Health inspection·February 21, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming, and oral care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 2 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide meaningful activities to residents. Residents Affected - Few This applies to 3 residents (R25, R32, & R33) reviewed for activities in a sample of 23. Findings include: 1. On 02/18/25 at 11:05 AM R25, who was alert and oriented, denied attending any activities and said that staff does not bring activities to her room. R25 said that she would like to attend activities. R25's 12/26/24 care plan showed that R25 enjoys socializing with peers, watching TV gameshows, and doing word search puzzles and visiting with family. The interventions include the resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. Assess the residents strengths and abilities. Evaluate the resident for participating in active and passive programs. Check in to see if the resident has any change in activity preferences. Continue assessment of activities enjoyed in the past that could be built upon to enhance current involvements. Encourage participants involvement and enjoyment of activities program; provide activities that resident can complete, has stated enjoyment. Encourage residents creativity and curiosity, encourage participant to try a new activity when they choose not be involved in programs. Offer individual activities designed to match the preference and resident goals. Offer recreational cart to increase independent leisure activities. Offer visits to ensure sufficient independent social and recreational contacts. Provide with calendar and identify time and place of recreational programs of assessed interests. Staff will encourage resident to attend programs of choice, offering escort and assistance with programs when resident agrees. Support preferences to spend time alone and introspectively. Validate feelings and emotions. 2. On 02/18/25 at 12:05 PM R33, who's cognition is intact, said that staff doesn't bring any activities to her room or come and visit or talk to her. R33's 11/27/24 care plan showed R33 prefers to spend duration of time in her room, relaxing in her bed, engage in informal room activities, reading novels, watching TV, listening to music, and taking short naps. Has good family support. The interventions including likes to talk about cats and animals in general. Allow freedom of choice of activity interests. Bring to R33's attention activity programs which coincide with past interests. During in room activities: ask resident where she would like staff to be seated. Express appreciation for willingness to try new activities. [NAME] rapport with frequent greetings without expectations; observe feeling of frustration. Introduce R33 to peers with similar interests. Ask resident and peers open-ended questions to promote opportunity for development of friendship. Observe R33 for signs of increased distress, anxiety or nervousness and positive signs of relaxation or calming and modify interventions accordingly. Offer brief visits as support and to keep open the opportunities for recreational pursuits. Offer individual activities designed to match the preference and resident goal. Offer simple explanation of programs contents. Offer to take R33 out of room for short period of time: a change of environment. Promote gradual exposure to alternate recreational setting as R33 becomes willing or comfortable. Remind of the open opportunity to decline recreational invitations without apologies. Remind to stay within her comfort zone. Respect residents right to refuse activities. Validate feelings and emotions. R33 prefers to socialize with staff about magazines that she enjoys reading, daily news, and family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 3 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On 02/18/25 at 11:55 AM, R32 was observed in her room with V32 (R32's Private Care Giver) and V32 said that she is there every day, all day, Mondays through Fridays and the facility does not bring any activities to R32 room or come in and read or talk to R32. V32 said that the staff does nothing with R32. R32's 10/17/24 care plan showed that R32 enjoys in engaging in independent leisure activities with assistance. She will occasionally participate in facility recreational, spiritual, and social activities. She enjoys relaxing in her room after meals listening to music, watching TV, talking on the phone, and spending time with family. The interventions include assess strengths and ability, evaluate the resident for participating in activities and passive programs. Check in to see if resident has any change in activity preference. Community life will provide rosary beads as needed. Encourage and support the development of new interests, hobbies, and skills. [NAME] rapport with frequent greetings without expectations. Offer individual activities designed to match the preference and resident goal. Offer recreational cart to increase independent leisure activities. Offered visits to ensure sufficient independent social and recreational contacts. Provide