Health inspection·February 6, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assaulting R2. V8 said the two were separated and taken to the nurse's station for assessment. V8 said she began neuro checks on R2, applied ice to his swollen left eye and sent him to the local emergency room for evaluation. A progress note in R2's EHR (Electronic Health Record) entered by V8 (LPN) and dated 1/15/2024 at 3:43am documented the following in part: CNA hollered down the hall for help. This nurse responded to room and CNA alerted that (R3) had physically hit (R2) with closed fist. Wounds noted superficial laceration to right side of head, skin tears to right arm, left eye swollen, bruised, and (left eye) busted vessel. Resident complaining of jaw pain r/t (related to) roommate physically hitting resident. R2's after visit emergency room visit summary, dated 1/15/2024, documented R2 was evaluated and diagnosed with trauma, chest pain, contusion of periorbital region, contusion of face and acute cystitis without hematuria. On 1/16/2024, R2 was seen by V10 (Nurse Practitioner/NP) for a post emergency room visit follow up. V10's visit note documented (R2) was evaluated at the emergency room on 1/15/2024 after being assaulted by his roommate at the nursing home. He complains of pain everywhere, was diagnosed with periorbital contusion of left eye and discharged back to the nursing home. A facility document titled Behavior and Mood Event--Aggressive/Combative Behavior, dated 1/15/2024 and entered by V8 (LPN) documented the following under event details: Altercation between resident (R3) and peer (R2), Physical aggression towards roommate (R2). Hit roommate (R2) with closed fist. Verbally aggressive. Roommate (R2) c/o (complains of) jaw pain and has superficial laceration to R (right) side of head. Bruising, swelling and broken blood vessel on L (left) eye. R (right) arm skin tears. On 1/31/2024 at 12:40pm, R2 said he heard he was in a fight, but did not remember it. At 1:33pm, V16 (Family) said he tried to talk to R2 about being hit by his roommate (R3), but R2 doesn't remember what happened. The facility's investigation file for R2 and R3 peer to peer which occurred on 1/15/2024 contained a hand written statement from V9 (CNA) which documented the following: At approximately 2:30am, I was doing bed check on 200 hall. I was coming out of a resident room and noticed R3 standing over R2 pounding him in his face and upper body area. I yelled down the hall for help and then proceeded in the room to diffuse the situation. R2 had his arms and hands raised trying to protect himself telling R3 to stop that was enough. A document in this same file titled Resident to Resident Agression Final and dated 1/22/2024 documented the following in part: On 1/15/2024 at aproximately 2:30pm, (V9/CNA) was performing her rounds. When exiting a room she noticed (R3) standing over (R2) and extending his arms in a swatting motion. (V9/CNA) called for help. (V9/CNA) was able to separate the two and R3 was unable to explain his actions. The facility's Abuse Prevention Program defines Abuse in part as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 1/31/2024 at 9:30am, V1 (Administrator) said she agreed that the facility's Abuse Prevention Program defines abuse as the willful infliction of injury. V1 agreed that physical assault of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 2 of 6 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 145685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864 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 0600 resident in the nursing home is abuse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 3 of 6 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 145685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864 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 Residents Affected - Few Based on interview and record review the facility failed to ensure residents who are transferred with a patient whole body lift machine are transferred safely and in accordance with the facility's lift machine policy for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling while being transferred with the patient lift machine and sustaining moderate to large volume left scalp hematoma, acute minimally displaced fracture of C7 vertebral body, acute mildly displaced fracture of T1 vertebral body, and non-displaced fracture of the right posterior first rib. This past non-compliance occurred from 12/16/2023 to 12/18/2023. Findings include: R1's EHR (Electronic Health Record) documents an admission to this facility on 12/8/2021 with diagnoses of Chronic Respiratory Failure, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Venous Hypertension, Lymphedema, Morbid Obesity, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hearing Loss among others. R1's MDS (Minimum Data Set) dated 12/4/2023 under section GG (Functional Abilities and Goals) documented R1 is dependent on staff for showers, shower transfers, dressing lower body, personal hygiene, toilet transferring and toilet hygiene, and chair/bed-to-chair transfers. This same MDS under section C (Cognitive Patterns) documented R1's mental function was assessed with the BIMS (Brief Interview for Mental Status) in which R1 scored 14 out of 15 total. A BIMS score of 14 out of 15 indicates R1 is cognitively intact. On 1/31/2024 at 9:30am, V1 (Administrator) said on 12/16/2023 at 1:00pm, she was notified of R1 falling from the mechanical lift machine while being transferred from her wheelchair to her bed and was sent to the emergency room to be evaluated for injuries. V1 said she and V2 (Director of Nursing) immediately came to the facility and began investigating R1's fall. V1 said while at the emergency room, R1 was diagnosed with scalp hematoma, neck sprain and bruised left shoulder/chest and sent back to the nursing home. V1 said while investigating, she determined V5 (Certified Nursing Assistant/CNA) had transferred R1 with the whole body mechanical lift by herself and not in accordance with the facility's policy. V1 said two staff must be present when transferring a resident with the mechanical lift. V1 said on 12/16/2023, she and V2 retrained all nursing staff and inspected all lift slings and lift machines. V1 said after V5 was retrained and disciplined for her actions. V1 said a few days later, R1 continued to have pain and was sent back to the emergency room for further evaluation where it was determined R1 had fractured a rib and two vertebrae. On 1/30/2024 at 3:30pm, V5 (Certified Nursing Assistant/CNA) said she and V6 (CNA) were the assigned CNA's working on the 200 hall on 12/16/2023. V5 said right after the residents finished their noon