Health inspection·November 9, 2023

F 0550 empty next to the transparent plastic catheter bag of urine. Level of Harm - Minimal harm or potential for actual harm Interview and observation on 11/09/23 beginning at 2:36 PM CNA B revealed CNAs were trained to make sure that the transparent plastic catheter bag was concealed inside the dark colored bag, known as a dignity bag. CNA B stated the catheter bag was supposed to be concealed in the dignity bag whether the resident was in bed or in a chair. CNA B stated that clean bags were in the clean utility closet. She stated that a resident may be embarrassed or ashamed if someone saw it. Residents Affected - Few Interview and record review on 11-9-2023 beginning at 2:47 PM with the DON revealed it was policy to place the transparent plastic catheter bag inside a dignity bag and staff were trained to follow that policy. The DON stated that the practice of putting the transparent plastic catheter bag in the dignity bag was to protect the resident from being self-conscious or embarrassment if someone saw it. Interview on 11-9-2023 at 2:55 PM with the ADM revealed the transparent plastic catheter bag was supposed to be placed inside the dignity bag shielded from sight. The ADM stated the dignity bag was used to prevent embarrassment if someone were to see it. Record review of the facility's Catheter Care, Indwelling Catheter, undated, did not address the use of dignity bags to conceal catheter bags from sight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to revise the care plan for 1 of 8 (Resident # 40) residents reviewed for care plans. Resident # 40's care plans inaccurately reflected indwelling catheter use. This failure placed the resident at risk of not having their needs met to achieve the highest quality of life. Findings included: Observation 11/7/2023 at 1130 AM of Resident #40 lying in bed revealed no indwelling catheter in use. Record review of Resident # 40 face sheet dated 11/09/2023 reflects a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes Dementia (a group of thinking and social symptoms that interfere with daily functioning), Atherosclerotic heart disease( a vascular disease where the blood vessels carrying oxygen away from the heart become damaged) Essential (primary) Hypertension( abnormally elevated blood pressure that is not the result of a medical condition). Record review of Resident #40 's Quarterly MDS dated [DATE] indicated a BIM score of 2 (0-7 suggests severe cognitive impairment) Section H indicates no appliances and Urinary continence was recorded as a 3 (always incontinent). Record review of Resident # 40 Care plan dated 11/9/2023 indicated a focus on the Resident having an indwelling catheter. At risk for UTI (Urinary Tract Infection), complication, and urinary retention initiated 4/17/2023. The goal of the foley catheter will remain patent through the next review date initiated on 4/17/2023 with revision on 10/18/2023. Record review of Resident # 40 Physician orders reflected no order for Foley, the last order for an indwelling Foley catheter was discontinued on 4/14/2023. An interview on 11/8/2023 at 11 am with LAR # 40 reveals that the resident has not had a foley since the day after she came back from the hospital. Interview on 11/09/23 12:12 PM MDS LVN revealed Care plans should be updated and current, we go over orders in our daily meetings. I am not sure why they are not up to date. potential harm to the resident would be not receiving the proper care. Interview on 11/09/2023 at 12:30 pm MDS RN revealed RN she has been here a couple of months, she was not sure why the care plans on the residents aren't up to date, they review the new orders in the morning meeting Monday - Friday and she takes her computer to update them in real-time. She stated that not updated care plans could cause potential harm to lack of care. Interview on 11/09/2023 12:45 pm DON stated her expectations are that the care plans are updated based on the orders and residents' needs in real-time. She stated that the care plan indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident had a foley and could not really cause any harm to the resident, asked if in general harm could come from an updated care plan, and she stated she did not see that there could be. Interview on 11/09/2023 13:00 pm ADM, her expectation was that care plans are updated as the resident's condition and orders change. she stated a care plan that was not updated could cause a potential lack of care for a resident. Record review 11/09/2023 13:30 Policy Comprehensive care plans undated 3. The comprehensive care plan will be c. reviewed and revised (including discharge plans) by the interdisciplinary team after each assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 8 residents (Residents # 15 and Resident # 53) reviewed for pressure ulcers. Residents Affected - Few The facility failed to perform repositioning Q (every) two hours for resident # 15 and Resident # 53 on 11-9-2023 to prevent skin breakdown and pressure ulcers. This failure placed residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, pain, infection, or hospitalization. Findings included: Observations and interviews pertaining to for Resident # 15. Record review of Resident # 15's admission Record, dated 11-9-2023, indicated an [AGE] year-old male admitted on [DATE] to the facility. Resident # 15 was diagnosed with disrupted blood flow to the brain, which caused complete paralysis and weakness of the right side, impaired ability to remember, think, or make decisions, and heart failure. Record review of Resident # 15's MDS, dated [DATE], indicated Resident # 15 had a BIMS score of 3, which suggests severe cognitive impairment, and was at risk for developing pressure ulcers/injuries. Section G of