a program of activities that is of interest and empowers the resident by encouraging allowing choice, self-expression, and responsibility. Staff will encourage R32 to attend programs of choice, offer escort and assistance with programs when resident agrees. Staff will visit resident in room for short durations based on resident's ability and acceptance of visits on a daily basis. On 02/19/25 at 10:15 AM V4 Activities Director provided the state surveyor a One on One Visits list updated 2-3-25 and it showed that R25, & R33 were on the list. V4 also provided a book with documentation showing when staff provided 1 to 1 activities for R25, & R33. V4 said that this was where the staff documents when they provide activities for the residents who stay in bed. R25's 1 to 1 Activities documentation showed that R25 only received activities for February 2025 on 2/5/25 and 2/13/25, and for January 2025 only received activities on 1/1/25, 1/3/25, 1/5/25, 1/5/25, & 1/16/25. R33's 1 to 1 Activities documentation showed that R33 only received activities for February 2025 on 2/3/25, 2/5/25, 2/11/25, 2/13/25, and January 2025 on 1/1/25, 1/4/25, 1/5/25, 1/7/25, 1/30/25, 1/31/25. On 02/19/25 at 02:08 PM a review of progress notes were done, and no notes were found showing R25, R32 or R33 refusing to attend or participate in activities. The Activities Participation Record [unit] book was also reviewed and there was no documentation in it for R25, R32 or R33. On 02/19/25 at 02:00 PM V2 DON (Director of Nursing) said that all residents are to get some form of activities every day in their room or outside of their room. The facility's Activity Program policy dated June 2018 showed that activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. The policy's Interpretation and Implementation showed: 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 4 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0679 Level of Harm - Minimal harm or potential for actual harm 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Residents Affected - Few 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 5 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident medications were safely secured. This applies 6 to 6 residents (R3, R13, R26, R33, R34, and R115) reviewed for medications in a sample of 23. The findings include: 1. On 2/18/25 at 10:13 AM, there were bottles of Advil (Ibuprofen 200mg), DayQuil severe cold and flu (Acetaminophen, Guaifenesin, Phenylephrine HCL, Dextromethorphan), and Loperamide hydrochloride (1mg per 7.5mg) on top of R34's bedroom dresser. V30 (R34's husband) said the Loperamide was his; he said his son brought it for them. V30 said his wife does not talk much. On 2/19/25 at 9:36 AM, the medications were still noted on R34's dresser. Review of R34's Electronic Medical Record (EMR) showed diagnoses of atrial fibrillation and dementia. R34's Minimum Data Set (MDS) of 1/22/25 shows that R34's cognition is severely impaired. Review of R34's orders shows that R34 had an order for Loperamide HCL solution 1gm/7.5ml to give 15ml by mouth for times a day. R34 did not have an order for Advil (Ibuprofen) or DayQuil; R34 did not have an order for medications to be stored in resident's room. 2. On 2/18/25 at 10:51 AM, there was a bottle of Nystatin 100 000 USP powder on R13's bedside table. At 11:24 AM, R34 said the Nystatin powder was his. On 2/19/25 at 9:44 AM, the Nystatin powder was still noted on R13's bedside table. Review of R13's EMR showed diagnoses of heart failure, atrial fibrillation and personal history of urinary tract infection (UTI). R13's MDS of shows that R13's 12/11/24 cognition is severely impaired. Review of R13's orders shows that R13 had an order for Nystatin External Powder 100 000 unit, apply to groin and scrotum topically every day and evening shift for redness; R13 did not have an order for medication be stored in resident's room. 3. On 2/18/25 at 10:54 AM, there was a bottle of Nystatin 100 000 USP powder on R3's bedside table; R3 said it was hers, and staff uses it on her. On 2/19/25 at 9:50 AM the Nystatin powder was still on R3's bedside table. Review of R3's EMR showed diagnoses of polyosteoarthritis, lymphedema, rash and other nonspecific skin eruption. R3's MDS of 12/3/24 shows that R3's cognition is intact. Review of R3's orders shows that R3 had an order for Nystatin External Powder 100 000 unit, apply to vaginal skin every shift for redness; R3 did not have an order for medication be stored in resident's room. 6. On 02/18/25 at 12:05 PM the following medications were found on R33's dresser: 2 medication cups half full of a white powder, 1 opened tube of Nystatin and Triamcinolone Acetonide cream, 2 opened tubes of Medihoney, and 1 plastic bag with 2 unopened tubes of Triamcinolone AC 0.5% cream inside the bag. R33's 2/12/25 MDS showed that R33's cognition is moderately impaired. A review of R33's electronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 6 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some health record did not show any order to have medications at bedside. R33's physicians orders showed: 11/16/24 Desenex External Powder 2%, & 2/8/25 Triamcinolone Acetonide External cream 0.5%. 