Health inspection·March 1, 2024

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure quarterly assessments were completed timely for 4 of 4 (R5, R32, R38 and R43) residents reviewed for quarterly assessments in a sample of 60. Residents Affected - Some The Findings Include: 1. R32's face sheet documents an admission date of 9/20/18 and includes the following diagnosis: unspecified dementia, protein calorie malnutrition, and contracture. On 2/28/24 2:03 PM, V8 (Medicare Coordinator) stated that R32's quarterly MDS had a target due date of 1/10/24 and transmitted and accepted on 2/28/24. A final validation report provided by V1 documents that R30's annual MDS had a target/due date of 1/10/24. This document had a warning message 'record submitted late'. 2. R5's face sheet documents an admit date of 7/12/23 and includes the following diagnosis: muscle weakness, repeated falls, lack of coordination and hypertension. On 2/28/24 2:03 PM, V8 stated that R5's quarterly MDS had a target due date of 1/24/24 and a discharge MDS due on 2/1/24 that have not been completed or transmitted yet. A final validation report provided by V1 documents that R5's annual MDS had a target/due date of 1/24/24. This document had a warning message 'record submitted late'. 3. R38's face sheet documents an admit date of 9/12/19 and includes the following diagnosis: unspecified dementia and cognitive communication deficit. On 2/28/24 2:03 PM, V8 stated that R38's quarterly MDS had a target due date of 1/16/24 and transmitted and accepted on 2/28/23. A final validation report provided by V1 documents that R30's annual MDS had a target/due date of 1/16/24. This document had a warning message 'record submitted late'. 4. R43's face sheet documents an admission date of 10/19/21 and includes the following diagnosis: cognitive communication deficit, diabetes mellitus type 2, and muscle weakness. On 2/28/24 2:03 PM, V8 (Medicare Coordinator) stated that R43's quarterly MDS (Minimum Data Set) had a target due date of 1/17/24 transmitted and accepted on 2/28/24. A final validation report provided by V1 (Administrator) documents that R43's quarterly MDS (Minimum Data Set) had a target/due date of 1/17/24. This document had a warning message 'record submitted late'. On 2/28/24 2:03 PM, V8 stated that they have recently had an employee resign that worked in the MDS office and she has taken over all the MDS assessments and has a calendar of due dates. V8 stated at this time that the above MDS's were submitted today, past the due date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 2 of 10 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 03/01/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a PASARR (Preadmission Screening and Resident Review) Level II Screening for 4 (R73, R45, R20, R50) of 4 residents reviewed for PASARR Screening in the sample of 60. Residents Affected - Some Findings Include: 1. R20's Face Sheet documented an initial admission date to the facility as 1/31/24. Diagnoses listed on this form included but were not limited to: Major Depressive Disorder and Bipolar Disorder. R20's Notice of PASRR Level I Screen Outcome dated 1/31/24 documented No Level II Required - No SMI (Serious Mental Illness) . 2. R45's Face Sheet documented an initial admission date to the facility as 5/19/23. Diagnoses listed on this form included but were not limited to: Major Depressive Disorder, Delusional Disorder, Anxiety Disorder, Post-Traumatic Stress Disorder, Auditory Hallucinations . R45's Notice of PASRR Level I Screen Outcome dated 5/19/23 documented No Level II Required - No SMI . 3. R73's Face Sheet documented an initial admission date to the facility as 12/30/23. Diagnoses listed on this form included but were not limited to: Other bipolar disorder, Major Depressive Disorder . R73's Notice of PASRR Level I Screen Outcome dated 12/28/23 documented No Level II Required - No SMI . 