Inspection·March 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety The American Burn Association Scald Statistics and Data Resources, dated 8/13/2018, documents Infants/toddlers and elderly adults have thinner dermal layers compared to persons of other ages, leading to deeper burn injuries of lower temperatures or shorter exposure times. Hot water will burn skin at temperatures much lower than boiling point. It only takes three seconds of exposure to 140 degrees Fahrenheit water to cause a burn serious enough to require surgery. 85 to 90% (percent) of scald burns are related to cooking/drinking/serving hot liquids. Residents Affected - Many R1's admission Record, dated 3/7/25, documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Spastic Diplegic Cerebral Palsy, Visual Hallucinations, Spasmodic Torticollis, Anxiety Disorder, Other forms of Scoliosis, Thoracic Region, Unspecified Osteoarthritis, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Muscle Spasm of Back, Dysphagia, Spondylosis without Myelopathy or Radiculopathy, and Thoracic Region. R1's MDS (Minimum Data Set) Assessment, dated 12/6/24, documents R1 is cognitively intact, requires supervision or touching assistance with eating, and is dependent on staff with all other ADLs (Activities of Daily Living). This same MDS documents R1 had a second or third-degree burn. R1's Contracture Risk Evaluation, dated 9/6/24 and signed by V4/MDS Coordinator, documents R1 currently has contractures, is confused at times, needs staff to turn and reposition, and is noted to have contracting throughout R1's body. R1's OT (Occupation Therapy) and Plan of Treatment, dated 3/19/24, documents (R1's) RUE (Right Upper Extremity) ROM (Range of Motion) = impaired (Right should flexion actively to 60 degrees passively, right shoulder abduction to 65 degrees actively and 80 degrees passively. Right elbow flexion 60 to 130 degrees actively, right wrist 25 to 30 degrees flexion/extension). LUE (Left upper extremity) ROM= impaired. (Left should flexion actively to 60 degrees and passively to 85 degrees, left elbow flexion 35 to 100 degrees actively, left wrist assisted active ROM contracted hand which has elicited superficial palm indentation). Joints: Shoulder=impaired, Elbow/Forearm=impaired; Wrist=Impaired; Shoulder = impaired; Elbow/Forearm=Impaired; Wrist=impaired. R1's Progress Note, dated 11/14/24 and signed by V12/LPN (Licensed Practical Nurse), documents (R1) spilt coffee on left posterior thigh. Area red no blisters noted. R1's Progress Note, dated 11/14/24 and signed by V13/LPN, documents (R1) red area to left thigh now presents with blisters related to spilling coffee on self. R1's Wound Evaluation and Management Summary, dated 11/19/24 and signed by V9/Wound Physician, documents Burn wound of the left thigh partial thickness. Etiology: Burn. Further Etiology Detail: Hot liquid. Duration: Less than five days. Wound size 20cm (centimeters) x 9cm x 0.01cm. Peri-wound radius: Erythema. Exudate: Sero-sanguinous (pinkish-red drainage). Additional Wound Detail: Hot coffee spilled on area last Thursday. R1's Illinois Department of Public Health Final Report, dated 11/22/24, documents R1 was in her room drinking her coffee after breakfast, per R1's normal activities, when V6/Activity Director entered R1's room around 9:00 AM and noticed R1 had spilled her coffee on herself. V13/LPN completed a skin assessment which revealed a reddened area with blisters. Interventions: Requested order from V7/R1's Physician for OT to evaluate and treat, assist R1 with drinking hot liquids and eating, and R1 will drink out of a two handled cup with a straw with staff assist as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Many R1's Progress Note, dated 1/25/25 and signed by V14/LPN, documents (R1) was eating in the dining room when staff reported that (R1) spilled coffee on her left leg. Upon assessment (R1) has a 14cm (centimeter) x 20cm red raised area to her left thigh and around the back of her left thigh. R1's Wound Evaluation and Management Summary, dated 1/28/25 and signed by V9/Wound Physician, documents non-pressure wound of the left posterior thigh. Etiology: Trauma/Injury. Further Etiology Detail: Burn. Duration: Less than two days. Wound size: 6cm x 6cm, x not measurable cm. Exudate: None Blister: Fluid Filled. Additional Wound Detail: hot coffee spilled on leg. Area is blistered with surrounding pink skin. Blisters are intact. R1's Wound Evaluation and Management Summary, dated 2/4/25 and signed by V9/Wound Physician, documents non-pressure wound of the left posterior thigh. Etiology: Trauma/Injury. Further Etiology Detail: Burn. Duration less than nine days. Wound size: 5.5cm x 4 x 0.01cm. Additional Wound Detail: Blister opened. R1's Illinois Department of Public Health Final Report, dated 1/30/25, documents (R1) was in the dining room eating breakfast. When (R1) was taking a drink of the coffee, (R1) spilled coffee on her leg. (V8/Wound Nurse) assessed (R1's) left thigh area and noted that (R1) had a burn to the left thigh area. This same report documents IDT (Interdisciplinary Team) met to discuss the root cause of (R1's) incident of spilling coffee on herself and sustaining a burn. Root cause of the spill was determined to be from (R1) unable to handle cup with lid upright to prevent from spilling it on herself. R1's Clinical Medical Record does not include a hot liquid risk assessment. R1's Order Summary Report, dated 