Health inspection·January 18, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide timely ADL (Activities of Daily Living) care for dependent residents for 3 of 8 residents (R1, R2, and R3) reviewed for ADL care in the sample of 8. Residents Affected - Few The findings include: 1. R2's Resident Face Sheet documents R2 was admitted to the facility on [DATE]. The same Resident Face Sheet documents some of R2's diagnoses as unspecified nondisplaced fracture of seventh cervical vertebra, unspecified fracture of first thoracic vertebra, Fracture of one rib, right side, chronic respiratory failure with hypercapnia, peripheral vascular disease, Insulin Dependent Diabetes Mellitus. R2's MDS (Minimum Data Set) dated 12/4/23 document in Section C that R2 has a BIMS (Brief Interview of Mental Status) of 14 which indicates R2 is cognitively intact. Section GG of the same MDS documents that R2 has impairment of both sides of upper and lower extremities, is dependent for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), is dependent for toilet transfer (ability to get on and off a toilet or commode). Section H of the same MDS documents that R2 is always incontinent of bowel and bladder. R2's care plan documents a problem area dated 12/11/23 of resident is incontinent of bowel and bladder and is not appropriate for B&B (bowel and bladder) program due to impaired cognitive status. Some of the approaches listed are provide incontinent care as needed, turn and reposition while in bed or chair for comfort and to reduce risk of impaired skin. The same care plan documents a problem area of resident is at risk for skin breakdown or pressure ulcers related to decreased mobility. Some approaches listed are keep linen clean and dry as possible and change when I need it, keep skin clean and dry as possible, provide incontinence care for episodes of incontinence prn (as needed). On 1/16/24 at approximately 11:15am, observations were made of R2's incontinence pad from her right side. There were 2 incontinence pads, a top sheet folded to serve as a turn sheet and a fitted sheet on the bed. The pads and the sheets were soaking wet with urine including R2's gown. There was brown around the edges of the urine on both pads and the sheet. There was also a strong urine odor. On 1/16/24 at approximately 11:15am, V5 (CNA) did not answer when asked if the urine on the incontinence pads and sheets appeared as if it had been there a while due to the brown edges. V2 (DON/Director of Nurses) also came in the room to assist with changing R2 and also did not answer, but shook her head no. V5 said he had been in R2's room around 9:30am but did not change her. R2 said she is not sure and really does not know the last time staff changed her under pads. Page 1 of 8 145685 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/16/24 at 1:35pm, R2 said that staff change her quite often and change her during the night if she is awake. 2. R3's Resident Face Sheet documents that R3 was admitted to the facility on [DATE]. The same Face Sheet documents that some of R3's diagnoses are unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, other lymphoid leukemia not having achieved remission, Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right foot with necrosis of muscle-right bottom of foot, non-pressure chronic ulcer of other part of right foot with unspecified severity-right second toe, laceration without foreign body of right buttock. R3's MDS dated [DATE], Section C, documents that R3 has a BIMS of 00 which indicates severe cognitive impairment. The same MDS documents that R3 has impairment on both sides of upper and lower extremities. Section GG of the same MDS documents that R3 is dependent for oral hygiene, toileting hygiene and eating, roll from left and right, and toilet transfers. Section H of the same MDS documents that R3 is always incontinent of bowel and bladder. R3's Physician order report dated 12/1/23-12/31/23 documents that R3 was admitted to a local hospice on 8/24/23. The same physician order report documents an order dated 11/1/23 to wear heel protectors, every shift; day shift Nurse 6:00am, 6:00pm night shift nurse. R3's care plan documents a problem area dated 2/15/23 of resident is at risk for impaired skin integrity r/t (related to) incontinent of B&B (bowel and bladder) and decreased mobility. Some of the interventions listed are: wear heel protectors every shift, provide incontinence care for episodes of incontinence. The same care plan documents a problem area of resident is