Inspection·March 18, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a shower because of staffing, so the night shift CNA gave her a quick bed bath. R5 stated she is supposed to get two showers a week. On 03/11/2025 at 3:20 P.M., V1 (Administrator) stated the facility does not have a staffing policy. V1 stated they utilize the staffing calculator and the staffing guidelines. V1 stated the staff who are scheduled to work the weekends are responsible for completing all tasks including showers. V1 stated staffing needs are based on census and the staffing calculator. The calculator will give hours of staff needed per day based on census. V1 stated the facility tries to staff 5 CNA's on day shift and 3 on night shift. V1 stated some of the CNA's are 12-hour shifts and some are 8 hour shifts. V1 stated when the staff at 2 p.m. leave, they try to get staff to come in and cover. V1 stated if they can't get anyone to cover, they have a CNA who works 5 pm to midnight a few days a week, and they help at that time. V1 stated the MDS nurse's office is on the locked unit. V1 stated he is often here till 6 -7 pm at night and helps the locked unit after 4:30 P.M. V1 stated he is available Monday through Friday. V1 stated she has had a resident state she has waited longer than they wanted to get a shower, but no resident has stated they have not gotten a shower to V1. V1 stated there have been resident complaints on occasion about call light times. On 03/11/2025 at 3:45 P.M., V2 (Director of Nursing) stated corporate cut the staffing the facility was using because they said they were over staffed. V2 stated their PPD (Per Patient Day) was too high, and we had to cut hours per the regional staff. V2 stated there have been issues on night shift with call ins and staff not showing up. V2 stated she cannot find the shower sheets for 03/08/2025. V2 stated she is not sure why the showers were not done. V2 stated she was unaware the residents did not get their showers on 03/08/2025. V2 stated, I am not going to say that we don't need more staff, but it all depends on how many of the staff are 8 hours and 12 hours. V2 stated between 2 pm and 6 pm if it gets busy, she has to help on the floor. V2 stated if the unit gets busy, the MDS nurse will help. V2 stated they try to get staff to cover, but if they can't then she stays over and works. V2 stated R5 has voiced concerns in the past about certain CNA's that would not provide the care that she wants. V2 stated one of those CNA's is no longer working at the facility. V2 said staff were educated about checking on the residents at least every two hours and as needed. The March 2025 Certified Nurse Assistant Day Shift Schedule documented on 03/08/2025 and 03/09/2025 there were two 12 hours shift CNA's on day shift and one 8 hour CNA on day shift. A document titled Facility Shower Schedule documented R5 was to receive showers on Wednesdays and Saturdays of every week. 2. R9's admission Record documents an admission date to the facility of 02/23/2022. Diagnoses listed are sepsis, Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus, hypothyroidism, hyperkalemia, benign prostatic hyperplasia, epilepsy, obstructive and reflux uropathy, gout, essential hypertension, chronic kidney disease stage 3, sleep apnea, and depression. R9's Minimum Data Set (MDS), with a date of 01/06/2025, documented a Brief Interview for Mental Status (BIMS) of 04, indicating R9 is severely impaired cognitively. Section GG of the same MDS documented R9 is dependent for toileting, dressing, and rolling left to right in bed. R9's Care Plan (undated) documents a focus area of self-care deficit as evidenced by: needs assistance with activities of daily living related to impaired mobility. Interventions documented include: Assist to turn and reposition every two hours in bed and wheelchair and bed mobility-two person physical assistance required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 2 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 On 03/12/2025 the following intermittent observations were made of R9: Level of Harm - Minimal harm or potential for actual harm 9:09 A.M. R9 was observed laying on his back in the middle of the bed. There were no pillows or wedges in the bed positioning R9. Residents Affected - Few 10:23 A.M. R9 was laying in the same position on his back in the middle of the bed with no pillows positioning him to one side or the other. 11:47 A.M. R 9 was laying is the same position on his back with no pillows observed positioning R9. 