3/7/25, document R1 has a physician order as follows: Apply emollient cream to R1's left thigh burn/scar tissue every night shift for wound healing. This same Report documents a physician order to apply emollient cream to R1's left thigh every eight hours as needed for wound healing. R1's current Care Plan documents, (R1) is at risk for impaired skin integrity due to impaired physical mobility. Interventions- Date Initiated 11/18/24: Staff to assist (R1) with meals due to spilling coffee. (R1) agreed, having staff assistance with meals would be beneficial. (R1) encouraged to refrain from eating and drinking hot liquids in room without staff assistance. Intervention- Date Initiated 2/4/25: Staff to ensure waterproof clothing protector and lap blanket to be worn during all meals and during as needed fluid and food intake. (R1) has a history of spilling food and liquid when attempting to eat meals per self. (R1) is at risk for ADL self-care performance deficit related to cerebral palsy as evidence by weakness, muscle wasting and atrophy, dysphagia, and right-hand contracture. Interventions- Date Initiated 12/16/22: Eating: (R1) requires extensive to total assistance times one staff with meals. Therapy encouraged use of smaller utensils for an effective grip while eating meals. Utilizes two handed cups for liquids. The facility's Food Temperature Log for Meal Service dated the week of 11/10/24 documents Coffee/hot water temps for breakfast, lunch, and supper. During this week the coffee/hot water temperature ranged from 171 degrees Fahrenheit to 177 degrees Fahrenheit. The facility's Food Temperature Log for Meal Service dated the week of 1/19/25 documents Coffee/Hot water temps for breakfast, lunch, and supper. During this week the coffee/hot water temperatures ranged from 170 degrees Fahrenheit to 176 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Many On 3/7/25 at 9:35 AM R1 was in her room in her wheelchair. R1 was leaning left in her wheelchair, with a contracted posture and her head contracted towards the left lying on a pillow. R1's left hand was observed to be in a closed fist position. R1's right hand was observed in a closed fist position with R1's fingers pointed inward towards her palm. R1 had a green two handled cup sitting in her lap. R1 grabbed the green cup with water with her right hand and used her pointer finger and thumb to hold on to the cup. R1 was shaky while holding the cup and the cup was leaning to the left as R1 was attempting to take a drink. R1 did not have on a waterproof clothing protector or lap blanket during this time as identified in R1's care plan. R1 stated, The first time I spilled my coffee I was in my room. It spilled all down the left side of me. The staff came in and noticed I had spilled my coffee. The second time I spilled my coffee I was in the dining room and a staff member (I don't know her name) handed me my coffee. I went to take a drink and dropped the entire cup. It ended up burning me in the same spot and that time it was more painful. Staff has never assisted me with drinking until just recently. On 3/7/25 at 10:10 AM V11/LPN (Licensed Practical Nurse) was preparing to apply R1's wound treatment to R1's left posterior thigh. R1's posterior left thigh area had approximate 20cm x 9cm, red/blanchable area. On 3/7/25 at 11:55 AM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. The coffee pot was observed to have three nozzles that dispensed hot water, decaffeinated coffee, and regular coffee. On 3/7/25 at 2:30 PM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. The dining room door across from the medical record office was observed propped open. The dining room door across from the Social Service Office was shut but was unlocked and was able to be opened. During this time V1/Administrator verified the door was propped open and the other door was unlocked and stated, The doors are supposed to be locked in between meals so no resident can enter. I do not know why the door is propped open and the other door was left unlocked. On 3/8/25 at 8:13 AM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. V3/Dietary Manager stated that all residents in house drink some sort of hot liquid like hot chocolate, hot tea, or coffee out of the automatic dispensing coffee pot. V3 then proceeded to calibrate a thermometer and then temped a cup of coffee after being poured directly from the automatic coffee dispenser in the main dining room. V3 temped the coffee at 163.2 degrees Fahrenheit. V5/CNA then came over to pour R1 a cup of coffee. Steam was rising from R1's cup of coffee. V3 temped R1's cup of coffee at 161 degrees Fahrenheit. On 3/7/25 at 1:15 PM V9/Wound Physician stated (R1's) burns that happened on the two different occurrences would be classified as second-degree burns. On 3/7/25 at 1:20 PM V16/Manufacturer Consultant stated, The automatic coffee pot dispenser setting is set at 185 degrees Fahrenheit for the hot water to brew the coffee. On 3/7/25 at 2:20 PM V3/Dietary Manager stated the hot water/coffee out of the coffee machine temperature ranges from 170 degrees Fahrenheit to 175 degrees Fahrenheit daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Many On 3/8/25 at 8:20 AM V2/Director of Nursing stated they (the facility) has not done any hot liquid risk assessments on R1 or any other resident prior to them drinking hot liquid on their own. On 3/8/25 at 8:35 AM V10/Vice President of Culinary Services