Health inspection·October 28, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm not have our own van.Facility policy states, It is the policy of this facility to safely transport residents to/from necessary appointments when needed. If the interdisciplinary team (IDT) determines a resident requires assistance, then arrangements must be made to send an appropriate escort to meet that particular need. Examples of residents requiring assistance are residents who need assistance with AOL's, have impaired decision making, are elopement risk or otherwise deemed unsafe to be out alone. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 2 of 4 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 observation, interview, and record review the facility failed to monitor and document pressure ulcer development for 1 (R2) of 3 residents reviewed for pressure ulcers in the sample of 7.Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan dated 10/23/2025 documents R2 currently has an alteration to R2's Integumentary System due to Surgical Incision Right Leg. Non-Blanchable area to right/left buttocks and coccyx. Blister to Left Buttock. On 9/25/25: R2 has a stage 1 to her buttocks/coccyx. Educate R2, Power of Attorney, POA or caregiver as to causes of skin break down, skin tear, or pressure ulcer: transfer/positioning or during ambulating. Encourage resident to do what she /he can do for self. Place nonslip pad in her wheelchair to prevent R2 from sliding down in her wheelchair.On 10/23/2025 at 9:55AM V4, Licensed Practical Nurse, LPN, V5, LPN and V6, Certified Nursing Assistant, CNA, assisted R2 back to bed via mechanical lift. Coccyx/lower buttocks area dressing changed. Coccyx/lower buttocks area has 2 open wounds. One on right side quarter size and one on left side dime size. V4 changed dressing according to orders. R2's Electronic Health Record had no documentation of wound measurements or wound monitoring. R2's Skilled Nursing assessment dated [DATE], Section G Skin/Wound, documents no new changes in skin integrity. Type of wound present - surgical. Other skin issues - none. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - skin shear on buttocks. Notable changes to wound present - skin shear on buttocks.R2‘s Braden Scale for Predicting Pressure Sore Risk dated 9/13/2025 documents R2 is at risk for pressure sore development. R2's order sheet dated 9/25/2025 documents Cleanse open area to left upper buttocks with normal saline. Apply foam bordered dressing. Change daily and as needed every evening shift for skin management.R2's order sheet dated 10/23/2025 at 4:56PM Cleanse open area to buttocks with NS. apply skin prep. Apply barrier protectant cream. Apply foam bordered dressing. Change daily & PRN.R2's order sheet dated 10/23/2025 at 4:23PM Cleanse open area to left upper buttocks with NS. Apply barrier protectant cream. Apply foam bordered dressing. Change daily and as needed.R2's shower sheets dated 9/29/2025 documents 2 spots with arrow pointing to lower buttocks. and blister burst when peri care was given. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents shear and red 8.3, 8.0, blister 0.1 x 0.4, R 4.0 x 3.0.R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents red with arrow pointing to coccyx area. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented. On 10/23/2025 at 10:20AM V11, Physician, stated, When I visit, I usually see most of the residents out of their bed and in the dining room area. I saw (R2) about two weeks ago and she had a Stage-1 sore on her coccyx that was just red at the time. (R2) always wanted to stay in bed most of the day, so I put in orders, after seeing her wound, for her to get out of bed to wheelchair for all meals and then out of bed for two hours between meals. I was off last week, and I have not seen her wound since then. If her wound has gotten worse than a stage-1 wound, then no one notified me about it. On 10/23/2025 at 3:16PM and 3:30PM Surveyor asked V1 for wound notes and measurements for R2's wounds. Surveyor asked V1 on 10/24/2025 at 8:20AM for R2's wound notes and measurements. V1 stated, The areas on R2's bottom are shearing from her Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145518 If continuation sheet Page 3 of 4 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 145518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mascoutah Rehab and Nursing 201 South 10th Street Mascoutah, IL 62258 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 FORM CMS-2567 (02/99) Previous Versions Obsolete sliding down. We have new orders now and I will send the measurements. On 10/24/2025 at 10:00AM V4, LPN, stated R2 has 2 areas but they aren't really pressure they are kind of connected and are from friction. I measured the area yesterday, but I don't think we had been measuring. On 10/24/2025 at 11:55AM V2, Director of Nursing, DON, stated I saw R2's wounds yesterday. The area that is quarter size did not appear open. It could be called a stage 2. I would expect a wound to be measured, and the resident referred to the wound company that comes in. From what I understand of R2's wound situation is that R2 was referred to the wound company when admitted . The wound company found R2 did not need services at that time. The facility did treatments here. Going forward our nurse manager V18 is going to do measurements and treatments. Facility policy updated 5/2/2022 states, To identify factors that place the residents at risk for the development of pressure ulcers. To implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of existing pressure ulcers. Event ID: Facility ID: 145518 If continuation sheet Page 4 of 4