Inspection·August 17, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's August 2023 Treatment Administration Record documents a treatment to apply a petroleum-based gauze and cover with an abdominal pad secured with tape, changed daily, to R1's left upper thigh/groin wound initiated on 8/14/23. On 8/15/23 at 9:25 AM, V21 (Certified Nursing Assistant/CNA) transferred R1 onto the toilet and there was a large, reddened area with peeling skin to R1's left upper thigh/groin. R1's wound was partially covered with a petroleum-based gauze but was not covered with a protective outer dressing. V21 stated R1's wound dressing has been like that since earlier this morning, and V21 had reported it to the nurse who said it would be changed after breakfast. On 8/15/23 at 10:53 AM, V7 (Registered Nurse/RN) administered R1's left thigh wound treatment. There was a large, reddened area from R1's outer thigh that extended across the thigh and down to R1's groin. The center of the wound contained an open, moist, shallow, circular wound that contained white, red, and pink tissue. There was a petroleum-based gauze on the wound, but it was not covered with an abdominal pad. V7 cleansed the wound, applied petroleum-based gauze, covered with an abdominal pad, and secured with tape. V7 confirmed R1's wound should be covered with an abdominal pad. At 11:05 AM, V7 stated no one had reported that R1's dressing was dislodged. On 8/15/23 at 11:36 AM, V18 (CNA) stated on 8/13/23 around 4:30 PM, V22 (Dietary Aide) told V18 that R1 spilled coffee on R1's pants. V18 stated V18 went to the dining room and R1 was sitting at the table eating, V18 didn't think anything of it at the time because V18 thought R1's coffee spilled onto the table and then onto R1's pants. V18 did not think about the coffee burning R1. V18 stated R1 did not appear to be in any pain/discomfort, and V18 did not physically check R1's pants nor report the coffee spill to a nurse. V18 stated V18 did not provide any care for R1 that evening and looking back, V18 should have reported the coffee spill to a nurse. On 8/15/23 at 12:38 PM, V3 (RN) stated V3 worked on 8/13/23 from 6:00 AM until 6:00 PM and was R1's nurse. V3 stated nothing was reported during V3's shift that R1 had spilled coffee or that R1 had any sign of injury to R1's thigh. On 8/15/23 at 12:39 PM, V22 (Dietary Aide) stated on 8/13/23 around 4:30 PM/5:00 PM, V22 saw that R1 had spilled coffee on R1's lap/groin and V22 reported this to a CNA. V22 stated V22 did not realize the coffee was hot enough to burn R1 and was unsure what the temperature of the coffee was that evening. On 8/15/23 at 2:27 PM, V8 (LPN) stated V8 came on duty at 6:00 PM on 8/13/23 and around 10:30 PM V9 (CNA) reported R1's wound. V8 stated R1 had what appeared to be a splash burn on R1's left thigh that extended to R1's groin, and the top part had broken skin where the initial contact was made. V8 stated the burn appeared to be a 2nd degree, that was red and blistered. V8 stated R1's coffee spill was not reported prior to that night. On 8/15/23 at 12:31 PM, V11 (LPN) stated V11 worked 6:00 PM to 6:00 AM on 8/13/23 and at 11:00 PM V8 LPN reported that R1 had an apparent burn with blisters to R1's left upper thigh. V11 stated R1 reported that R1 had spilled coffee at breakfast, but R1's time perception is not always accurate. V11 stated R1's left thigh wound was red with small, raised blisters and one open circular wound. V11 stated V11 did not document V11's assessment of R1's burn/wound. V11 stated none of the staff on evening shift were aware that R1 had spilled coffee on herself earlier that day until the wound was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 2 of 7 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/15/23 at 1:22 PM, V10 (CNA) stated V10 was assigned to R1's care on 2nd shift on 8/13/23. V10 stated no one had reported that R1 had spilled coffee that evening and V10 was not aware that R1 had a skin injury to the left thigh. V10 stated V10 had toileted R1 prior to supper and did not provide any care for her until R1 was checked for incontinence around 9:00 PM/9:30 PM and R1 was dry. V10 stated V10 rolled R1 over in bed to check the back of R1's incontinence brief. V10 confirmed V10 did not observe R1's groin or thighs when V10 checked R1 for incontinence. On 8/15/23 at 1:35 PM, V2 (Director of Nursing/DON) stated V11 (LPN) reported on the evening of 8/13/23 that R1 had what appeared to be a burn wound to the left thigh/groin area, and R1's incident happened at supper. V2 stated V2 was informed that staff had witnessed R1 spill coffee at dinner, and confirmed this was the cause of R2's burn. V2 stated the facility is currently educated staff that when a coffee spill occurs, they should notify a nurse or CNA so that the clothing can promptly be removed, and the area assessed for injury. V2 stated an investigation should be initiated and the physician and family notified of the incident. V2 confirmed that staff should have assessed R1's