4. On 2/18/25 at 11:20 AM, during initial tour, surveyor went to R115's room. On her bedside table, there was saline nasal spray on top of her bedside table. R115 stated she brought it from home. On top of R115's dresser, there was a Fluticasone Propionate nasal spray. R115 stated she brought it from the hospital. R115's face sheet shows an admission date of 7/11/23. R115's POS (Physician Order Sheet) shows no order for the saline nasal spray. It indicates a physician order of Fluticasone Propionate Nasal Suspension 50 MCG (Micrograms)/ACT-2 sprays in each nostril at bedtime for nasal agent. There is no order for the medication to be stored at the bedside. R115's MDS (Minimum Data Set) dated 2/20/25 shows a BIMS (Brief Interview for Mental Score) of 14, which means she is cognitively intact. 5. On 2/18/25 at 12:58 PM, on R26's bedside table, there was Nystatin 100,000 units/GM powder. R26 stated that it's always kept in her room. R26 stated, The CNA (Certified Nursing Assistant) comes and cleans me. Then she puts the powder in my groin area and then she changes me and puts a new brief on me. R26's MDS dated [DATE] shows a BIMS score of 13 which indicates normal cognition and intact cognitive response. R26's POS shows an order for Nystatin External Powder 100000 unit/GM-Apply to groin topically everyday and evening shift for fungal infection. There was no order for the medication to be stored at the bedside. On 2/20/25 at 11:15 AM, V2 (DON-Director of Nursing) stated, All medications brought from home should be given back to the resident's family or be put in the medication cart. They should be not stored in the room. Specialty medications brought from home can be used but must need a doctor's order. All medications that residents take should have physician orders for it. Antifungal creams are medicated creams. They can be left at the bedside without a physician's order. Facility's policy titled Storage of Medications (Undated) showed The facility stores all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs are biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 7 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. On 02/20/25 at 10:38 AM V1 (Administrator) said that the facility has never tested the facility's water for Legionella or any other opportunistic waterborne pathogen. Residents Affected - Many The facility's Water Management Plan dated 12/1/2017 showed, collect water samples from appropriate locations and have the samples tested for Legionella by a highly qualified laboratory that has certifications and approvals applicable to the facility's location - e.g., certified by the CDC's ELITE program in the US; certified per the Public Health England external quality assessment (EQA) Legionella isolation scheme in the UK; approved by the state environmental laboratory approval program (ELAP). Sample domestic water system and other drinking water (e.g. bottled water dispenser) at the following minimum frequencies initially, and then more frequently if indicated by test results: residential buildings occupied primarily by seniors nursing homes, health care facilities, and other buildings occupied by persons at high risk four times yearly. Based on observation, interview, and record review, the facility failed to ensure staff and visitors wore corresponding PPE (Personal Protective Equipment) for resident isolation status, and failed to have measures to test for growth of Legionella and other opportunistic water borne pathogens in the building water system. This affects 3 out of 3 residents (R28, R54, R211) and all 54 residents in the facility. Facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/18/2025 to 2/21/2025 showed a census of 54 residents. Findings include: 1. On 2/18/2025 at 11:14 AM, R28 was on contact and droplet isolation. On 2/18/2025 at 12:10 PM, V8 (RN-Registered Nurse) was observed in front of R28's door when a visitor arrived. V8 stepped aside and let the visitor enter the room with only a surgical mask on. V8 did not educate or encourage visitor to wear appropriate PPE. Review of R28's EHR (Electronic Health Record) shows diagnosis of Covid-19. 2. On 02/19/25 at 02:00 PM, a visitor was observed inside R211's room. Visitor was not wearing any PPE. R211's EHR documents she is on contact isolation for Herpes Simplex. On 2/20/2025, V27 (IP-Infection Preventionist) said visitors are expected to follow facility policy when entering an isolation room. He said for droplet isolation, visitors are expected to wear gown, gloves, well fitted mask and eye protection. He said for contact isolation, visitors are expected to wear gown and gloves. He said he expects staff to educate visitors of what PPE to wear before going inside an isolation room. He said it is important for visitors to wear appropriate PPE to stop spread of infection. He said it is the responsibility of staff to provide education to visitors regarding use of proper PPE. Facility's undated Isolation - Categories of Transmission-Based Precautions Policy showed Transmission-based precautions are additional measures that protects staff, visitors, and other residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 8 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many from becoming infected. The policy stated for contact isolation, staff and visitors will wear gloves and disposable gowns upon entering the room. Policy showed for droplet precautions, mask, gloves, gown, and goggles should be worn if there is a risk for spraying respiratory secretions. 