Health inspection·January 24, 2025

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain range of motion for 1 (R25) of 1 resident reviewed for decreased range of motion in the sample of 36. The findings Include: R25's Face Sheet documented R25 as a [AGE] year-old with an admission date of 08/02/2024 to the facility. Diagnoses listed are chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, chronic obstructive pulmonary disease, venous insufficiency, chronic systolic congestive heart failure, obstructive sleep apnea, major depressive disorder, essential hypertension, non - pressure chronic ulcer of other part of right lower leg, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R25's Physician's orders with no print date document an order for AROM (Active Range of Motion) 6-7 times per week and Bed Mobility 6-7 times per week. Both orders were discontinued on 01/22/2025. On 01/22/2025 there was a new order for PROM (Passive Range of Motion) to right lower extremity 6-7 times a week. R25's admission MDS (Minimum Data Set) with a date of 08/12/2024 noted that R25 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R25 is cognitively intact. Section GG documents for functional limitation in range of motion that R25 has an impairment on both sides for lower extremity. Section GG for self-care documents that R25 is dependent on toileting, putting on / taking off footwear, lower body dressing, upper body dressing and shower/bathe. Section O of the same MDS documents R25 received 1 day of active range of motion and 0 days of passive range of motion (with a look back period of 7 days). R25's Quarterly MDS dated [DATE], documented in section GG, documents for functional limitation in range of motion that R25 has an impairment on both sides for lower extremity. Section GG for self-care documents that R25 is dependent on toileting, putting on / taking off footwear, lower body dressing, upper body dressing and shower/bathe. Section O of the same MDS documents R25 received 0 days of passive / active range of motion (with a look back period of 7 days). R25's Care Plan with a start date of 10/16/2024 documents a focus area activities of daily living / functional status / rehabilitation potential, I am alert and oriented times 4, I am able to make all my needs / wants known appropriately. I utilize my call light. I have a BIMS of 15. I prefer to remain in bed, I am non-ambulatory and transfer with two assists utilizing a mechanical lift. I am frequently incontinent, and I keep a urinal at bedside. I require substantial to dependent staff assist Page 1 of 10 145685 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with bed mobility, dressing, toileting hygiene, and bathing. I have decreased range of motion, mobility, bilateral lower extremity venous insufficiency, chronic pain and respiratory deficits. Interventions listed are active / passive range of motion with care as tolerance, assist with activities of daily living, assist as needed with toileting with start date of 10/16/2024. R25's Behavior Analysis Report with a date range of 08/02/2024 -01/22/2025 documented range of motion was completed on the following dates: 08/12/2024, 08/13/2024, 08/22/2024, 08/26/2024, 10/16-10/19/2024, 10/24/2024, 10/26/2024, 10/31/2024 and 01/14/2025. On 01/22/2025 at 1:37 PM, R25 stated he does not receive range of motion from the facility staff. On 01/22/2025 at 2:20 PM, V13 (Restorative Certified Nurse Aide) stated that R25 does not like to participate in restorative therapy. V13 stated that R25 refuses care. On 01/22/2025 at 2:22 PM, R25 stated that no staff members offer to do range of motion on him. On 01/24/2025 at 1:00 PM, V2 (DON) stated that she changed the order on R25's range of motion from active too passive because the resident needs passive range of motion. Review of facility policy titled Restorative Nursing with a date of August 2023 documented It is the policy of company name to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible. Restorative nursing focuses on achieving and maintaining the optimum level of physical, mental, and psychological function of the resident. 4. Restorative treatments are recorded in the electronic health record.6. Services which are provided at least 15 minutes per day in a 24-hour period are also recorded on the MDS if in the MDS observation period.8. The restorative nurse documents the resident's progress and indicates if the current plan should continue or if the resident should be referred back to therapy for a screen / evaluation. 