12:32 P.M. R9 was laying on his back in the middle of the bed. There were no pillows observed repositioning him to his left or right side. 1:37 P.M. R9 was laying on his back in the middle of the bed. 2:40 P.M. R9 was laying on his back in the middle of the bed. 3:53 P.M. R9 was laying on back in bed no position change. There were no pillows observed in the bed for positioning R9. On 3/13/25 the following intermittent observations were made of R9: 8:51 A.M. R9 was on his back in the middle of the bed. 9:57 A.M. R9 was on his back. 10:44 A.M. R9 was on back in the middle of the bed. 11:36 A.M. R9 was on back in the middle of the bed. 12:21 P.M. R9 was observed to be on his back in the middle of the bed. 1:46 p.m. R9 was observed to be laying on his back in bed. 3:14 P.M. R9 was in same position, on his back. There were no pillows or wedge in the bed repositioning R9. On 03/12/2025 at 1:58 P.M., V2 (Director of Nursing) stated it is her expectation for all residents to be turned and repositioned every two hours or as needed, even if they are on hospice. On 03/13/2025 at 3:20 P.M., V7 (Certified Nurse Assistant) stated she thinks she repositioned R9 at some point after 2:00 P.M. today, but is not sure what time she actually turned R9. V7 stated they are supposed to do bed checks every 2 hours. On 03/13/2025 at 3:48 P.M., V11 (Regional Nurse) was made aware R9 had been observed every hour for the last two days in the same position. V11 stated they should do bed checks every 2 hours. The facility policy titled ADL Support, with a revision date of 05/02/2023, documented, Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 3 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 4 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 - 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 interview, observation, and record review, the facility failed to ensure sufficient staff were scheduled / available to provide timely care to meet the resident's needs. This failure has the potential to affect all 47 residents residing at the facility. Findings Include: 1. R5's admission Record documented R5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus with diabetic chronic kidney disease, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease, stage 3, diverticulitis, and neuromuscular dysfunction of the bladder. R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. Section GG of R5's MDS documented R5 is dependent for toileting, showers, upper and lower body dressing, and personal hygiene. Section GG goes on to document R5 is dependent for rolling side to side. R5's Care Plan (undated) has a focus area of, (R5) requires extensive assistance with ADL's (Activities of Daily Living) rt (related to) reduced mobility, lack of coordination, impaired mobility and weakness. Interventions documented include: bed mobility- two person physical assistance required, two person assist for pulling resident up in bed, may require one or two person assist for repositioning in bed depending on resident condition, assist to tum and reposition every 2 hours in bed and wheelchair, and mechanical lift required. On 03/11/2025 at 3:09 P.M., R5 stated she doesn't get ice water on a consistent basis. If certain staff do not pass it in the morning, they just pass it in the afternoon. If (V8, Certified Nurse Assistant/CNA) is here she makes sure we get ice water in the morning and at night. R5 stated last week she went two days with no fresh ice water. R5 stated when she turns her call light on, it takes anywhere from 15 minutes to two hours to get it answered. R5 stated V2 (Director of Nursing) has told the staff they have to check on her every two hours, and the staff are not. R5 stated V2 has written up staff three times for not checking on her every two hours. R5 stated the facility is very short staffed. R5 stated V2 is never here when there are issues. R5 stated she is not getting her showers on weekends. R5 stated she is supposed to get showers on Wednesday and Saturday, and didn't get her shower Saturday 03/08/2025. R5 stated they are short staffed on weekends, so they don't have time for showers. R5 stated they have a shower aide who works Monday through Friday 6 am to 2 pm. R5 stated the last 3 weeks have been worse with staffing. R5 stated a lot of days there are just two staff working, and she doesn't care what the schedule says. R5 stated she prefers a shower not a bed bath. R5 stated when she can't have a shower, she won't refuse a bed bath, but last weekend she did not get a shower because of staffing, so the night shift CNA gave her a quick bed bath. R5 stated she is supposed to get two showers a week. 2. R9's admission Record documents an admission date to the facility of 02/23/2022. Diagnoses listed are sepsis, Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus, hypothyroidism, hyperkalemia, benign prostatic hyperplasia, epilepsy, obstructive and reflux uropathy, gout, essential hypertension, chronic kidney disease stage 3, sleep apnea, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 5 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 - Many R9's Minimum Data Set (MDS), with a date of 01/06/2025, documented a Brief Interview for Mental Status (BIMS) of 04, indicating R9 is severely impaired cognitively. Section GG of the same MDS documented R9 is dependent for toileting, dressing, and rolling left to right in bed. R9's Care Plan (undated) documents a focus area of self-care deficit as evidenced by: needs assistance with activities of daily living related to impaired mobility. Interventions documented include: Assist to turn and reposition every two hours in bed and wheelchair and bed mobility-two person physical assistance required. On 03/12/2025 the following intermittent observations were made of R9: 9:09 A.M. R9 was observed laying on his back in the middle of the bed. There were no pillows or wedges in the bed positioning R9. 