stated The coffee pot the facility currently has must brew the coffee at 175 degrees Fahrenheit or above for coffee sanitary purposes. You and I both know that to have no burns at the facility the coffee should be served at 120 degrees or less. V10 verified the only way to keep the residents from being burned is take the automatic coffee machine out of the dining room and install it in the kitchen with a machine that keeps the coffee and the hot water at a lower temperature. On 3/8/25 at 8:43 AM V5/CNA stated, On 1-25-25 I took (R1) to the dining room and got (R1) a cup of coffee that had two handles and a lid and gave it to her. I did not assist (R1) with the coffee. Five to ten minutes after giving (R1) her coffee, I realized (R1) spilled the coffee onto her lap. (R1's) cup was lying all the way to the left. I thought (R1) was able to drink the coffee by herself. I did not know there was a [NAME] (Care plan) we could look at to see updates and I still don't know how to access a resident's [NAME]. I did not know (R1) needed assistance with drinking hot liquids or eating her meals. On 3/8/25 at 9:38 AM V15/CNA stated the doors to the dining room are shut most of the time to the dining room in between meals, but sometimes the door is propped, or the doors are unlocked so we can get in that way to get coffee or a drink for the residents. On 3/8/25 at 10:50 AM V1/Administrator stated (the facility's) managing company just sent a Policy for Hot liquids yesterday. V1 stated We (the facility) did not have a Hot Liquids Policy in place prior to yesterday (3/7/25) and should have to try and prevent burns in the facility. V1 also stated After the first time (R1) was burned we put an intervention in place to have staff assist (R1) while drinking and eating, especially with hot liquids. The second time (R1) was burned by the spilled coffee, (V5/CNA) was newer to our building and did not know (R1) required assistance with hot liquids. (V5) just handed (R1) a two handled cup of hot coffee with a lid and did not assist her. (R1) ended up spilling the coffee again on her left side, sustaining another burn to her left posterior thigh. The immediate jeopardy started on 11/14/24 when the facility failed to identify a hot water/coffee dispenser used in the main room as a potential burn hazard, and failed to establish protocols and provide adequate monitoring to ensure hot water within a water/coffee dispenser located in the main dining room were kept below temperature levels to prevent burns, resulting in R1 spilling hot coffee on herself and sustaining a second degree burn to her left posterior thigh. V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 3/10/25 at 11:40 AM. On 3/11/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/10/25 all residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury. 2. On 1/25/25 R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. On 1/25/25 a wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 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 - Immediate jeopardy to resident health or safety waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks. 3. On 3/8/25 a Hot Liquid Policy was developed and implemented. 4. On 3/8/25 a Hot Liquid Risk Assessment was developed and implemented. Residents Affected - Many 5. On 3/8/25 V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services on 3/8/25 for their respective employees. All employees of the facility have been in-serviced on these topics and policies. 6. On 3/8/25 all residents, including R1, were assed with the facility hot liquids assessment to determine if they are at risk of being injured 7. On 3/10/25 R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat. 8. On 3/8/25 the facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury. 9. On 3/8/25 all at risk residents for being injured due to hot liquids were identified on meal tray cards. 10. On 3/8/25 V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries. 11. On 3/8/25 the coffee machine in the main dining room was disconnected. 12. 3/10/25 the coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served. 13. On 3/8/25 a new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit. 14. On 3/10/25 waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid. 15. On 3/10/25 a Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less. 16. On 3/8/25 V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool we be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 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 145616 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Many for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services on 3/8/25 for their respective employees. All employees of the facility have been in-serviced on these topics and policies. 17. A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. On 3/10/25 V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week. 18. On 3/8/25 V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans. 19. On 3/10/25 V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids. 20. On 3/10/25 V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool we be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids. 21. On 3/10/25 a copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual. 22. A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week. Completion Date: 3/10/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145616 If continuation sheet Page 7 of 7