145685 Page 2 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement dietary supplements as ordered for 4 (R39, R44, R45 and R63) of 8 residents reviewed for nutrition in a sample of 36. This failure resulted in R63 experiencing a 7.88 percent weight loss within one month. Residents Affected - Few Findings include: 1. R63's Resident Face Sheet documented an admission date of 3/13/24 with diagnoses including: dementia, underweight, mild protein-calorie malnutrition, muscle wasting and atrophy. R63's 12/13/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 1, indicating R63 had severe cognitive impairment. R63's Progress Note dated 12/19/24 from V3 (Dietician) documents, Note r/t (related to) wound. Resident has skin tear to R (right) hip/buttock. Wt (Weight) 104# (pounds), usual for resident and stable. Diet order: regular, regular texture, thin liquids. Health shake one daily. Dietary intake is poor to fair. Recommend health shake BID (twice daily) and vit C 1000mg (milligrams) r/t wound healing. R63's Active Physician Orders sheet document Vitamin C 1000 mg once a day with a start date of 1/23/25 and Health shakes twice a day, morning and evening with a start date of 1/23/25. R63's Care Plan documented in part .Problem Start Date: 8/23/23 .Category: Nutritional Status . I am risk for impaired nutrition and hydration related to underweight, poor appetite, vitamin deficiencies, protein calorie malnutrition, electrolyte imbalance, impaired cognition . January 2025: weight loss 7.8% one month and 7.8% loss 3 months . with a approaches documenting in part . Approach Start Date: 8/23/23 . Nutritional supplements/ vitamins as ordered and monitor for side effects . Approach Start Date, 8/29/23 Health Shake daily for nutritional supplement (related to) underweight/ poor intake . R63's Weight Log from 3/13/24 to 1/24/25 documents R63's weight on 12/3/24 as 104 pounds with a BMI (Body Mass Index) of 18.42 and a weight on 1/3/25 as 95.8 pounds with a BMI of 16.97. This weight loss represents a 7.88 percent (severe) weight loss in one month. On 1/23/25 at 9:31 AM, V7 (Dietary Manager) said when a resident has a diet or supplement change, nursing staff will bring the order to dietary staff. V7 said she was unsure how often the V3 (Dietitian) came to the facility to review residents. V7 said V1 (Administrator) was meeting with V3 while V7 was still learning the duties of the Dietary Manager. V7 said she did not receive V3's reports and Nutritional Recommendations, V1 was the staff that would receive them. On 1/23/25 at 9:46 AM, V1 said V3 would send her the Nutritional Recommendations and she would then give them to V7 and V2 (Director of Nursing/ DON). V1 said V2 would print out the Nutritional Recommendations and give them to the resident's medical provider and when they were signed nursing staff would put the order in the Physician Order Set and notify dietary via a diet communication slip. On 1/24/25 at 11:17 AM, V9 (Nurse Practitioner) said a resident with weight loss was at risk to develop significant weight loss if not provided with ordered supplements. 145685 Page 3 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0692 On 1/23/25 attempts were made to reach V3 via phone. A voicemail was left and not returned. On 1/24/25 an email was sent to V3 which again resulted in no contact back from V3. Level of Harm - Actual harm Residents Affected - Few 2. R45's face sheet documents an admission date of 5/4/24 and included the following diagnosis: Unspecified severe protein-calorie malnutrition. R45's Nutritional Recommendation dated 12/12/24 by V3 documents, recommended Health shake twice a day related to weight loss. R45's current physician order sheet includes an order with a start date of 1/24/25 for Health Shakes twice daily. R45's care plan has a problem area of: Problem I am risk for impaired nutrition and hydration related to electrolyte imbalances, vitamin deficiencies. An approach to this problem area is a health shake twice a day with a start date of 1/23/24. On 1/22/25 at 2:30 PM, V1 (Administrator) stated that V7 (Dietary Manager) is a new employee and had not been given the list of residents who had dietary recommendations from the December dietary recommendations made by V3. On 1/23/25 at 9:31 AM, V7 (Dietary Manager) provided a list of residents receiving supplements and R39, and R45 were not on the list. On 1/24/25 at 11:28 AM, V9 stated she expected the facility to follow the orders written for dietary supplements and provide them as ordered with meals and/or snacks. 