skin at the time of the coffee spill. V2 confirmed that when hot liquids are left in contact with skin it can potentially worsen the burn. V2 stated staff should notify the nurse when a dressing is dislodged so that the dressing can be replaced. At 2:50 PM, V2 confirmed there is no documented assessment of R1's burn until 8/14/23. V2 stated V2 had instructed the nurses to do a general assessment of the wound, and that should had been documented in an assessment or progress note. The facility's Treatment Administration policy dated April 2023 documents to administer treatments as ordered, record treatments on the Treatment Administration Record, and record significant observations in the electronic medical record. The facility's Accidents & Incidents policy dated as revised March 2021 documents employees who witness an incident or accident must report the incident to their supervisor as soon as practical. This policy documents to notify the charge nurse, examine the resident, provide medical attention, report the incident/accident to the resident's physician, and document follow up assessments on the accident/incident form. The facility's Food Safety: Preventing Burns policy dated 2017 documents hot liquids will be served between 160 and 185 degrees Fahrenheit and will be served at safe temperatures in order to prevent burns. This policy includes a chart that documents the following estimated time to receive a 2nd degree and 3rd degree burns based on water temperature: less than 1 second for 2nd degree and 1 second for 3rd degree for 150 degrees, 3 seconds for 2nd degree and 5 seconds for 3rd degree at 140 degrees, 17 seconds for 2nd degree and 30 seconds for 3rd degree at 131 degrees, 2 minutes for 2nd degree and 4.2 minutes for 3rd degree at 124 degrees, and 8 minutes for 2nd degree and 10 minutes for 3rd degree at 120 degrees. The facility's Burns Clinical Guidelines dated 4/2023 documents all burns and scalds are investigated to prevent reoccurrence and treated to provide comfort and prevent infection. Further documents nursing staff should do the following: Remove resident from danger if it is present and remove or cut away clothing that has been soaked in a chemical or boiling fluid. If clothing is stuck, do not force. Assess resident and induration of burn. a. Extreme pain at the site of injury (deep burns may be less painful due to damage of the nerve endings) b. Swelling that develops rapidly in the burned area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 3 of 7 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0684 c. Redness around the burn Level of Harm - Minimal harm or potential for actual harm d. small fluid filled blisters under the top layer of skin. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete If possible, hold the burned part under cold running water for 10 - 20 minutes. Protect the area with a sterile dressing large enough to cover burned area completely. Never use wool or an adhesive dressing. Notify the physician or nurse practitioner for treatment orders or transfer to the hospital if necessary. Notify the resident representative. Document in the progress notes and complete an incident report in Risk Management Notify the DON and Wound Care Nurse of the incident. Event ID: Facility ID: 145449 If continuation sheet Page 4 of 7 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure safety of a resident by failing to ensure R1 was assessed for independent safe handling of extremely hot liquids. This resulted in R1 sustaining 2nd degree burns to R1's left thigh. The facility also failed to implement an intervention for an adaptive cup for one (R1) of three residents reviewed for accidents in the sample list of three. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 has Dementia with moderate cognitive impairment and requires setup and supervision assistance for eating. R1's Care Plan dated 8/14/23 documents (R1) has a skin burn of the left lateral thigh/groin r/t (related to) burn from hot coffee spilled at dinner. This care plan includes an intervention to use a spill proof cup for hot liquids during meals. R1's Skin Report dated 8/13/23 at 4:30 PM recorded by V11 (Licensed Practical Nurse/LPN) documents a Certified Nursing Assistant (CNA) alerted V11 that R1 had a skin concern to the left outer thigh and R1 stated R1 had spilled coffee on R1's self during dinner. This report documents the area was assessed and describes the wound as a burn on the left hip, but there is no description of the wound or measurements of this burn until 8/14/23. The interdisciplinary team (IDT) note dated 8/14/23 documents the root cause of R1's burn was determined to be R1 spilled hot coffee on R1's lap during dinner and the new intervention was for R1 to use a spill proof container for hot liquids during meals. R1's Skin assessment dated [DATE] at 5:00 PM documents a 6 (centimeter) by 6 by 0.1 new open area to the left hip. V18 (Certified Nursing Assistant/CNA) written statement dated 8/14/23 documents at 