undone, call lights are on for way to long, and ice water does not get passed.On 1/16/26 at 3:15 AM V23 (CNA) stated that there are some nights there is not enough time to pass ice water to all the residents.On 1/16/26 at 3:30 AM V24 (LPN) stated the facility has not had clean linens or second shift laundry staff for the past two weeks. V24 stated the linens they do have are stained.On 1/17/26 at 7:10 AM V14 (RN) stated, There was one night that (V21) was the only CNA in the building. There were a lot of nights there were only two CNAs working within the entire building for four hallways of residents. Ice water does not get passed and call lights take a long time to get answered.On 1/17/26 at 11:30 AM V2 (Director of Nursing) stated that from 11/1/25 through 12/10/25 the facility should have staffed five CNAs on day shift, four CNAs on second shift, and three CNAs on third shift to meet the needs of the residents. V2 stated that starting on 12/10/25 the facility should have staffed six CNAs on day shift, five CNAs on second shift, and four CNAs on third shift to meet the needs of the residents. V2 confirmed that the facility was unable to staff the required number of CNAs to meet the needs on the residents during multiple days during these timeframes.This surveyor chose a random number of days to review the direct care staffing within the facility which included 12/14/25, 12/31/25, 1/7/26, and 1/14/26. The facility's CNA Schedules and Staff Time Sheets dated 12/14/25 documents there were only three CNAs that worked on day shift. The facility's CNA Schedules and Staff Time Sheets dated 12/31/25 documents there were only five CNAs that worked on day shift and only three CNAs that worked on third shift. The facility's CNA Schedules and Staff Time Sheets dated 1/7/26 documents there were only four CNAs that worked on day shift and only three CNAs that worked on third shift. The facility's CNA Schedules and Staff Time Sheets dated 1/14/26 documents there were only four and a half CNAs that worked on day shift. On 1/17/26 at 11:30 AM V2 confirmed on 12/14/25, 12/31/25, 1/7/26, and 1/14/26 the facility did not staff the minimum number of CNAs needed. 145774 Page 7 of 7