3. R39's face sheet documents an admission date of 9/24/2024. This same document include the following diagnosis: unspecified severe protein-calorie malnutrition. R39's Nutrition Recommendation dated 12/12/24 by V3 documents health shake snack daily related to weight loss. R39's current Physician orders include an order for sugar free health shake daily, once a day- day shift starting 10/22/24 with no end date and a second order for sugar free health shakes twice a day, morning and evening starting 1/23/25. Review of R39's care plan problem: I am risk for impaired nutrition and hydration related to vitamin deficiencies, weakness/fatigue, acid reflux, decreased cardiac function, hypo/hyperglycemia, or poor intake. My appetite is fair to good. The goal for this problem area is: I will be nutritionally stable as evidenced by no significant weight changes through the next review. An approach to this problem area with a start date of 1/24/24 is to provide a sugar free health shake twice a day. 4. R44's Resident Face Sheet documented an admission Date of 8/23/24 and listed diagnoses including Dementia, Hypertension, and Anxiety Disorder. R44's Minimum Data Set, dated [DATE] documented that R44 is severely cognitively impaired, requires partial or moderate assistance for eating, and requires a mechanically altered diet, R44's Care Plan dated 12/20/24 documented a problem area, I am at risk for impaired nutrition and hydration related to poor intake, tearful behavior, decreased activity tolerance, vitamin deficiency, and electrolyte imbalance. 145685 Page 4 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0692 R44's January 2025 Physicians Order Sheet documented an order for a regular mechanical soft with thin liquids, and a 1/23/24 order for health shakes three times daily. Level of Harm - Actual harm Residents Affected - Few R44's 12/12/24 Registered Dietician Progress Notes, authored by V3, Registered Dietician, documented, Note related to weight loss, wound. Weight 123lb., significant loss in the past 1 month. Resident's condition has declined, and she was put on palliative care with comfort measures on 11/22/24. Weight loss is related to change in condition and decrease in oral intake. Resident has an open area to right ischium which is being treated. Recommend offer health shake three times daily if resident does not eat meals. There was no documentation in the record to indicate R44 received health shakes from 12/12/24 through 1/23/25. On 1/21/25 at 1:26pm, R44 was alert only to herself. R44 was sitting up in bed with a lunch tray on the overbed table in front of her. R44's plate contained a whole boneless chicken breast which had not been cut up. There was no health shake on the tray. When R44 was asked why she didn't eat the chicken, R44 stated it was too tough. On 1/22/25 at 11:16am, V4, Family Member, stated R44 is weak at times, with a generally poor appetite. V4 stated she has been to visit during meals several times in the past few months and has not witnessed anybody offering a R44 health shake nor has she seen one on her tray. On 1/23/25 at 10:01 AM, V5, Certified Nursing Assistant (CNA) working on the 200 hall, stated R44 was transferred there from the 300 hall yesterday. V5 stated R44 had fed herself breakfast that morning and ate about 50 percent of the meal. V5 stated she did not offer R44 a health shake and was not aware she should have had one. On 01/23/25 at 10:09 AM, V6, CNA working on the 300 hall, stated some days R44 will feed herself, and some days she needs assistance. V6 stated R44 is on a mechanical soft diet. V6 stated she has never given R44 any supplements and doesn't think any were ordered. On 01/23/25 at 11:08 AM, V7, Dietary Manager, stated she was not sure if R44 was supposed to be getting a health shake. V7 stated if R44 was to be offered a health shake due to poor meal intake, the CNAs should notify the kitchen and they would send it along with a snack. On 01/23/25 at 02:31 PM, V1, Administrator, stated there is no documentation of R44 receiving health shakes as V3's 12/12/24 order was overlooked and not implemented. V1 stated on 1/23/25, R44's Primary Care Provider ordered health shakes to be given three times daily regardless of meal intake. On 1/23/25 at 2:31 PM, V1 said none of the Nutritional Recommendations from December of 2024 had been completed. The facility's revised February 2024 Weight Management Program documented in part . 