Health inspection·February 10, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician was notified with a change in condition for 1 of 3 (R1) residents reviewed for physician notification in the sample of 15. Findings Include:R1's Resident Face Sheet with a print date of 2/5/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status of 09, indicating a moderate cognitive deficit. R1's Care Plan documents a Problem area of, I am at risk for impaired nutrition and hydration related to: I am on a regular DIET with a start date if 10/1/25. This Problem area includes the intervention of, Monitor weight and notify provider of significant weight changes .Date Created: 10/12/2025 .R1's Physician Order Report dated 1/5/26 to 2/5/26 documents a physician order with a start date of 10/07/25 of, Weight: daily. Special Instructions: Daily weight before breakfast, notify MD (physician) for weight gain greater than 3 pounds in 1 day or 5 pounds in 1 week and an order with a start date of 12/8/25 of, bumetanide tablet; 1 mg (milligram); amt: 1 tab; Take 1 tablet 1 mg by mouth daily as needed for weight gain more than 2 Ibs (pounds) every day or more than 3 lbs in 5 days.R1's Vitals Report dated 1/1/26 to 1/31/26 documents the following weights. 1/1- 133.5, 1/2- 133.5, 1/3- 138, 1/4- 138, 1/5137, 1/6- 136.5, 1/7- 138.5, 1/8- 139, 1/9- 142, 1/10- no weight, 1/11 -144, 1/12-140, 1/13- 139.5, 1/14139.5, 1/15- 139, 1/16- 141.5, 1/17- 141.2, 1/18- 142, 1/19- 141, 1/20 - no weight, 1/21- 141, 1/22/26- 144 pounds. This indicates R1's physician should have been notified of a weight gain of three pounds in one day on 1/3, 1/9, and 1/22/26 and a weight gain of five pounds in one week on 1/7/26. On 2/5/26 at 2:03 PM, V11 (Licensed Practical Nurse) stated she provided care to R1 on 1/22/26 and noted the weight gain of 3 pounds in one day. V11 stated she treated R1 with the as needed medication for the weight gain but did not remember notifying the physician. On 2/9/26 at 10:55 AM, V3 (Regional Clinical Director) stated R1's physician was to be notified if she had a weight gain of three pounds in one day or five pounds in one week. V3 reviewed R1's weights for January 2026 and stated if the physician was notified of the weight change it would be documented in R1's progress notes. V3 reviewed R1's progress notes and stated she was not able to locate documentation R1's physician had been notified of the weight changes as ordered. On 2/9/26 at 11:11 AM, V12 (Nurse Practitioner) stated she provided care to R1 and saw her routinely and as needed. V12 stated she was not notified of any weight gains for R1 in January 2026. V12 stated if she had been notified, she would have told them to administer the as needed bumetanide as ordered for weight gain. The facility Obtaining and Following Physician Orders policy dated July 2017 documents, Policy: It is the policy of (name of facility) that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. Page 1 of 3 145135 145135 02/10/2026 Richland Nursing & Rehab 900 East Scott Street Olney, IL 62450

F 0580 If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145135 Page 2 of 3 145135 02/10/2026 Richland Nursing & Rehab 900 East Scott Street Olney, IL 62450

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 (R1) residents reviewed for medication administration in the sample of 15. Findings Include: R1's Resident Face Sheet with a print date of 2/5/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status of 09, indicating a moderate cognitive deficit. R1's Care Plan does not document a Problem area related to medication administration. R1's Physician Order Report dated 1/5/26 to 2/5/26 documents a physician order with a start date of 12/08/2025 for bumetanide one milligram take one tablet by mouth daily as needed for weight gain more than two pounds every day and more than three pounds in five days. R1's Vitals Report dated 1/1/26 to 1/31/26 documents the following weights. 1/1- 133.5, 1/2- 133.5, 1/3- 138, 1/4- 138, 1/5- 137, 1/6- 136.5, 1/7- 138.5, 1/8- 139, 1/9- 142, 1/10- no weight, 1/11 -144, 1/12-140, 1/13139.5, 1/14- 139.5, 1/15- 139, 1/16- 141.5, 1/17- 141.2, 1/18- 142, 1/19- 141, 1/20 - no weight, 1/21- 141, 1/22/26- 144 pounds. This indicates R1 should have been administered bumetanide on 1/3, 1/7, 1/9, 1/11, 1/16, and 1/22/26 for a weight gain of two pounds in one day and on 1/6/26 for a weight gain of three pounds in five days. R1's Medication Administration Record (MAR) dated 1/1/26 to 1/22/26 documents a physician order for bumetanide 1 milligram take one table by mouth daily as needed for weight gain more than two pounds every day or more than three pounds in five days. This same MAR documents initials with parenthesis around them on 1/1, 1/2, 1/4-1/8, 1/10, 1/12, 1/13, and 1/15-1/21/26. On 2/9/26 at 10:55 AM, V3 (Regional Clinical Director) stated the parenthesis around the initials indicates the medication was not administered. V3 stated the medication should have been administered anytime R1 had a weight gain of two pounds in one day or three pounds in five days (1/3, 1/6, 1/7, 1/9, 1/11, 1/16, and 1/22). This indicates R1 did not have bumetanide administered as ordered on 1/6, 1/7 and 1/16/26. The facility policy titled Obtaining and Following Physician Orders dated July 2017 documents, Policy: It is the policy of (name of facility) that physician orders will be obtained by licensed personnel and followed. If the licensed professional does not in his/her best judgment think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified. Residents Affected - Few 145135 Page 3 of 3