4:30 PM (on 8/13/23) a dietary staff member reported that R1 had spilled coffee and R1's pants may be wet. V18's statement documents V18 went to the dining room and did not notice R1's pants to be soiled. There is no documentation that R1's pants were changed or that R1's skin was immediately assessed for injury. V13 (Certified Nursing Assistant/CNA) written statement dated 8/13/23 documents at 10:30 PM V13 was assisting R1 with toileting and noticed what appeared to be a burn to R1's left thigh. V13 reported this to the nurse. V8 (LPN) written statement dated 8/13/23 documents at 10:30 PM V8 was notified that R1 had a wound to R1's left upper thigh/groin, and R1's wound appeared to be a scald burn. R1 reported that R1 had spilled coffee on herself. V11's Written Statement, dated 8/13/23, documents at 11:03 PM V8 reported that R1 had blistered, red areas to R1's left upper thigh and groin area. R1's medical record does not document R1 was assessed to determine R1's ability to safely handle hot liquids prior to R1's incident. The 8/13/23 Evening Meal Food Temperature Log documents the coffee temperature was 170 degrees Fahrenheit. On 8/15/23 at 9:25 AM, V21 (Certified Nursing Assistant/CNA) written transferred R1 onto the toilet and there was a large, reddened area with peeling skin to R1's left upper thigh. V21 stated V21 was told by V2 (Director of Nursing/DON) that R1 burned herself with coffee. V21 stated R1 usually feeds herself and requires only setup assistance. V21 stated R1 has spilled drinks when R1 is really tired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 5 of 7 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0689 Level of Harm - Actual harm Residents Affected - Few On 8/15/23 at 10:53 AM, V7 (Registered Nurse/RN) administered R1's left thigh wound treatment. There was a large reddened, raised area from R1's outer thigh that extended across the thigh and down to R1's groin. The center of the wound contained a large, circular, open, moist, shallow wound that contained white, red, and pink tissue. R1 asked V7 what did I (R1) do there. V7 (RN) told R1 that R1 had spilled coffee there. On 8/15/23 at 11:11 AM, R1 was sitting in the dining room. V21 (CNA) poured R1 coffee that was served in a ceramic coffee mug that did not contain a lid. There was no staff sitting with R1 providing assistance. At 11:15 AM, V23 (Dietary Aide) poured R1's coffee out of the mug and into an adaptive cup with a sipper lid. At 11:24 AM, V21 stated staff were given education following R1's coffee burn, but it did not say anything specific other than dietary is supposed to check the coffee temperature prior to serving. V21 stated R1 does not use any specialized or adaptive cups and V21 was unsure what interventions were implemented to prevent R1's burn injury from reoccurring. V21 stated V21 had added ice to R1's coffee today prior to serving. On 8/15/23 at 11:36 AM, V18 (CNA) stated on 8/13/23 around 4:30 PM, V22 (Dietary Aide) told V18 that R1 spilled coffee on R1's pants. V18 stated V18 went to the dining room and R1 was sitting at the table eating, V18 didn't think anything of it at the time, because V18 thought R1's coffee spilled onto the table and then onto R1's pants. V18 did not think about the coffee burning R1. V18 did not physically check R1's pants nor report the coffee spill to a nurse. V18 stated V18 did not provide any care for R1 that evening. V18 stated R1 does not need assistance with eating, staff just need to keep an eye on R1. On 8/15/23 at 11:42 AM, V9 (Certified Nursing Assistant/CNA) written stated R1 feeds herself, requires cues, and sometimes R1 places R1's coffee mug between her legs while wandering the facility in R1's wheelchair. V9 stated sometimes R1 would spill coffee while wandering. On 8/15/23 at 12:18 PM, V3 RN stated R1 feeds herself, but occasionally spills food onto her clothes. On 8/15/23 at 1:22 PM V10 CNA stated R1 spills liquids all the time and R1 does not use any type of special cups. On 8/15/23 at 12:39 PM, V22 (Dietary Aide) stated on 8/13/23 around 4:30 PM/5:00 PM V22 saw that R1 had spilled coffee on R1's lap and V22 reported this to a CNA. V22 stated R1's coffee is always served in a standard coffee mug and R1 does not use any type of specialized cups. V22 stated V22 did not realize the coffee was hot enough to burn R1 and was unsure what the temperature of the coffee was that evening and that they generally start serving coffee around 4:00 PM. V22 stated we now have to check the temperature of the coffee when the first cup is poured and record it on the log. V22 was unsure of any other interventions implemented after R1's incident. On 8/15/23 at 2:27 PM, V8 (LPN) stated V8 came on duty at 6:00 PM on 8/13/23 and around 10:30 PM V9 (CNA) reported R1's wound. V8 stated R1 had what appeared to be a splash burn on R1's left thigh that extended to R1's groin, and the top part had broken skin where the initial contact was made. V8 stated the burn appeared to be a 2nd degree, that was red and