incontinent of bowel and bladder and is not appropriate for B&B program due to impaired cognitive status. Some listed interventions are to provide incontinent care as needed, turn and reposition while in bed or chair for comfort and to reduce risk of skin impairment. On 1/16/24 at 10:40am, R3 was observed lying in her bed on her left side. R3 was not wearing heel protectors. R3's incontinence pad was soaked with urine that had a brown ring around the edges. R3's eyes were matted with dry, crusty, gold colored matter. R3's lips were observed to be very dry with dried brownish gray colored matter on her lips. R3's tongue was very dry in appearance. R3's breakfast tray was sitting on her dresser by her bed and none of the food/drinks had the covers taken off of them and appeared untouched. R3 was lying there with her eyes closed and did not wake up when attempting to talk to her. On 1/16/24 at 10:40am, V2 (DON/Director of Nurses) said the urine on R3's pad did appear to be fresh. V2 did not answer when asked about the brown ring around the outer edges of the urine on the pad. V2 also did not answer when asked if R3 had been receiving mouth care when shown the brown matter on her lips and dryness. V2 said it was her expectation that residents be checked every 2 hours. When shown R3's breakfast tray that was untouched on R3's dresser, V2 said that sometimes R3 will get up and eat and sometimes she won't. On 1/16/24 at 10:40am, V3 (CNA/Certified Nurse Assistant) said she had not gotten to R3 that morning and she had not changed her since she had been on shift. V3 said she came on shift at 7am. V3 said the girls on night shift had changed her last. V3 said they had gotten busy taking residents to breakfast and then toileting them after and she just had not gotten to her. V3 said the urine on R3's incontinence pads did not appear fresh. V3 said that she did try and feed R3 that morning but R3 145685 Page 2 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0677 Level of Harm - Minimal harm or potential for actual harm would not eat and did not want to wake up to eat. V3 also said she did not know why R3's heel protectors were not on. On 1/16/24 at 10:45am, V4 (CNA) said that R3 did not want to wake up for breakfast and she would not eat. V4 also said the urine on R3's pad did not appear to be fresh. Residents Affected - Few 3. R1's Resident Face Sheet documents that R1 was admitted to facility on 12/6/23 and discharged on 1/8/24 with a status of expired. R1's Face Sheet documents diagnoses including acute respiratory disease, adult failure to thrive, acute cholecystitis, nausea with vomiting, chronic kidney disease, stage 2, chronic atrial fibrillation, muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, other lack of coordination, unsteadiness on feet, muscle wasting and atrophy, and acute kidney failure. R1's January 2024 Physician's Order Report documents orders dated 1/3/24 to admit R1 to hospice and turn and reposition every 2 hours. R1's hospice consultation note from R1's hospital records date 1/3/24 documents that R1 was admitted to hospice care on 1/3/24 with a terminal diagnosis of COVID 19. The same note documents that R1 is incontinent of bowel and bladder and is unresponsive except to pain. On 1/16/24 at 8:30am, V12 (family member) said that several times during the week of 1/1/24 to 1/8/24 they found R1 in a urine-soaked bed. V12 said the urine on the pad had brown rings around the edges each time. V12 said that R1's heels were never floated off the bed. On 1/17/24 at 11:31am, V9 (hospice nurse) said she sees R3 and did see R1 regularly. V9 said she believes that on 1/7/24, R1 was lying in bed and the incontinence pad had urine with brown around the edges when she arrived. V9 also said that R3 had also been found with incontinence pad with brown edges around the urine. V9 said that staff had not been cleaning R3's eyes and she thinks she ordered baby shampoo washes for R3's eyes to keep them from matting. V9 also said that mouth care should have been done also on R3. On 1/17/24 at 12:45pm, V8 (ADON/Assistant Director of Nursing) said she would not expect any resident to be left in urine and have dark brown edges around the edges on their clothes or incontinence pads. V8 said she would expect a resident to be checked and changed, if necessary, every 2 hours. On 1/17/24 at 2:00pm, V1 (Administrator) said it is her expectation that residents be checked at least every 2 hours and changed if they are wet and that it can be different for each resident. A facility policy titled Toileting with a revision date of July 2014, documents that it is the policy of the facility to ensure all of our resident's toileting needs are met. Check each resident every two hours and change if found incontinent. 