10. The DON or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake . results will be given to the register dietician (sic) for assessment and recommendations. 11. The DON will then distribute the R.D. (Registered Dietitian) recommendations per wing to the charge nurse. 12. The charge nurse will notify the attending physician of the current resident's condition and of the R.D.'s recommendations and document the physician's order on the physician order sheet and the 24 hour report sheet. 13. The charge nurse will then initiate a Diet Order & Communication form to the Dietary Manager who will chart the change in the dietary progress note and to the MDS Coordinator to update the care plan . 145685 Page 5 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0692 Level of Harm - Actual harm A (Trade Name) Supplementation Policy dated November 2017 stated, It is the policy of (the facility) to provide each resident with additional supplementation as ordered by the Physician to promote weight maintenance or gain, to promote skin integrity, or to maintain nutritional status if meal intake is inadequate to meet needs. Residents Affected - Few 145685 Page 6 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 (R25) of 5 residents reviewed for unnecessary medications in the sample of 36. The Findings Include: R25's Face Sheet documented R25 as a [AGE] year old with an admission date of 08/02/2024 to the facility. Diagnoses listed are chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, chronic obstructive pulmonary disease, venous insufficiency, chronic systolic congestive heart failure, obstructive sleep apnea, major depressive disorder, essential hypertension, non - pressure chronic ulcer of other part of right lower leg, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R25's MDS (Minimum Data Set) with a date of 12/03/2024 noted that R25 has a BIMS (Brief Interview of Mental Status) of 15 which indicates R25 is cognitively intact. R25's Orders printed 01/24/2025 documented an order for bupropion 100 mg by mouth daily with a start date of 12/12/2024, and duloxetine 120 mg by mouth daily related to increased depression with a start date of 08/16/2024. R25's Care Plan has a focus area of: I receive an antidepressant medication for diagnosis of depression with an initial date of 08/19/2024. Documented interventions are given bupropion 100mg by mouth daily with a start date of 12/12/2024, duloxetine 120 mg by mouth daily with a start date of 08/19/2024, monitor residents' mood and response to medication with a date of 08/19/2024. Care Plan has a focus area of I am at risk for adverse side effects due to the use of medications with a black box warning with a start date of 10/16/2024. Documented interventions are monitor patient at the start and throughout therapy for any signs of clinical worsening, suicidal ideations, or unusual change in behaviors, behavior tracking per policy with a date of 10/16/2024. R25's Behavior Analysis Report from 08/02/2024 - 01/22/2025 shows no behaviors occurred for the dates listed. R25's document titled Psychotropic Medication Tracking/ GDR Tracking with an initiation date of 08/02/2024 documented on 12/12/2024 to increase bupropion to 100 mg by mouth daily for depression. R25's Progress Note dated 12/12/2024 authored by V11 (Registered Nurse) documented, V12 (Nurse Practitioner) in facility to see resident on 12/11/24. Received the following recommendations: Increase bupropion to 100mg po daily related to increase in irritability over the last 30 days. Resident agreeable. Will monitor x30 days. On 01/24/2025 at 10:23 AM, V1 (Administrator) stated that if the staff do not chart any behaviors, then the report will show no behaviors tracked. V1 stated that the behavior tracking for R25 has no behaviors charted. On 01/24/2025 at 10:27 AM, V5 (Certified Nurse Assistant) stated the behaviors that R25 has is 145685 Page 7 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0758 Level of Harm - Minimal harm or potential for actual harm refusing care, peeing in a water cup instead of a urinal, and will urinate in a towel then throw it in the floor. V5 stated she has not seen any crying, irritability, or sadness from R25. On 01/24/2025 at 10:30 AM, V10 (Certified Nurse Assistant) stated that R25 refuses care from staff but she has not seen any signs or symptoms of crying, irritability, or sadness. Residents Affected - Few The facility policy titled Psychotropic Medication Use with a date of December 2018 documented It is the policy of company name that all residents receiving psychotropic medications, be monitored to ensure the least amount of medication is given to treat the diagnosis. This is accomplished through tracking behaviors and effectiveness of interventions. 