Resident # 15's MDS, Functional Status, indicated ADL Self-Performance was a code of 3 for bed mobility. The code of 3 indicated the resident required extensive assistance when resident moved in bed, turned, or positioned their body. Section G of Resident # 15's MDS, Functional Status, indicated ADL Support Provided was a code of 3 for bed mobility. The code of 3 indicated the resident required 2+ persons to physically assist. Record review of Resident 15's Care Plan, revised on 11-8-2023, indicated that Resident # 53 had ADL self-care performance deficits related to loss of oxygen to the brain and paralysis of one side of the body. The goal for Resident # 15 was to improve level of functioning in bed mobility through 11-30-2024. Interventions for CNAs pertaining to bed mobility indicated extensive assistance was required to turn and position Q 2 hours for PRN comfort. Record review or Resident # 15's Care Plan, revised on 11/08/2023, indicated Resident # 15 was at risk for skin break down related to decreased mobility, incontinence, equipment, nutritional status, and disease process. The goal was to have no reports of skin breakdown due to decreased mobility, incontinence, equipment, nutritional status, and disease process through 11-30-2023. Interventions for CNAs, LVNs, and RNs were to (1) encourage and assist resident to suspend heels when in bed with pillows; (2) encourage resident and provide assistance to turn and reposition Q 2 hours and PRN (as needed) for comfort; and (3) follow facility policies/protocols for the prevention of skin breakdown. Interview on 11-7-2023 at 10:41 AM with LAR # 15 revealed concerns that Resident # 15 did not get the attention needed during the day, and on the weekends. LAR # 15 felt the care was good, and Resident # 15 liked the facility, but LAR # 15 wished staff went in the room more often to check on Resident # 15 to change and re-position him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0686 Level of Harm - Minimal harm or potential for actual harm Observation on 11-9-2023 at 8:32 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Residents Affected - Few Observation on 11-9-2023 at 9:32 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Resident # 15 was in the same position as the previous observation at 8:32 AM. Observation on 11-9-2023 at 10:10 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Resident # 15 was in the same position as the previous observation at 9:32 AM. Observation on 11-9-2023 at 10:20 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Resident # 15 was in the same position as the previous observation at 10:10 AM. Observation on 11-9-2023 at 10:36 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Resident # 15 was in the same position as the previous observation at 10:20 AM. Observation on 11-9-2023 at 11:03 AM reflected Resident # 15 in bed. His heels were on the mattress, both slightly curved outwards; his lower extremities (knee to ankle) were on the mattress; his lower extremities (knees to buttocks) were on the mattress; his buttocks and sacrum were against the mattress; his back and upper body were elevated at 30-45 degrees against the mattress; and his shoulders and head were elevated against the mattress. Resident # 15 was in the same position as the previous observation at 10:36 AM. Observations and interviews pertaining to for Resident # 53. Record review of Resident # 53's admission Record, dated 11-9-2023, indicated a [AGE] year-old female admitted on [DATE] to the facility. Resident # 53 was diagnosed with blockage of blood to the heart muscle, heart failure, and paralysis of left upper limb. Record review of Resident # 53's MDS, dated [DATE], indicated Resident # 53 had a BIMS score of 6, which suggests severe cognitive impairment, and was at risk for developing pressure ulcers/injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Section M of Resident 53's MDS, which covers skin conditions, reflected that the resident required a pressure reducing device for chair, a pressure reducing device for bed, and was on a turning/repositioning program. Section GG of Resident # 53's MDS, Functional Abilities and Goals, GG0170 Mobility, indicated the code of 01 for Section A- Roll left and right. A code of 01 indicated that Resident # 53 was categorized as Dependent. Categorized as Dependent meant that the helper did all the effort, and the resident did not provide any effort. The assistance of 2 or more helpers was required to complete the activity. Record review of Resident 53's Care Plan, revised on 10-18-2023, indicated that Resident # 53 had ADL self-care performance deficits related to fatigue, impaired balance, and a stroke. The goal for Resident # 53 was to maintain current level of functioning through 1-16-2024. Interventions for CNAs pertaining to bed mobility indicated extensive assistance was required to turn and position Q 2 hours for PRN comfort. Record review or Resident # 53's Care Plan, revised on 10-18-2023, indicated Resident # 53 had potential for pressure ulcer development related to immobility. The goal for Resident # 53, revised on 10-18-2023 was to have intact skin, free from redness, blisters, or discoloration by/through review date. The target date was 1-16-2024. Interventions for CNAs were to follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident # 53's Care Plan, revised on 10-18-2023, indicated Resident # 53 was at risk for skin breakdown / and of pressure ulcers related to decreased mobility, incontinence, and nutritional status. The goal for Resident # 53 was to have no reports of skin breakdown through 1-16-2024. Interventions for CNAs, LVN's, and RNs were to encourage resident and provide assistance to turn and reposition Q 2 hours and PRN comfort. Interview on 11-8-2023 