4. R50's Face Sheet documented an initial admission date to the facility as 1/4/24. Diagnoses listed on this form included but were not limited to: Bipolar Disorder . R50's Notice of PASRR Level I Screen Outcome dated 1/3/24 documented No Level II Required - No SMI . On 3/1/24 at 11:14 AM, V1 (Administrator) acknowledged the error in the PASARR screenings and that R73, R45, R20, and R50 have all been referred to have the level II completed. V1 stated that the facility is conducting an audit to ensure no other residents are also eligible to have a level II screening. Resident Assessment - Coordination with PASARR Program dated 10/2017, documented This facility coordinates with the preadmission screening and resident review (PASARR) program to ensure that residents are appropriately placed in nursing homes for Long-Term Care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 3 of 10 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 03/01/2024 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based interview and record review the facility failed to ensure the Activity Director had the appropriate qualification to conduct the activity program of the facility. This has the potential to affect all 87 residents living in the facility. Residents Affected - Many Findings include: On 2/28/2024 at 9:25 AM, V4 (Activity Director) stated that she has been in the role as Activity Director for 10 months and is not certified at this time. V4's Activity Director's personnel file, revealed a hire date of 2/28/2023 as the Activity Director. There was no evidence in the personnel file to show that V4 was qualified to be the Activity Director. On 2/29/2024 at 2:20 PM, V1 (Administrator) confirmed that V4 does not have Certification in Activities. V1 acknowledged that the Activity Director should be certified or enrolled in the certification classes. V1 stated that V4 is currently signed up for the on-line certification classes as of 2/28/2024. An email provided by V1 dated 2/28/24 documents that V4 was now registered for the Outcome Services (OSI) of Illinois Activity Director Correspondence Course, attached was a copy of the registration form and course description. The Facility's Activity Director Job Description documents in part .Education and experience requirements . The activity director must have the following: Activities Certification preferred; must be eligible and willing to become certified in Illinois if not. The Long Term Care Facility Application for Medicare and Medicaid (CMS Form 671) signed and dated 2/27/24, documents 87 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 4 of 10 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 03/01/2024 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to provide timely physician notification of symptoms of a urinary infection and timely collection of specimens for 1 (R22) of 1 resident reviewed for Urinary Tract Infections in the sample of 60. This failure resulted in R22 experiencing untimely treatment of a Urinary Tract Infections with symptoms of pain and burning expressed by R22 beginning on 2/15/24, with antibiotic treatment not initiated until 2/28/24. Findings Include: R22's face sheet documents an admission date of 12/29/17 to the facility and includes the following diagnoses: major depressive disorder, need for assistance with personal care, and disorder of kidney and ureter. R22's most recent completed MDS (Minimum Data Set) dated 11/7/23 Section C documents a BIMS (Brief Interview of Mental Status) score of 15, indicating that R22 is cognitively intact. Section GG for toileting hygiene, shower/bathe self and personal hygiene are coded as needing substantial/maximal assist. In this same Section GG is coded as being dependent for toilet transfers. On 2/27/24 at 9:00 AM, R22 stated that she has been hurting when she urinates for weeks, and she doesn't understand why they are taking so long to get her medication. R22 stated that they have had to collect two or three samples of her urine in the meantime, and she doesn't know if they are losing it or what but would like this urinary tract infection taken care of. R22 states that she gets infections kind of regularly. R22's progress note entry on 2/15/24 at 6:12 PM, documents that R22 c/o (complained of) pain, burning upon urination and a message was sent to V13 (Nurse Practitioner) and awaiting return orders. The progress note further documents that the POA (Power of Attorney) was aware of c/o (complaints of) and was ok with whatever V13 orders. A progress note dated 2/22/24 documents (R22) c/o pain /discomfort when urinating. Urine obtained for UA (urinalysis) C & S (culture and sensitivity). A Progress note dated 2/27/24 made by V15 (Licensed Practical Nurse)(LPN) documents Received new order to start resident on ceftriaxone 1 gm (gram) daily x 5 days r/t (related to) UTI (Urinary Tract Infection). Resident and POA made aware of new order. A progress note dated 2/28/24 made by V16 (Registered Nurse) documents First dose of ceftriaxone was administered to rt (right) buttock, resident tolerated well. Ceftriaxone was diluted