Health inspection·June 13, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of abuse to the Illinois Department of Public Health (IDPH) for 1 of 4 residents (R1) reviewed for abuse in the sample of 6. The findings include: R1's face sheet documents she was admitted to the facility on [DATE]. The same face sheet documents R1's diagnoses to include Unspecified dementia, severe, with agitation, urinary tract infection, site not specified, restlessness and agitation, nutritional deficiency, unspecified, other symptoms and signs concerning food and fluid intake. R1's MDS (Minimum Data Set) dated 5/14/24 documents R1 has a BIMS (Brief Interview of Mental Status) of 04 which indicates R1 has severe cognitive impairment. On 6/11/24 at 10:00am, V1 (Administrator) stated that last night V13 (MDS (Minimum Data Set) coordinator/Care plan coordinator) called her and said she had a CNA (Certified Nurse Assistant) (V3) with her. V13 told V1 that V12 (family member) had came to her and said that a housekeeper had shoved her mom out of her room in her wheelchair and yelled at her. V1 said V3 had told her that (R1) had hit the housekeeper. V3 told V1 that is not what she had told V12 and that she had told her that the housekeeper came out of the room yelling she hit me, she hit me. V1 said she did not do an investigation or report it to IDPH since that is not what happened. On 6/12/24 at 1:30pm, V1 stated she felt the incident with R1, and the housekeeper was not to the level of abuse, and it was handled within minutes, not days apart. V1 said she felt the situation was handled and V12 was satisfied with the outcome. V1 said she did not do an investigation or report it. Facility document labeled Abuse Prevention Program, revision date 9/29/22 documents on page 8 that the allegation shall either be called or faxed into the Regional Public Health Office. Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated and the report shall contain the following information: 1. Name, age, diagnosis and mental status of the resident allegedly abused or neglected. 2. Type of abuse reported (physical, sexual, misappropriation, neglect, verbal or mental abuse). 3. Date, time, location and circumstances of the alleged incident. 4. Any obvious injuries or complaints of injury. 5. Steps the facility has taken to protect the resident. . Page 1 of 2 145685 145685 06/13/2024 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate and conduct a thorough investigation of an allegation of abuse for 1 of 4 residents (R1) reviewed for abuse in a sample 6. Residents Affected - Few The findings include: R1's face sheet documents she was admitted to the facility on [DATE]. The same face sheet documents R1's diagnoses to include unspecified dementia, severe, with agitation, urinary tract infection, site not specified, restlessness and agitation, nutritional deficiency, unspecified, other symptoms and signs concerning food and fluid intake. R1's MDS (Minimum Data Set) dated 5/14/24 documents R1 has a BIMS (Brief Interview of Mental Status) of 04 which indicates R1 has severe cognitive impairment. On 6/11/24 at 10:00am, V1 (Administrator) stated that last night V13 (MDS (Minimum Data Set) coordinator/Care plan coordinator) called her and said she had a CNA (Certified Nurse Assistant) (V3) with her. V13 told V1 that V12 (family member) had came to her and said that a housekeeper had shoved her mom out of her room in her wheelchair and yelled at her. V1 said V3 had told her that (R1) had hit the housekeeper. V3 told V1 that is not what she had told V12 and that she had told her that the housekeeper came out of the room yelling she hit me, she hit me. V1 said she did not do an investigation or report it to since that is not what happened. When V1 was asked to provide any documented information on the incident between R1 and the housekeeper V1 provided a document provided written by V1 dated 6/12/24 that documented in part, Timeline for Monday, June 10th, 2024 .5:50 p.m.- V12 approached V13 and reported that (V3) told her that the housekeeper shoved her mother out her room after the resident hit her .This was treated as a grievance and not a reportable matter because it was secondhand information/gossip from the daughter and there was no willful intent . During this investigation V1 could not provide a grievance regarding the incident from June 2024 between R1 and a housekeeper. Facility document labeled Abuse Prevention Program, revised 9/29/22 documents in part, 5. Internal Reporting Requirements and Identification of Allegations .Supervisors shall immediately inform the administrator of all reports of incidents, allegation, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation .7. Internal investigation of abuse, neglect or misappropriation allegations and response. a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. b. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation . 145685 Page 2 of 2