145685 Page 3 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide sufficient staffing levels to provide care by considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This has the potential to affect all 73 residents residing in the facility. The findings include: R2's Resident Face Sheet documents R2 was admitted to the facility on [DATE]. The same Resident Face Sheet documents some of R2's diagnoses as unspecified nondisplaced fracture of seventh cervical vertebra, unspecified fracture of first thoracic vertebra, Fracture of one rib, right side, chronic respiratory failure with hypercapnia, peripheral vascular disease, Insulin Dependent Diabetes Mellitus. R2's MDS (Minimum Data Set) dated 12/4/23 document in Section C that R2 has a BIMS (Brief Interview of Mental Status) of 14 which indicates R2 is cognitively intact. Section GG of the same MDS documents that R2 has impairment of both sides of upper and lower extremities, is dependent for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), is dependent for toilet transfer (ability to get on and off a toilet or commode). Section H of the same MDS documents that R2 is always incontinent of bowel and bladder. R2's care plan documents a problem area dated 12/11/23 of resident is incontinent of bowel and bladder and is not appropriate for B&B (bowel and bladder) program due to impaired cognitive status. Some of the approaches listed are provide incontinent care as needed, turn and reposition while in bed or chair for comfort and to reduce risk of impaired skin. The same care plan documents a problem area of resident is at risk for skin breakdown or pressure ulcers related to decreased mobility. Some approaches listed are keep linen clean and dry as possible and change when I need it, keep skin clean and dry as possible, provide incontinence care for episodes of incontinence prn (as needed). On 1/16/24 at approximately 11:15am, observations were made of R2's incontinence pad from her right side. There were 2 incontinence pads, a top sheet folded to serve as a turn sheet and a fitted sheet on the bed. The pads and the sheets were soaking wet with urine including R2's gown. There was brown around the edges of the urine on both pads and the sheet. There was also a strong urine odor. On 1/16/24 at approximately 11:15am, V5 (CNA) did not answer when asked if the urine on the incontinence pads and sheets appeared as if it had been there a while due to the brown edges. V2 (DON/Director of Nurses) also came in the room to assist with changing R2 and also did not answer, but shook her head no. V5 said he had been in R2's room around 9:30am, but did not change her. R2 said she is not sure and really does not know the last time staff changed her under pads. On 1/16/24 at 1:35pm, R2 said that staff change her quite often and change her during the night if she is awake. R3's Resident Face Sheet documents that R3 was admitted to the facility on [DATE]. The same Face Sheet documents that some of R3's diagnoses are unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, other lymphoid leukemia not having 145685 Page 4 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many achieved remission, Type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right foot with necrosis of muscle-right bottom of foot, non-pressure chronic ulcer of other part of right foot with unspecified severity-right second toe, laceration without foreign body of right buttock. R3's MDS dated [DATE], Section C, documents that R3 has a BIMS of 00 which indicates severe cognitive impairment. The same MDS documents that R3 has impairment on both sides of upper and lower extremities. Section GG of the same MDS documents that R3 is dependent for oral hygiene, toileting hygiene and eating, roll from left and right, and toilet transfers. Section H of the same MDS documents that R3 is always incontinent of bowel and bladder. R3's Physician order report dated 12/1/23-12/31/23 documents that R3 was admitted to a local hospice on 8/24/23. The same physician order report documents an order dated 11/1/23 to wear heel protectors, every shift; day shift Nurse 6:00am, 6:00pm night shift nurse. R3's care plan documents a problem area dated 2/15/23 of resident is at risk for impaired skin integrity r/t (related to) incontinent of B&B (bowel