in 2.1 mL (milliliters) of lidocaine per pharmacy direction. (Local Hospital) lab was contacted several times to send over UA results, UA results were never sent x3. On 2/29/24 at 3:00 PM, V2 (Director of Nursing) stated that the initial urine sample was not labeled properly so it had to be redrawn. When they got the culture back, they waited for the sensitivity prior to notify the doctor to get an antibiotic ordered. V2 confirmed at this time no broad spectrum antibiotic was started while waiting for the sensitivity to come back. R22's current physician order sheet for March 2024 has an order with a start date of 2/29/24 for Ceftriaxone 1 gram injection with an end date of 3/4/24. On 3/1/24 at 9:15 AM, V2 stated that R22 had no complaints when V13 (Nurse Practitioner) rounded on her on 2/15/24. R22 must have became symptomatic after seeing V13. The order was obtained on 2/18/24 to collect the urine for a urinalysis and was sent off on 2/19/24. It was determined on 2/19/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 5 of 10 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 03/01/2024 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 0690 Level of Harm - Actual harm Residents Affected - Few that the collection was not properly labeled and needed to be recollected. The next sample collected was on 2/22/24 and an antibiotic order Ceftriaxone 1 gram daily for 5 days was started on 2/28/24. V2 stated that the nurse did not get the order into the system until after midnight, so the order shows a start date of 2/29/24. V2 went on to state that the lab picks up samples early in the morning prior to 8:00 AM Monday-Friday. V2 stated that the second collection fell on a weekend and if the provider does not order a stat lab they will wait until Monday morning to collect the sample. V2 stated that is what happened with R22 and why the delay occurred with obtaining the second sample and getting the results. V2 provided 24 hour report sheets with the following information for R22. On 2/15/24 R22 has documentation on the 6AM-6PM shift that she is complaining of burning upon urination and that a message was sent for a urinalysis. On 2/16/24 the 6PM-6AM shift documents that faxed communication to (V13) related to burning with urination. Awaiting new orders. On 2/17/24 the 6PM-6AM shift documents burning with urination, awaiting orders. On 2/18/24 the 6PM-6AM shift documents burning with urination, awaiting orders and the 6AM-6PM shift reports new order for urinalysis. On 2/20/24 the 6AM-6PM shift documented urinalysis not labeled and need to redo. On 2/21/24 the 6PM-6AM shift reported need urinalysis. On 2/22/24 6PM-6AM reported need urine, and the 6AM-6PM reported ok urinalysis in fridge. On 2/23/24 6PM-6AM reported the urinalysis in fridge. On 2/24/24 the 6PM-6AM shift reported faxed urinalysis results, awaiting results. A lab report provided documents that the specimen was collected on 2/19/24 and was not labeled. The report advised the facility to collect a new specimen properly labeled with full name, date of birth , and date/time of collection. A patient report from local hospital dated 2/23/24 documents a positive nitrite in the urinalysis and a culture and sensitivity to follow. A lab report dated 2/27/24 documents the culture and sensitivity results of >(greater than) 100,000 CFU (colony forming unit)/ML(milliliters) of Escherichia Coli. On 3/1/24 at 9:05 AM, V13 (Nurse Practitioner) stated that in reviewing documentation, she does not see where she was notified of R22 experiencing burning with urination until 2/18/24, when at that time she gave the order for a Urinalysis with Culture and Sensitivity if indicated. V13 also stated she was never notified of a specimen not being labeled correctly, which resulted in a prolonged collection time with urinary infection symptoms present. V13 stated that it is her expectations that if the facility is not receiving a response via fax, that they should call her for orders and communicate any concerns. V13 acknowledges the untimely collection for the facility obtaining the culture, resulted in delayed treatment to R22. V13 agreed that it is fair to say R22 would have experienced prolonged discomfort with the lack of timely treatment provided. V13 stated her expectations are that if a resident is experiencing symptoms of infection, such as burning with urination, the lab would be ordered to be completed immediately and not that a routine culture would be obtained at just the next available pickup date. An undated antibiotic stewardship policy documents .Procedure: 1. When the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes: a. resident signs and symptoms. i. complete set of vital signs ii. interview of resident for symptoms iii. assessment. 