3. On 02/19/25 at 08:43 AM, R54's wound care was observed. Wound care was done by V23 (Wound Care Nurse). R54 has pressure ulcer on her right buttock. All throughout providing wound treatment, V23 was only wearing gloves. After wound care, V23 said I forgot to wear a gown. R54's EHR documents she is on EBP (Enhanced Barrier Protection) due to wounds. On 2/20/2025, V27 (IP-Infection Preventionist) said residents are put on EBP when they have open wounds that require dressing. He said staff should wear gown and gloves when providing care to protect both staff and resident. Facility's Policy and Procedure on Enhanced Barrier Protection dated 4/1/24 documents that EBP precautions are defined as use of gowns and gloves during high contact care activities that generate opportunities for transfer of MDROs (Multidrug-resistant Organisms) in the form of blood or body fluids, onto the hands and/or clothing of the caregiver. Policy states that precautions are generally in place until there is resolution of the wound. Policy further documents dressing care/changes/management of dressings as an example of high contact resident care activity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 9 of 10 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 146125 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hearthwood Snf Senior Living 829 Carillon Drive Bartlett, IL 60103 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to provide the mandatory 12 hours of annual training to their CNA's (Certified Nursing Assistants). Residents Affected - Many This applies to all 54 residents in the facility reviewed for staff training. The findings include: On 2/18/2025, V1 (Administrator) submitted Form CMS (Centers for Medicare and Medicaid Services) 671: Long Term Care Facility Application for Medicare and Medicaid. It documents the facility has a current census of 54 residents. On 2/19/25 at 9:30 AM, V22 (CNA Supervisor/Staffing Coordinator) stated I don't have any record of the 12 hours of dementia and abuse training that CNA's are supposed to do. I think they do that in the skills fair. I will talk to human resources. On 2/20/25 at 10:02 AM, V2 (DON-Director of Nursing) stated, We don't have the 12 hours of training for the CNA's. We usually do it in our skills fair. Yes, CNA's are supposed to do the required 12 hours every year. Yes, it is required for my CNA's to do the dementia and abuse training. HR (Human Resources) was responsible for doing it at the skills fair. We had it 2 years ago in (2023) before our annual survey (4/25/24). We didn't have a skills fair in 2024. We are going through a transition with a new HR and new management. The skills fair is part of it. Competencies and inservices are done by (V22), me or my ADON (Assistant Director of Nursing). On 2/20/25 10:12 AM, V3 (HR-Human Resources Director) stated, I took over the role as HR Director in November 2024 very suddenly. We usually would have an annual skills fair encompassing all of that training. They did not do a skills fair in 2024. I'm unable to provide you any documentation that says my CNA's got 12 hours of training. The 12 hours are mandatory every year. On 2/20/25 at 10:50 AM, V3 came back to the conference room with a list of all her CNA's. The document shows the facility currently has 36 CNA's. She stated the skills assessment quiz doesn't show how many hours the subjects were. V3 stated that V16 (Former Director of Assisted Living) did an inservice on dementia in March 2024. However, she was unable to find the inservice sign in sheets at this time. The following five CNA's files were reviewed with V3: V14 (hire date of 6/22/22), V17 (hire date of 4/20/09), V18 (hire date of 5/23/16), V19 (hire date of 12/28/10), and V20 (hire date of 10/19/10). They did not have the required 12 hours of annual training. V3 showed a skills fair quiz from 2023 for the CNA's, but it did not specify the number of hours for each topic and V3 was unable to determine how many hours of presentation the skills fair was for. Facility's policy titled Nurse Aide Qualification and Training Requirements (August 2022) show the following: 6. Nurse aides will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents: a. communication and interpersonal skills; b. infection control; c. safety/emergency procedures; d. promoting residents' independence; e. respecting residents' rights; f. basic nursing skills; g. personal care skills; h. mental health and social service needs; i. care of the cognitively impaired residents; j. basic restorative services; and k. resident rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146125 If continuation sheet Page 10 of 10