10:23 A.M. R9 was laying in the same position on his back in the middle of the bed with no pillows positioning him to one side or the other. 11:47 A.M. R 9 was laying is the same position on his back with no pillows observed positioning R9. 12:32 P.M. R9 was laying on his back in the middle of the bed. There were no pillows observed repositioning him to his left or right side. 1:37 P.M. R9 was laying on his back in the middle of the bed. 2:40 P.M. R9 was laying on his back in the middle of the bed. 3:53 P.M. R9 was laying on back in bed no position change. There were no pillows observed in the bed for positioning R9. On 3/13/25 the following intermittent observations were made of R9: 8:51 A.M. R9 was on his back in the middle of the bed. 9:57 A.M. R9 was on his back. 10:44 A.M. R9 was on back in the middle of the bed. 11:36 A.M. R9 was on back in the middle of the bed. 12:21 P.M. R9 was observed to be on his back in the middle of the bed. 1:46 p.m. R9 was observed to be laying on his back in bed. 3:14 P.M. R9 was in same position, on his back. There were no pillows or wedge in the bed repositioning R9. On 03/12/2025 at 1:58 P.M., V2 (Director of Nursing) stated it is her expectation for all residents to be turned and repositioned every two hours or as needed, even if they are on hospice. V2 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 6 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 - Many the staff know and have a bed check routine in order to make sure all residents are turned when they are supposed to be. On 03/11/2025 at 3:20 P.M., V1 (Administrator) stated the facility does not have a staffing policy. V1 stated they utilize the staffing calculator and the staffing guidelines. V1 stated the staff who are scheduled to work the weekends are responsible for completing all tasks including showers. V1 stated staffing needs are based on census and the staffing calculator. The calculator will give hours of staff needed per day based on census. V1 stated the facility tries to staff 5 CNA's on day shift and 3 on night shift. V1 stated some of the CNA's are 12-hour shifts and some are 8 hour shifts. V1 stated when the staff at 2 p.m. leave, they try to get staff to come in and cover. V1 stated if they can't get anyone to cover, they have a CNA who works 5 pm to midnight a few days a week, and they help at that time. V1 stated the MDS nurse's office is on the locked unit. V1 stated he is often here till 6 -7 pm at night and helps the locked unit after 4:30 P.M. V1 stated he is available Monday through Friday. V1 stated she has had a resident state she has waited longer than they wanted to get a shower, but no resident has stated they have not gotten a shower to V1. V1 stated there have been resident complaints on occasion about call light times. On 03/11/2025 at 3:45 P.M., V2 (Director of Nursing) stated corporate cut the staffing the facility was using because they said they were over staffed. V2 stated their PPD (Per Patient Day) was too high, and we had to cut hours per the regional staff. V2 stated there have been issues on night shift with call ins and staff not showing up. V2 stated she cannot find the shower sheets for 03/08/2025. V2 stated she is not sure why the showers were not done. V2 stated she was unaware the residents did not get their showers on 03/08/2025. V2 stated, I am not going to say that we don't need more staff, but it all depends on how many of the staff are 8 hours and 12 hours. V2 stated between 2 pm and 6 pm if it gets busy, she has to help on the floor. V2 stated if the unit gets busy, the MDS nurse will help. V2 stated they try to get staff to cover, but if they can't then she stays over and works. V2 stated R5 has voiced concerns in the past about certain CNA's that would not provide the care that she wants. V2 stated one of those CNA's is no longer working at the facility. V2 said staff were educated about checking on the residents at least every two hours and as needed. On 03/11/2025 at 12:15 P.M., V5 (Licensed Practical Nurse) stated, Today is a good day with staffing. It is not every day that we have this many Certified Nurse Assistants working. On 03/11/2025 at 12:30 P.M., V6 (Certified Nurse Assistant) stated, Back on the locked unit, there are two CNA's and one nurse. At 4 P.M. the other CNA leaves and at 4:30 P.M. the nurse leaves. V6 stated it leaves her by herself to care for all 14 residents. V6 stated she cannot get to the residents in a timely manner. On 03/12/2025 at 9:11 A.M., V7 (Certified Nurse Assistant) stated the staffing level in the facility is terrible. V7 stated on the schedule today she is the only CNA after 2 P.M. for the north and south halls. V7 stated there are 29 residents on the north and south halls. V7 stated there is no way she can provide the appropriate care to all 29 residents, especially with all the residents who require two person assist. V7 stated this has been a problem since she started less than two months ago. V7 stated, The staffing issues and being left by yourself is why they can't keep help. V7 stated she was unable to complete showers on 03/08/2025 due to the staffing