2. The nurse will utilize the McGeer Contitutional Criteria infection criteria protocol to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. 3. Notify the physician/practitioner of resident change of condition and evaluation information. The nurse to communicate to physician of infection criteria protocol to treat the respective infection. 4. When diagnostics are ordered by the practitioner, the nurse will contact the lab/radiology to notify of physician order. a. Physician will be notified of results of diagnostics to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 6 of 10 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 03/01/2024 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 0690 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. 5. If indicated, based upon (identified) criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. a. In the event the prescribing physician orders an antibiotic without identification of infection criteria, the physician will be requested to identify rationale for ordered antibiotic . Event ID: Facility ID: 145685 If continuation sheet Page 7 of 10 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 03/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to date insulin pens when opened for use and ensure discontinued medications were disposed of per current standards of practice for 4 of 35 residents (R40, R33, R24, and R71) reviewed for medication storage in the sample of 60. Findings include: On 2/27/2024 at 11:32 AM, the 100-hall medication cart was observed in the presence of V7 (Licensed Practical Nurse, LPN) to have a total of 6 Insulin pens that were not dated. R40 had 2 undated pens including an Aspart (Novolog) insulin pen and a Levemir (Detemir) insulin pen, R33 had 2 undated insulin pens including a Lispro (Humalog) insulin pen and a Lantus (insulin Glargine) insulin pen, R24 had an undated Aspart (Novolog) insulin pen, and R71 had an undated Aspart (Novolog) insulin pen. R40's Face Sheet documented an admission date to the facility as 4/12/2023 with diagnosis including, but not limited to: Type 2 Diabetes, End Stage Renal Disease, mixed Hyperlipidemia, and Hypertension. Current physician orders reviewed with orders for Insulin Aspart per sliding scale, and Insulin Detemir U-100 10 units subcutaneous at bedtime with discontinue date of 5/5/2023. R33's Face Sheet documented an admission date to the facility as 8/10/2023 with diagnosis including, but not limited to: Type 2 Diabetes, Anxiety disorder, hyperlipidemia (unspecified), Parkinson's. R33's Active Orders in the electronic health record (EHR) documents orders for Insulin Lispro (Humalog) pen 100 units per sliding scale dated 8/10/23 and Insulin Glargine (Lantus) 30 units subcutaneous twice daily dated 11/16/23. R24's Face Sheet documented an admission date to the facility as 2/15/2023 with diagnosis including, but not limited to: Type 2 Diabetes, Parkinson's (unspecified), hyperlipidemia (unspecified) and heart disease (unspecified). R24's Active Orders in the electronic health record (EHR) document an order for Novolog FlexPen u100 insulin per sliding scale with a start date of 10/5/23. R71's Face Sheet documented an admission date to facility as 11/22/2023 with diagnosis including, but not limited to long term (current) use of insulin, [NAME] Syndrome, Hypertension, Congestive Heart Failure, Toxic Liver disease. R71's Face Sheet documents a discharge date of 2/12/24. Physician Order Report dated 1/29/24 to 2/29/24 documents and order for Insulin Aspart u100 per sliding scale. On 2/28/2024 at 9:30AM, V11 (Registered Nurse, RN) confirmed that Insulin pens are to be dated when they are opened and to be used within the timeframe specific to that type of Insulin. V11 confirms that she has had training on dating Insulin pens when they are opened. V11 confirmed that if she discovers an Insulin pen that is on the cart that is not dated that she would dispose of and replace the insulin pen. On 2/28/2024 at 10:40 AM, V2 (Director of Nursing) confirmed that she has previously educated all the nurses on the proper technique to dating and disposing of Insulin pens. V2 stated she is in the process of again educating the nursing staff again on proper dating of Insulin pens and