meal, she began assisting residents to the toilet while V6 went on her 30 minute lunch break. V5 said she noticed R1 was really wet and wanted to get out of her wheelchair and lay down. V5 said R1 does not stand and is transferred using a whole body mechanical lift machine. V5 said it's the facility's policy for two staff to be present when using the lift machine to transfer patients. V5 said she decided to go against policy and transfer R1 with the mechanical lift without a second staff member present. V5 said they were not short of staff that day and she could have asked for another staff to come assist her, but she didn't. V5 said she hooked all four of the corner lift straps to the lift machine and lifted R1 up into the air about shoulder level. V5 said suddenly one of the lift straps slipped off and R1 flipped out of the lift sling and fell to the floor. R1 said she yelled for help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 4 of 6 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 145685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864 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 and the nurses came to help R1. V5 said she was re-trained on whole body mechanical lift machine policy and procedure and given discipline. Level of Harm - Actual harm Residents Affected - Few On 1/30/2024 at 12:15pm, R1 said she can't walk or stand and must be transferred with a whole body mechanical lift machine to move her body from one place to another. R1 said the staff place a mechanical lift sling underneath her body and hook the four corner straps of the sling to the lift machine. The staff uses the mechanical lift machine to raise and lower her into and out of her bed or into and out of her wheelchair. R1 said on 12/16/2023 after she ate lunch, she was wet, needed changed and wanted to lay down in her bed for a rest period. R1 said V5 (Certified Nursing Assistant/CNA) took her to her room to provide her care and put her to bed. R1 said V5 hooked R1's mechanical lift sling to the mechanical lift machine and began to lift R1 out of her wheelchair. R1 said next thing she knew, one of the corner straps of the mechanical lift sling came off causing her to flip over and fall out of the lift sling. R1 said she hit her head on the floor when she fell and had pain all over her body. R1 said she was sent to the emergency room and was diagnosed with a big knot on her head and a sprained neck, but that was wrong. R1 said a few days after her fall, she still had severe pain and was sent back to the emergency room and was diagnosed with a two fractured vertebrae and a broken rib. R1 said she spent a few days in the local hospital and now must wear a neck brace and back brace for them to heal. Hospital admission records dated 12/20/2023 document R1 was admitted due to injuries sustained from a fall from a patient lift machine on 12/16/2023 while a the nursing home. These same records document on 12/20/2023, R1 was given CT (Computed Tomography) Scans of the head, neck and spine. The results of the CT Scans documented R1's injuries from her fall as: moderate to large volume left scalp hematoma, acute minimally displaced fracture of C7 vertebral body, acute mildly displaced fracture of T1 vertebral body and non-displaced fracture of the right posterior first rib. R1's fall event and fall investigation report dated 12/16/2023 under the section titled Conclusion with root cause documented: Mechanical lift was in use with resident in mid-air with 1 strap not attached to arm of (mechanical lift). All CNA staff educated on policy of the facility of hoyer lift usage. This same report under section titled Additional Information documented: Upon investigation, resident was put in mechanical lift by one CNA and then was in mid transfer from wheelchair to bed when hoyer sling was not hooked properly and caused resident to fall out of (lift sling). Hematoma noted to back of head. Sent to ER (Emergency Room) for further evaluation and treatment. Head and Spine CT clear and returned to facility. Staff in-serviced on mechanical lift policy. All hoyer pads checked for no frayed or ripped areas. IDT (Interdisciplinary Team) met and reviewed investigation, continue current interventions. On 12/19/2023, resident returned to (local emergency room) for altered mental status. Radiology impressions report acute fracture of right rib, C7, and T1. IDT met and reviewed current interventions, continue current and CNA's checked off on mechanical lift transfers. A facility policy titled Mechanical Lift with a revision date of September 8, 2023 documented in part: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety for residents and nursing personnel, The mechanical lift must be able to accommodate the weight of the resident and two staff members are required when transferring a resident with a mechanical lift. On 2/6/2024 at 11:00am, V18 (Maintenance Director) verified he had performed inspections on both of the facility's mechanical lift machines on 12/18/2023 and again on 1/17/2024. V18 said the next check will be performed on 2/16/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 5 of 6 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 145685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864 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 On 2/6/2024 at 11:30pm, V19 (Laundry Aide) said the laundry staff inspect each mechanical lift sling every week and document the finding of the inspection. Level of Harm - Actual harm Residents Affected - Few On 1/31/24, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: A meeting was held on 12/16/2023 in which V1 (Administrator) and V2 (Director of Nursing) were in attendance and identified an Opportunity for Improvement/Deficient Practice: 1.) Immediate Corrective Actions for those affected by the deficient practice: Sent to ER (Emergency Room) related to fall. Returned with hematoma to scalp and a sprained neck. 2.) Process/Steps to Identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. 3.) Measures put into place/systematic changes to ensure the deficient practice does not recur: Education provided to all nurses and Certified Nursing Assistants on the policy and procedures for using a mechanical lift, completed on 12/16/2023. All mechanical lifts slings inspected, completed on 12/16/2023. Maintenance inspected mechanical lifts, completed on 12/18/2023. 4.) Plan to monitor performance to ensure solutions are sustained: Audit to use of mechanical lifts by observing staff twice a week for 60 days, Laundry to perform inspection of mechanical lift slings, Maintenance to perform monthly Mechanical Lift Inspections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 6 of 6