Inspection·January 18, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the Facility failed to ensure a resident's allegation of staff abuse was reported to the Abuse Coordinator for one (R22) of 14 Residents reviewed for Abuse in a sample of 29. Residents Affected - Few Findings include: Facility Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media Policy, revised 3/15/18, documents: the Facility, for protection of the Resident; screening, training, reporting incidents, investigations and facility response to the result of the result of the investigation, identification of possible incidents or allegations which need investigation, investigation of incidents or allegations, protection of Residents during investigations and prevention policies and procedures; all Residents have the right to be free from verbal, sexual, physical, mental abuse, corporal seclusion, neglect, misappropriation of property and exploitation; Abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish, abuse includes deprivation by an individual; and Abuse may be verbal, sexual, physical or mental; a Facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a Resident shall immediately report the matter to the Facility Administrator; and the Facility Administrator who becomes aware of the alleged abuse or neglect of a Resident shall immediately report to the Local Health Department. Facility Electronic Mail correspondence, dated 1/17/24 at 1:12 pm, documents the Facility notification of R22's alleged Abuse investigation, that occurred on 1/3/24, to the local Health Department. R22's admission Record Face Sheet, dated 1/17/23, documents diagnoses including Parkinson, Osteoporosis, Left Foot Drop, Overactive Bladder, History of Falling, Unsteadiness on Feet, Difficulty Walking and Muscle Weakness. R22's Nursing Progress Note, dated 1/4/24, documents that, (R22) had an involuntary stool, which is abnormal for (R22). (R22) shared with (V7/Certified Nursing Assistant/CNA) that an incident had occurred last night (1/3/24), with an unknown CNA. (R22) had been assisted into recliner but was not given (R22's) call light. (R22) waited on CNA to return to assist (R22) to bed but CNA (she) did not return so R22 put self to bed. (R22) could not lift legs into bed and pushed call light for assistance. A CNA came in and scolded R22 and proceeded to tell R22 that R22 should have been in bed already. The CNA said that she came in early to help out and it was not (her) job to put R22 to bed when 'second shifters' were standing around at desk. On 1/17/23 at 1:35 pm, R22 (alert and oriented) stated, On that night, a little after supper time, an Aide (CNA) came in to my room and helped me into my chair but did not leave me my call light, so after waiting a long time, I tried putting myself to bed, but I could not lift my legs in to the bed, but I was able to put on my call light, and a tall and slender Aide (CNA), came in and was not very nice at all to me. The Aide (CNA) was throwing stuff around and complaining to me about why I should have already been in bed. The Aide was very mean and kept scolding me. The next night, I told another Aide (V7/CNA) about it, but I have not heard anything from anyone about it, I do not know that they even did anything. On 1/17/24 at 2:34 pm, V4 (CNA) stated, I work a lot of overtime, by coming in early, because we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 2 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few are short all the time. I went in to (R22's) room on the night of 1/3/24. All the other 'CNAs' were just sitting around and not answering call lights, which was annoying to me, so I went in and (R22) had, had a small bowel movement, so I helped get her cleaned up and back into bed. I do not feel that I was mean to (R22). I was annoyed by the other staff sitting around though. On 1/17/24 at 2:10 pm, V6 (Licensed Practical Nurse/LPN) stated, I was (R22's) nurse on 1/4/24, and (V7/CNA) came to me and told me that (R22) had complained about a possible abuse from a 'CNA,' from the night before. I am not sure who the 'CNA' is but, (R22) told (V7) that a 'CNA' was scolding (R22), but we are not sure which 'CNA' it was. I did put in a nursing note, but I may be forgot to tell (V1/Administrator/Abuse Coordinator) or any other boss. I normally would put in my nursing note that I notified (V1), but I must have, for some reason, not told anyone, I was probably busy that night. I should have told (V1) so they could investigate it and report it. On 01/18/24 at 8:52 am, V1 stated, I have been the Administrator for about six months now, and I am the Abuse Coordinator. I have in-serviced the staff at least three times on the Abuse Policy since I have been here in that position and they should have reported that incident (of 1/3/24) to me, they are all aware of what should be done. (V6) should know better. So, I just now reported it and started an investigation to the Department of Public Health last night (1/17/24). We should have been told about this incident at the time, so we could have thoroughly investigated it and reported it if we determined if it was abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 3 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide transfer/discharge notification, to the Ombudsman, for one (R11) of one resident reviewed for transfer/discharges in a sample of 29. Findings include: R11's medical record documents R11 was an active resident on 10/17/23, discharged to the hospital on [DATE], re-admitted to the nursing home on [DATE], discharged back to the hospital on [DATE], and re-admitted to the nursing home on [DATE]. R11's nurses notes document 10/24/23 at 6:23 PM informed (family) of (R11's) fall and sending (R11) to the hospital. R11's nurses notes document 10/30/23 at 3:35 PM Resident returned from hospital. R11's nurses notes document 10/30/23 at 4:13 PM 911 called at this time to transport (R11) to the emergency room. R11's nurses notes documents on 11/9/23 at 4:30 PM R11 is up in the dining room for her meal. R11's medical record has no documentation the Long-Term Care Ombudsman was notified of the transfer or discharge in writing. On 1/17/24 at 12:23 PM, V1 Administrator stated, Social Services is responsible for notifying the ombudsman of discharges/transfers and it is not being done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 4 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify R11 or R11's representative of the facilities bed-hold in writing for one (R11) of one resident reviewed for transfer/discharges in a sample of 29. Findings include: Facility Bed-Hold Notification