checking expiration dates on all stock medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 8 of 10 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 03/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's pharmacy policy titled Vials and Ampules of Injectable Medications dated 10/25/2014, documents in section F Medication in multi dose vials may be used (until the manufacturer's expiration date/for the length of time allowed by state law according to facility policy/ for thirty days), if inspection reveals no problems during that time. USP (united states Pharmacopeia) recommends discarding multi dose vials (other than some insulins) at 28 days after opening. The same policy includes a document titled Insulin Expiration Dates, dated 2/2019, documents All insulins should be stored in the refrigerator until opening. Once opened or removed from the refrigerator for storage in the medication cart, the insulin should be dated as it will expire in a given time frame per manufacturer: Lantus Vial (insulin glargine) and Solostar Pen, 28 day expiration date after opening or removing from refrigerator, whichever comes first, .Humalog (Lispro) 10mL Vial and 3mL KwikPen, 28 day expiration date, .Levemir 10mL vial, 3mL Flextouch Pen, 42 day expiration date .Novolog (Insulin Aspart) 10mL (milliliter) vial and 3mL Flextouch, 28 day expiration date. The facility policy titled Discontinued Medications (undated) documents All non-scheduled medications discontinued by the physician will be returned to pharmacy for credit if completely unused or will be destroyed in accordance with local, state, and federal regulations. Under the section titled Procedure step #3 it documents that Authorized staff will remove the medication from the medication cart or any other storage area where it is located. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 9 of 10 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 03/01/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to properly store and label food items, failed to maintain the ice machine in a safe and sanitary manner and failed to prevent potential cross contamination of food and food contact areas by staff not wearing hair restraints. This has the potential to affect all 87 residents that reside in the facility. The Findings Include: During the initial tour of kitchen on 2/27/24 at 8:30 AM the following concerns were observed: 1. A package of waffles were found in the walk in cooler not dated and open to air not sealed back up. 2. Margarine spread buckets were open/partially used and not dated or labeled. 3. Yellow shredded cheese was open, and half used not dated or labeled. 4. Lunch meat and cheese slices were wrapped in plastic wrap in smaller packages not in original packaging not dated and not labeled. 5. Styrofoam cups without a handle were found in the bulk sugar, corn meal, bulk thickener. There was also a container of white powder not dated and not labeled. At this time V3 (Dietary Supervisor) stated that all of these items found at initial tour of the kitchen will be discarded. On 2/28/24 at 11:24AM, V5 (Cook) and V6 (Dietary Aide) were observed in the kitchen without hair restraints. At this time V1 (Administrator) stated that the expectation is that hair restraints are to be worn at all times in the kitchen and she instructed them to get a hair restraint on. On 2/29/24 at 11:30 AM, the ice machine in the service hall by the kitchen was found to have a white hard water build up accumulated on the outside of the ice machine and also dripping water down the front causing a rust colored water to be building up on the door that opens to the ice machine. Inside the ice machine black and pink spots were found on the plastic shield where the ice drops down into the holding bin to be then scooped out for use. The Food and Supply Storage policy with a revision date of January 2012 documents in part 4. Prepared foods stored in the refrigerator until service will be covered, labeled and dated with an expiration date 6. All foods will be covered, labeled and dated The Personal Hygiene and Uniform Appearance policy with a revision date of January 2012 states that staff shall report to work in clean uniforms according to the facility uniform policy. Hair nets or hair covering shall be worn while in the kitchen or storage units. The Long Term Care Facility Application for Medicare and Medicaid (CMS Form 671) signed and dated 2/27/24, documents 87 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 10 of 10