and bladder) and decreased mobility. Some of the interventions listed are: wear heel protectors every shift, provide incontinence care for episodes of incontinence. The same care plan documents a problem area of resident is incontinent of bowel and bladder and is not appropriate for B&B program due to impaired cognitive status. Some listed interventions are to provide incontinent care as needed, turn and reposition while in bed or chair for comfort and to reduce risk of skin impairment. On 1/16/24 at 10:40am, R3 was observed lying in her bed on her left side. R3 was not wearing heel protectors. R3's incontinence pad was soaked with urine that had a brown ring around the edges. R3's eyes were matted with dry, crusty, gold colored matter. R3's lips were observed to be very dry with dried brownish gray colored matter on her lips. R3's tongue was very dry in appearance. R3's breakfast tray was sitting on her dresser by her bed and none of the food/drinks had the covers taken off of them and appeared untouched. R3 was lying there with her eyes closed and did not wake up when attempting to talk to her. On 1/16/24 at 10:40am, V2 (DON/Director of Nurses) said the urine on R3's pad did appear to be fresh. V2 did not answer when asked about the brown ring around the outer edges of the urine on the pad. V2 also did not answer when asked if R3 had been receiving mouth care when shown the brown matter on her lips and dryness. V2 said it was her expectation that residents be checked every 2 hours. When shown R3's breakfast tray that was untouched on R3's dresser, V2 said that sometimes R3 will get up and eat and sometimes she won't. On 1/16/24 at 10:40am, V3 (CNA/Certified Nurse Assistant) said she had not gotten to R3 that morning and she had not changed her since she had been on shift. V3 said she came on shift at 7am. V3 said the girls on night shift had changed her last. V3 said they had gotten busy taking residents to breakfast and then toileting them after and she just had not gotten to her. V3 said the urine on R3's incontinence pads did not appear fresh. V3 said that she did try and feed R3 that morning but R3 would not eat and did not want to wake up to eat. V3 also said she did not know why R3's heel protectors were not on. On 1/16/24 at 10:45am, V4 (CNA) said that R3 did not want to wake up for breakfast and she would not eat. V4 also said the urine on R3's pad did not appear to be fresh. 145685 Page 5 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many R1's Resident Face Sheet documents that R1 was admitted to facility on 12/6/23 and discharged on 1/8/24 with a status of expired. R1's Face Sheet documents diagnoses including acute respiratory disease, adult failure to thrive, acute cholecystitis, nausea with vomiting, chronic kidney disease, stage 2, chronic atrial fibrillation, muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, other lack of coordination, unsteadiness on feet, muscle wasting and atrophy, and acute kidney failure. R1's January 2024 Physician's Order Report documents orders dated 1/3/24 to admit R1 to hospice and turn and reposition every 2 hours. R1's hospice consultation note from R1's hospital records date 1/3/24 documents that R1 was admitted to hospice care on 1/3/24 with a terminal diagnosis of COVID 19. The same note documents that R1 is incontinent of bowel and bladder and is unresponsive except to pain. On 1/16/24 at 8:30am, V12 (family member) said that several times during the week of 1/1/24 to 1/8/24 they found R1 in a urine-soaked bed. V12 said the urine on the pad had brown rings around the edges each time. V12 said that R1's heels were never floated off the bed. On 1/17/24 at 11:31am, V9 (hospice nurse) said she sees R3 and did see R1 regularly. V9 said she believes that on 1/7/24, R1 was lying in bed and the incontinence pad had urine with brown around the edges when she arrived. V9 also said that R3 had also been found with incontinence pad with brown edges around the urine. V9 said that staff had not been cleaning R3's eyes and she thinks she ordered baby shampoo washes for R3's eyes to keep them from matting. V9 also said that mouth care should have been done also on R3. On 1/17/24 at 1:30pm, V3 said she does not feel they have enough staffing. V3 said it is very hard to get everything done with 2 staff on her hall (the 100 hall). On 1/16/24 at 1:15pm, V10 (family member) said he comes to the facility every day around 5:40am. V10 said that R8 is usually already dressed when he arrives. V10 says he does his R8's laundry