form, undated, documents When a resident is transferred to a hospital, they have the right to request that their bed be held until their return. R11's medical record documents R11 was an active resident on 10/17/23, discharged to the hospital on [DATE], re-admitted to the nursing home on [DATE], discharged back to the hospital on [DATE], and re-admitted to the nursing home on [DATE]. R11's nurses notes document 10/24/23 at 6:23 PM informed (family) of (R11's) fall and sending (R11) to the hospital. R11's nurses notes document 10/30/23 at 3:35 PM Resident returned from hospital. R11's nurses notes document 10/30/23 at 4:13 PM 911 called at this time to transport (R11) to the emergency room. R11's nurses notes documents on 11/9/23 at 4:30 PM R11 is up in the dining room for her meal. R11's medical record has no documentation R1 or R1's representative was notified of the facilities bed-hold in writing. On 1/17/24 at 12:23 PM, V1 Administrator stated, I cannot find (R11's) bed-hold notifications, I found bed-hold notifications on other residents, but I am not sure where (R11's) are. On 1/18/23 at 3:30 PM, V1 Administrator stated, I cannot find (R11's) bed-hold notifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 5 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have physician's orders, for adaptive equipment, for one resident (R1) of 29 residents reviewed for physician's orders in a sample of 29. Residents Affected - Few Findings include: On 1/16/24 at 11:38 AM, In R1's room, there was a right arm splint on the bedside table, and a right arm walker in the room. R1 had a left AFO/Ankle-foot Orthosis on her foot. R1's current Care Plan documents May wear left AFO/Ankle-foot Orthosis for foot drop with a date initiated on 3/11/16. Apply right hand splint at bedtime with a date initiated on 4/21/22. R1's electronic medical record has no orders for R1's right arm splint or left AFO. On 1/16/24 at 2:38 PM, V1 Administrator and V2 Director of Nursing stated (R1) has a right arm splint and AFO she wears. I will check into her orders. On 1/17/24 at 1:36 PM, V1 Administrator stated We don't have any orders for (R1's) splints. Sometimes when residents go out to the hospital the orders fall off and don't get re-ordered. There are no orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 6 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to implement appropriate interventions to prevent two falls out of bed for one (R46) of six residents reviewed for falls in a sample of 29. Residents Affected - Few Findings include: Facility Fall Assessment and Management Policy, revised 4/2019, documents: it is the policy of the Facility to assess each Resident's fall risk on admission, quarterly and with each fall; this will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk; that factors related to the risk will be addressed and care planned; the interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the Resident; and interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. The Facility Fall Log, undated, documents that R46 sustained a fall to the ground on 10/18/23 at 3:45 pm, and a fall on the floor on 11/16/23 at 2:15 pm. R46's current Care Plan, undated, documents that R46 is a fall risk and that R46 has a history of falls. R46's Minimum Data Set/MDS, Section C/Cognitive Patterns, dated 12/23/23, documents that R46 is never/rarely understood and cognitively is severely impaired. R46's Minimum Data Set/MDS, Section GG, dated 12/23/24, documents that R46 requires maximal assistance of staff with chair/bed transfers and rolling in bed. R46's Fall Details Report, dated 10/18/23 at 3:45 pm, documents: R46's fall on the floor in Resident (R46's) room; R46's cognition (oriented to person); R46's root cause of fall was determined that R46 was too close to the edge of the bed and R46 wiggled out onto the floor; the intervention was to educate the staff to make sure that R46 was laying in the center of the bed to prevent R46 from rolling on to the floor. R46's Fall Details Report, dated 11/16/23 at 2:15 pm, documents: R46's fall on the floor in Resident (R46's) room; R46's cognition (oriented to person); R46 was noted to be lying on the floor next to R46's bed; R46 requires two person staff assistance with transfers; an investigation and interviews determined that R46 rolled out of bed and sustained a head trauma/goose egg mid forehead to the center side of forehead; the intervention was to order a fall matt to be placed next to R46's bed and R46 was moved to a different room. On 1/28/24 at 2:15 pm, V2 (Director of Nursing/DON) stated, Our intervention on the first fall was to make sure that (R46) was placed in the center of R46's bed, then R46 fell again out of bed. We probably should have re-evaluated that intervention, because on the second fall R46 fell out of bed also and the only intervention was to place R46 in the center of the bed. R46 had a history of falls from the bed, and at one point we even had (R46) in a low bed but (R46) quit falling, so we discontinued that intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 7 of 8 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason City Area Nursing Home 520 North Price Avenue Mason City, IL 62664 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 57 residents residing in the facility. Findings include: The facility's Direct Care Staffing Requirements Policy and Procedure, revised 1/16/ 2018, documents the facility will meet the staffing needs of the resident population. This same policy documents 1. There shall be at least one registered nurse on duty seven days per week, eight consecutive hours, in a skilled nursing facility. The facility's Daily Staffing Report Sheets document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 12/25/23; 12/31/23; 1/13/24; or 1/14/24. The facility's Nurse Schedules for December 2023 and January 2024 document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 12/25/23; 12/31/23; 1/13/24; or 1/14/24. On 1/16/24 at 12:47 PM, V1 (Administrator) stated, We only have one RN who works weekends and it's every other weekend, so we have some weekends with no RN coverage. V1 stated RN management will take call on the weekends, but stated they don't usually come to the facility unless needed. On 1/18/24 at 2:10 PM, V1 verified the facility was without eight consecutive hours of RN coverage on 12/25/23; 12/31/23; 1/13/24; and 1/14/24. CMS/Centers for Medicare & Medicaid Services Form-671 (Long-Term Care Facility Application for Medicare and Medicaid) signed and dated by V1 (Administrator) on 1/16/24 documents 57 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 8 of 8