at 9:47 AM with LAR # 53 revealed concerns that Resident # 53 was not checked on enough and Resident # 53 was left in the same position most of the day. Observations on 11-9-2023 at 8:37 AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. There were no visible pads or pillows placed against the resident providing a position change. Observations on 11-9-2023 at 9:34 AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. Resident # 53 was in the same position as the previous observation at 8:37 AM. Observations on 11-9-2023 at 10:10 AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. Resident # 53 was in the same position as the previous observation at 9:34 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 11-9-2023 at 10:21AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. Resident # 53 was in the same position as the previous observation at 10:10 AM. Observations on 11-9-2023 at 10:37AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. Resident # 53 was in the same position as the previous observation at 10:21 AM. Observations on 11-9-2023 at 11:04 AM reflected Resident # 53 in bed. Her heels were in pressure relieving boots under the covers; her lower extremities (knee to ankle) were on the mattress; her lower extremities (knees to buttocks) were on the mattress; her buttocks and sacrum were against the mattress; her back and upper body were elevated at 30-45 degrees against the mattress; and her shoulders and head were elevated against the mattress. Resident # 53 was in the same position as the previous observation at 10:37 AM. Interview and observation on 11-9-2023 beginning at 11:12 AM with CNA A revealed she was assigned to Resident # 15 and Resident # 53's rooms' today, 11-9-2023, between 8:32 AM and 11:04 AM; her shift began at 6:00 AM. CNA A stated one of her duties was to perform repositioning every two hours for Resident # 15 and Resident # 53. Re-positioning was important for the residents because some of them could not turn themselves. The reason they are supposed to be repositioned was to relieve pressure against certain areas on the body, because constant pressure would cause skin breakdown or pressure ulcers. CNA A demonstrated how she would log into a remote computer screen, called a kiosk, on the hall after providing a service, and chart the last time she repositioned a resident. She stated that the last time she repositioned Resident # 15 was before breakfast, which was served at 7:30 AM. She stated the last time she repositioned Resident # 53 was about 7:00 AM, 11-9-2023. Interview on 11-9-2023 at 11:40 AM with RN A revealed repositioning was important for the residents. Re-positioning and checking on the residents were supposed to happen Q 2 hours. It was important to check and turn residents to prevent pressure ulcers, skin breakdowns, pain, or infection. She stated that she and CNA A repositioned Resident # 53 at 11:22 AM. Interview and record review on 11-9-2023 beginning at 11:47 AM with the DON revealed the kiosk used to document CNA duties in the hallway provided a date and time stamp on the computer and the history of services was maintained up to the minute The DON printed the histories for re-positioning for Resident # 15 and Resident # 53. The printout for Resident # 15 did not indicate any repositioning entries for 11-9-202. The printout for Resident # 53 indicated a repositioning entry for 10:48 AM, on 11-9-2023. The printout reflected CNA A entered the documentation on the kiosk. Interview and record review on 11-9-2023 beginning at 12:10 PM with CNA A reflected she provided repositioning for Resident # 15 just before breakfast, which was served at 7:30 AM, on 11-9-2023. She stated that she had not provided any repositioning for Resident # 15 since before 7:30 AM. CNA A stated she provided repositioning for Resident # 53 around 7:00 AM on 11-9-2023. The printed history for Resident # 53's repositioning was provided to CNA A; she stated that the entry for 11-9-2023 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 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 676462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Anthony's Care Center 7501 Bagby Ave. Waco, TX 76712 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10:48 AM was an accidental entry. CNA A stated she had not repositioned Resident # 53 since 7:00 AM until the recent repositioning at 11:22 AM. CNA A admitted the entry for repositioning Resident # 53 at 10:48 AM on 11-9-2023 was an accidental entry and it did not occur. Interview on 11-9-2023 at 2:57 PM with the DON revealed residents were supposed to be repositioned Q 2 hours. She stated residents left in one position too long could lead to contractures, developing/worsening pressure ulcers, and infection. The DON stated that fail safes were in place to prevent the development of skin deterioration such as repositioning Q 2 hours, skin assessments, and passing skin concerns off to the nursing staff. Interview with the ADM on 11-9-2023 at 2:59 PM revealed residents were supposed to be repositioned Q 2 hours. The ADM stated it was important to turn residents to keep skin healthy, prevent pressure ulcers, and infections; the ADM added that residents could get bored looking in one direction and that could become sad and lonely. Record review of the facility's Prevention of Pressure Policy, undated, indicated that equipment, such as foot cradles, pillows, and other devices were utilized to (3d) provide pressure relief. The policy indicates (10) a schedule was established for positioning and turning a resident to meet their needs; as well, documentation of the service would contain date, time, and method to provide pressure relief. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676462 If continuation sheet Page 9 of 9