and has seen where staff have hung her pants over her walker due to being soaking wet. V10 said a while back, R8 told him she pushed her call light and staff came in and told her it wasn't time to get up and left the room. V10 said that R8 was soaked from head to toe. V10 said he feels they do not have enough staff. On 1/16/24 at 8:30am, V12 (family member) said that several times during the week of 1/1/24 to 1/8/24 they found R1 in a urine-soaked bed. V12 said the urine on the pad had brown rings around the edges each time. V12 said that R1's heels were never floated off the bed. A document titled Facility Assessment Tool documents Date(s) of assessment or update of 12/27/23, with a review date of 11/2022 to 10/2023, documents in Section 3.2 Staffing Plan that the total number needed or average or range of Nurse's Aide hours are 1.72-1.92 PPD (per patient day). A handwritten document with no label provided by V1 documents the number of skilled and intermediate residents in the facility and the number of hours of Certified Nurse's scheduled for the dates of 12/7/23 through 1/16/24. On 1/18/24 at 10:37am, V1 confirmed that the numbers listed on the document next to the date were the number of residents receiving skilled and intermediate care and the addition of the two numbers would be the total census for that day. V1 also confirmed that the Nurse's Aide hours scheduled should be divided by the total census for that day to calculate the PPD. The 145685 Page 6 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0725 following dates are documented and do not meet the required hours of 1.72-1.92 PPD as documented on the Facility Assessment Tool: Level of Harm - Minimal harm or potential for actual harm 12/7/23 total census (16 + 55) 71, 113.82 total Nurse's Aide hours, 113.82 divided by 71=1.6 hours PPD Residents Affected - Many 12/24/23 total census (12 + 56) 68, 113.76 total Nurse's Aide hours, 113.76 divided by 68=1.67 hours PPD 12/25/23 total census (13+ 55) 68, 115.38 total Nurse's Aide hours, 115.38 divided by 68=1.7 hours PPD 12/28/23 total census (15 + 56) 71, 119.28 total Nurse's Aide hours, 119.28 divided by 71=1.68 hours PPD 1/2/24 total census (14 + 59) 73, hours 122.31 total Nurse's Aide hours, 122.31 divided by 73=1.68 hours PPD 1/3/24 total census (18 + 60) 78, hours 128.50 total Nurse's Aide hours, 128.50 divided by 78=1.65 hours PPD 1/4/24 total census (19 + 61) 80, hours 114.50 total Nurse's Aide hours, 114.50 divided by 80=1.43 hours PPD 1/7/24 total census (19 + 59) 78, hours 120.87 total Nurse's Aide hours, 120.87 divided by 78=1.55 hours PPD 1/8/24 total census (18 + 56) 74, hours 124.91 total Nurse's Aide hours, 124.91 divided by 74=1.69 hours PPD 1/11/24 total census (22 + 55) 77, hours 123.24 total Nurse's Aide hours, 123.24 divided by 77=1.60 hours PPD The facilities working schedules from 11/19/23 through 1/16/24 were reviewed and compared to the Nurse's Aide hours provided by V1. The Resident Council Meeting Minutes dated 12/27/23 documents under Old Business that Residents state the call lights on 100 hall is still an issue with long wait times. Under Nursing it documents Wait times for call lights are still an issue on all shifts. The Resident Council Meeting Minutes dated 11/22/23 documents under Nursing that wait times for call lights are still an issue on all shifts. The Resident Council Meeting Minutes dated 10/25/23 documents under Nursing that 100-200 call lights still an issue with waits but has gotten better. The Resident Council Memorandum dated 10/26/23 documents under Issue that Residents stated call lights (on) 100 and 200 hall all shifts long waits. Has gotten a little better but still wait a long while. Under Response it documents customer service in-service training scheduled. The Resident Council Memorandum dated 10/11/23 documents under Issue that residents stated on 200 hall they are waiting too long with call lights on. This is happening on first and second shift. Under response it documents that rotated staff halls for fresh eyes, verbal counseling during walking rounds to answer call lights timely. Nurses counseled to assist as needed to answer call lights. There were no observations of delayed call light response times made during 145685 Page 7 of 8 145685 01/18/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0725 the survey. Level of Harm - Minimal harm or potential for actual harm On 1/16/24 at 9:45am, V1 said they have 73 residents currently residing in the facility. Residents Affected - Many 145685 Page 8 of 8