145685 Page 8 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the correct physician's ordered diet and dietary recommendations for 3 of 12 residents (R5, R26, R44) reviewed for therapeutic diets in the sample of 36. Findings include: 1. R44's Resident Face Sheet documented an admission Date of 8/23/24 and listed diagnoses including Dementia, Hypertension, and Anxiety Disorder. R44's Minimum Data Set, dated [DATE] documented that R44 is severely cognitively impaired, requires partial or moderate assistance for eating, and requires a mechanically altered diet, R44's Care Plan dated 12/20/24 documented a problem area, I am at risk for impaired nutrition and hydration related to poor intake, tearful behavior, decreased activity tolerance, vitamin deficiency, and electrolyte imbalance. R44's January 2025 Physicians Order Sheet documented an order for a regular mechanical soft with thin liquids. R44's Physician Order sheet documents in part, Diet: Regular consistency: mechanical soft. Start date of 11/18/24. On 1/21/25 at 1:26pm, R44 was alert only to herself. R44 was sitting up in bed with a lunch tray on the overbed table in front of her. R44's plate contained a whole boneless chicken breast which had not been cut up. When R44 was asked why she didn't eat the chicken, R44 stated it was too tough. On 1/22/25 at 11:16am, V4, Family Member, stated R44 is weak at times, with a generally poor appetite. V4 stated R44 is to have ground meat. On 01/23/25 at 10:09 AM, V6, CNA working on the 300 hall, stated some days R44 will feed herself, and some days she needs assistance. V6 stated R44 is on a mechanical soft diet. On 01/23/25 at 11:08 AM, V7, Dietary Manager, stated R44 is on a mechanical soft diet and confirmed the meat served to R44 should be ground. A December 2024 Consistency Modified Diets Policy documented, Mechanical soft: This diet is used for patients with limited chewing ability. Food menus include ground moist poultry and meat without bones. 2. R5's face sheet documents an admission date of 12/6/2024. This same document includes the following diagnosis: Diabetes Mellitus, End Stage Renal Disease, and Muscle wasting and atrophy. R5's current month physician orders documents an order with a start date of 1/23/25 of Prostat 30 milliliters (ml) once a day for wound healing. R5's progress note documents on 12/19/2024 V3 (Dietitian) documented weight fluctuates related to fluid status on dialysis. No significant sustained weight loss is noted at this time. Recommend Pro Stat 30 ml daily and zinc sulfate 220 mg daily related to wound healing. R5's care plan documents a problem area of: Problem: I am risk for impaired nutrition and hydration 145685 Page 9 of 10 145685 01/24/2025 Mount Vernon Countryside Manor 606 East IL Hwy 15 Mount Vernon, IL 62864

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some related to poor intake, electrolyte imbalance, vitamin deficiencies, wounds, edema, hyper/hyperglycemia, weakness. The goal for this problem area is: I will be nutritionally stable as evidenced by no significant weight changes through the next review. An approach for this problem area dated 1/24/25 is: ProStat 30mL a day. 3. R26's face sheet documents an admission date of 11/27/2024 with the following diagnosis: moderate protein calorie malnutrition. R26's Nutrition Recommendation by V3 dated 12/12/24 documents at Pro Stat 30 ml daily, Vit C 1000 mg daily and zinc sulfate 220 mg daily for multiple wounds/pressure ulcers. R26's care plan documents a problem area of risk for impaired nutrition and hydration related to poor intake. An approach to this problem area dated 1/10/25 to provide nutritional supplements as ordered. R26's current physician order sheet has an order for health shake daily twice daily with a start date of 1/23/25. On 1/22/25 at 2:30 PM, V1 (Administrator) stated that V7 (Dietary Manager) is a new employee and had not been given the list of residents who had dietary recommendations from the December dietary recommendations made by V3 (Dietician). On 1/23/25 at 2:31 PM, V1 said none of the Nutritional Recommendations from December of 2024 had been completed. 145685 Page 10 of 10