levels. On 03/12/2025 at 9:18 A.M., V3 (Certified Nurse Assistant) stated she is on the schedule for 6am - 2 pm. V3 stated she works 6am - 2 pm, and was not aware the staffing sheet says that she was staying until 6 p.m. V3 stated she was leaving at 2 p.m. today. V3 stated V8 (Certified Nurse Assistant) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 7 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 - Many was supposed to do showers today, but is working the floor due to a CNA quitting. V3 stated last weekend, she was the only staff member on the locked unit from 6 am to 2 pm, V3 stated the staffing on the weekend is worse than during the week. V3 stated she was not able to do any showers on the locked unit because she was the only staff member on the unit. V3 stated she is not able to provide the care to all the residents. On 03/12/2025 at 9:23 A.M., V8 (Certified Nurse Assistant) stated the facilities staffing level is poor. V8 stated, No matter how short we are, I do my best to provide the care that all the residents need. After 2 P.M., there is lower staffing and usually they do not let anyone stay over. V8 stated she will stay over occasionally. V8 stated she was supposed to be the shower aide, but a CNA quit, so she is working the floor today. V8 stated she typically only works Monday - Friday. V8 stated what she hears from the residents is that they do not receive showers on weekends. On 03/12/2025 at 3:55 P.M., V10 (Licensed Practical Nurse) stated, Staffing is a huge issue. The issue is more on north and south halls versus the locked unit. V10 said she always offers to stay over and help, and most of the time I get told no. V10 stated she is leaving at 4:30pm and she isn't sure who is taking over. V10 stated they sent the transportation aide back to the locked unit and pulled V6 (CNA). V10 stated there are 2 CNA's, 2 nurses, and a transportation aide covering the 47 residents. V10 stated at 4:30 P.M., the north hall nurse is usually responsible for the entire building. V10 stated that is a lot with the acuity they have. V10 stated she makes sure the residents on the locked unit are taken care of. V10 stated staffing was cut because they were told they were over on their PPD. V10 stated they are not staffing the building how it should be. V10 stated last night, there were two nurses on night shift. V10 stated they did that because there are surveyors in the building. On 03/13/2025 at 9:07 A.M., V2 stated staffing agency employees started last night in the building. V2 stated she just got approval. V2 stated with the agency staff, they are able to have four Certified Nurse Assistants on night shift. On 03/13/2025 at 3:14 P.M., V5 (Licensed Practical Nurse) stated, After 2 pm today, it is only (V7, Certified Nurse Assistant) and an agency CNA, who's first day in the building is today. V5 stated they do the best they can when they are left like this. V5 stated she helps a lot on the floor when there are just two CNA's. V5 stated another CNA was supposed to stay over, but she did not, so she will be getting written up. On 03/12/2025 at 2 P.M. ,surveyor observed there to be one certified nurse assistant on the north / south hall with 30 residents. V6 was observed working on the north hall with V7. V10 was observed to be on the locked unit and the transportation aide was back on the locked unit to assist V10. On 03/12/2025 at 2:30 P.M., V10 stated V6 was pulled from the locked unit, and V10 was sent to the locked unit to cover for V6 being pulled to the north hall. The facility document titled Grievance Summary, dated 01/15/2025, under category, the call bell response time was documented. Under grievance details it documents, Residents voiced concern of call bell response time mainly in evenings and nights during the resident council meeting. Summary of actions taken: discussed with all shifts importance of timely call light response. Ads placed for more CNA's for evening / night coverage. The March 2025 Certified Nurse Assistant Day Shift Schedule documented on 03/08/2025 and 03/09/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 8 of 9 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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 there were two 12 hours shift CNA's on day shift and one 8 hour CNA on day shift. Level of Harm - Minimal harm or potential for actual harm The March 2025 Certified Nurse Assistant Night Shift Schedule documented on 03/02/2025 two CNA's from 6 P.M. to 6 A.M. The same schedule also documents on 03/05/2025 and 03/06/2025 there were two CNA's scheduled from 6 P.M. to 6 A.M. and a third CNA scheduled from 5 P.M. until 12 A.M. Residents Affected - Many The Facility Assessment (undated) documented under the section titled Staffing and Staff Assignments no staffing data. The entire section is left blank. Also attached to this section is a blank staffing calculator. V1 stated that she didn't realize she had to put numbers in the facility assessment for how much staff they use on each shift and daily. The facility Resident Matrix, dated 03/11/2025, documented there were 47 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146119 If continuation sheet Page 9 of 9