Health inspection·October 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few initial encounter. Avulsion of skin of left forearm, initial encounter. Disposition: Discharge. Condition: Stable.On 9/30/25 at 10:35am, R1 was alert and oriented to person, place, and time. R1 stated she might be somewhat fuzzy on the details, but on 9/19/25 she was riding in the facility van when V4, Transport Staff, turned right, and R1's wheelchair tipped over to the left, but not all the way over. R1 stated she somehow sustained a skin tear to her left forearm, which was observed to be covered with a clean dry dressing dated 9/30/25. R1 stated she also thinks she hit the back of her head on something, but she is not sure what. R1 stated she has had some back pain after the incident which she thinks was from being in a sitting position on the floor of the van afterwards, but nothing requiring intervention with narcotic pain medications. R1 stated V4 was not driving fast or not in an unsafe manner. R1 stated examination and imaging at the ER showed the only injury was the skin tear. R1 stated following the incident her memory and level of functioning are baseline. R1 stated all transport staff have always been extremely safe and careful with her. When asked her if there was any issue with any of the straps not being attached properly to the wheelchair, R1 stated she had no idea if this was a factor. When asked about the Incident Report stating there was bruising to the body, R1 stated she was not sure if she sustained bruises, but it was no big deal and it was probably gone by now. When asked by the Surveyor if she would allow observation of a nursing skin assessment, she stated not today as she was tired and wanted to rest.On 9/30/25 at 11:10am, V4 stated on 9/19/25 she had taken R1 to the bank. V4 stated she had gotten R1 out of the van and into the building to do her banking, then they came back out, and she strapped in R1's wheelchair into the van in what she thought was a secure manner. V4 stated she made a right turn, which was not a sharp turn, and she was not speeding, and heard R1 yell out and V4 looked around to see the wheelchair was tipping over toward the left side of the van. V4 stated she quickly made a right turn into a parking lot to pull over, at which time the wheelchair tipped over toward the left even more. V4 stated R1's body was not making contact with anything inside of the van. V4 stated she unhooked R1's lap belt and carefully lowered R1 into a sitting position on the floor of the van. V4 stated R1's left arm was bleeding, and V4 assumed in being jostled around the arm had made contact with the arm of the wheelchair. V4 stated R1 was alert and oriented. V4 stated she asked R1 if she had hit her head and R1 stated she didn't think so. V4 stated R1 initially was not panicking or in pain but was somewhat upset about her arm injury. V4 stated she had not needed to put pressure on the skin tear as it was not profusely bleeding. V4 stated she called V1, Administrator, who called 911. V4 stated it took about 12-15 minutes for the ambulance to arrive, and when questioned by paramedics, R1 stated she thought maybe she had hit her head but wasn't sure, and she complained of back pain from sitting on the floor of the van. V4 stated upon her return to the facility, V1 wrote V4 up for not double checking if the wheelchair was securely strapped in. V4 stated she and other transport staff were reeducated on proper use of the restraint belts in the van. V4 stated the proper procedure is to buckle the lap belt, and there are 2 back and 2 front restraint straps which attach to the wheelchair frame. V4 stated she recalled attaching the back and front straps by weaving then through the wheels, which she later learned was not proper procedure. V4 stated she does not think she was initially properly trained about securing the wheelchair straps.The facility's undated Van Usage Policy and Procedure documented, Policy: When employees operate a facility owned van, they have inherent responsibilities to care for the vehicle and the residents, obey all state and local traffic laws, and abide by established driver operating procedures. This policy is designed to ensure that employees authorized to operate vehicles for the purpose of conducting business and transporting residents for the company will comply with certain conditions. Procedure: To ensure proper van usage: 3. Employees must practice safe driving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145685 If continuation sheet Page 2 of 3 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 10/09/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete procedures and obey the rules of the road when operating a facility owned van. C. Ensure all residents and wheelchairs are safely secured.On 9/30/25 at 1:50pm, V5, Maintenance Staff, stated on 9/19/25 after the above referenced incident, all Transport Staff were reeducated on securing wheelchairs in the van, with return demonstration given. V5 stated all were required to pass a safe driving test he administered and all passed. V5 stated when V4 demonstrated how she secured R1's wheelchair, she failed to properly secure the chair, but upon return demonstration, did so appropriately. V5 stated he did not think V4 had been properly trained initially.On 9/30/25 at 2:25pm, V2, Director of Nurses, stated when R1 was readmitted from ER, there was a skin tear to the left forearm and significant bruising to body in several areas, most likely due to anticoagulant therapy. V2 stated R1 was now at baseline in all areas including level of functioning and cognition. V2 stated R1 has had some occasional complaints of back pain which have been effectively controlled with analgesics.On 9/30/25 at 2:00pm, V1, Administrator, produced a 9/19/25 document titled Ad Hoc QAPI (Quality Assurance Improvement Plan). V1 stated the quarterly QA (Quality Assurance) meeting is scheduled for October 2025. V1 stated by 9/20/25, prior to the Surveyors entrance to the facility on 9/30/25, the facility implemented all the below referenced steps as stated in the QAPI Ad Hoc.Prior to the survey date, the facility took the following actions to correct the non-compliance:1. On 9/19/25, (V4) received disciplinary action regarding the appropriate procedure for securing a wheelchair during transport.2. On 9/19/25, a safety inspection was conducted on all vehicles.3. On 9/20/25, all drivers were educated on the proper procedure for securing wheelchairs during transport.4. On 9/20/25, all drivers were evaluated for competency by conducting a road test with (V5, Maintenance Staff).5. The Administrator or designee will audit resident transportation twice weekly for 4 weeks to ensure wheelchairs are secured for transport.6. The Administrator will report the findings of the audit to the QA Committee. Event ID: Facility ID: 145685 If continuation sheet Page 3 of 3