blistered. V8 confirmed R1 has spilled liquids previously and stated it was related to R1's age and shaky hands. V8 stated we should either monitor residents while they are drinking coffee or add ice cubes to the coffee. On 8/15/23 at 12:31 PM, V11 (LPN) stated V11 worked 6:00 PM to 6:00 AM on 8/13/23 and at 11:00 PM V8 (LPN) reported that R1 had an apparent burn with blisters to R1's left upper thigh. V11 stated R1 reported that R1 had spilled coffee at breakfast, but R1's time perception is not always accurate. V11 stated R1's left thigh wound was red with small, raised blisters and one open circular wound. V11 stated none of the staff on evening shift were aware that R1 had spilled coffee on herself earlier that day until the wound was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 6 of 7 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 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 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 0689 Level of Harm - Actual harm Residents Affected - Few On 8/15/23 at 12:24 PM, V19 (Social Services Director/Former Dietary Manager) stated V19 was the Dietary Manager for 4 years up until a few weeks ago. V19 stated prior to R1's incident the facility had been checking the coffee temperatures when dispensed from the machine and from the carafe when taken to the dining room, and now we are checking the temperature when the first cup is poured from the carafe. The coffee temperature dispensed from the machine was 180 degrees Fahrenheit (F) and the temperature from the carafe was between 160-170 degrees F. V19 stated on 8/14/23 R1 was provided a spill proof cup to use during meals. V19 stated V19 was not aware if the facility has a policy regarding assessing residents for safe handling of hot liquids. V19 stated if residents are noted to have safety concerns it is brought up in the interdisciplinary team meetings, the resident is then assessed to determine if safety interventions are needed. V19 denied that R1 had a history of spilling food/liquids prior to R1's incident. On 8/15/23 at 12:00 PM, V2 (DON) stated V2 is unsure if the facility has a policy regarding the provision of hot liquids and assessing residents for safe handling of hot liquids. V2 stated nursing does not conduct any kind of assessment for that, but maybe dietary does. At 1:35 PM, V2 stated V11 (LPN) reported on the evening of 8/13/23 that R1 had what appeared to be a burn wound to the left thigh/groin area, and R1's incident happened at supper. V2 stated V2 was informed that staff had witnessed R1 spill coffee at dinner, and confirmed this was the cause of R2's burn. V2 stated the incident was reviewed with IDT and we implemented for R1's hot liquids to be in a spill resistant cup. On 8/15/23 at 1:05 PM, V1 (Administrator) stated we prefer the coffee from the dispensary machine to temp between 180-190 F. V1 stated there is no routine assessment done to assess residents for ability to safely handle hot liquids, it is just done on an as needed basis when concerns have brought them to IDT. V1 stated there had been no prior reported concerns that R1 has spilled hot liquids and R1 has not had any burns previously. On 8/16/23 at 2:37 PM, V6 (Physician) stated V6 was notified that R1 had a burn on 8/13/23 caused from a coffee spill. V6 stated a burn like that could happen instantly and the damage would have happened within the first few seconds to minutes of the spill. V6 stated V6 thought the facility did ongoing assessments of resident's spill risk. V6 stated it hadn't been reported to V6 that R1 had a history of spilling food/liquids, and if R1 had repeated spilling V6 may have recommended the use of lids or keeping the coffee temperature below a certain range. The facility's Food Safety: Preventing Burns policy dated 2017 documents the following: Hot food and beverages will be served at a safe temperature that prevents burns. Hot beverages will be served at 160 (degrees Fahrenheit) F to 185 (degrees) F, the optimum temperature for patient satisfaction. Hot beverages will be handled carefully during food delivery and meal set-up in an attempt to avoid spills that could cause burns. Appropriate supervision to obtain hot beverages and/or reheat foods in a microwave will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds based on clinical assessments. Lap trays, slip guards, or cup holders on wheelchairs may be used to help hot liquids remain upright. This policy includes a chart that documents the following estimated time to receive a 2nd degree and 3rd degree burns based on water temperature: less than 1 second for 2nd degree and 1 second for 3rd degree for 150 degrees, 3 seconds for 2nd degree and 5 seconds for 3rd degree at 140 degrees, 17 seconds for 2nd degree and 30 seconds for 3rd degree at 131 degrees, 2 minutes for 2nd degree and 4.2 minutes for 3rd degree at 124 degrees, and 8 minutes for 2nd degree and 10 minutes for 3rd degree at 120 degrees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 7 of 7