Health inspection·July 26, 2024

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview and record review the facility failed to have adequate staffing in their dietary department. This failure has the potential to affect all 49 residents who reside at the facility. Residents Affected - Many Findings Include: On 7/24/24 at 10:00 AM V4 (Dietary Manager) stated she took the dietary manager position over on July 1, 2024, after V7(Previous Dietary Manager) was terminated. V4 stated that she had been a dietary aide since June 2023. V4 reports that the schedules were usually done on paper and then thrown away. V4 stated there was no consistency to anyone's schedule, a lot of times people had to work alone and that wasn't right. It's too much to do with just one person. On 7/24/24 at 1:00 PM V5 (Dietary Aid) stated I have had no training and prior to (V4/Dietary Manager) taking over, I worked by myself most nights, so meals were always late. I had no idea what I was doing. V5 confirmed that V7 (Previous Dietary Manager) wrote schedules on a notebook piece of paper and threw it away when it was finished. On 7/24/24 at 12:45 PM V1 (Administrator in Training) stated (V7/Previous Dietary Manager) told me he was doing the schedules, I assumed he was doing them correctly. I never saw a dietary schedule and never asked about dietary staffing. On 7/25/24 at 8:00 AM V1 (Administrator in Training) provided a dietary schedule for the night of 6/23/24 based on timecard punches. This information confirmed that V5 (Dietary Aide) was working alone on 6/23/24. V1 confirmed that there were no dietary schedules to review for the past year. On 7/24/24 at 9:15 AM R6 stated The kitchen is a mess. There is usually only one person at night. On 7/24/24 at 9:17 AM R4 stated They need more help in the kitchen. On 7/24/24 at 9:20AM R5 stated They need more people at night to serve the food. On 7/24/24 at 9:25 R7 stated There is never enough help in the kitchen at night or on the weekends. The Resident Roster dated 7/24/24 lists 49 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146080 If continuation sheet Page 2 of 4 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 146080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Care Center 400 West Grant Street Macomb, IL 61455 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review and interview the facility failed to ensure one of three residents (R1) reviewed for mechanically altered diets was served the Physician ordered diet. This failure resulted in R1 receiving the wrong texture of diet causing R1 choking on his food requiring back thrusts, the Heimlich maneuver and transfer to the local area hospital. This failure also put R1 at risk for death and/or brain damage from lack of oxygen due to choking. These failures resulted in an Immediate Jeopardy. Findings Include: The Immediate Jeopardy began on 6/23/24 at 5:50 PM when the facility failed to provide the proper mechanically soft diet with ground meat and gravy on all meats as ordered for R1. The immediacy was removed on 07/26/2024 and the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their In-service training and Quality Assessment oversight. V2 (Director of Nursing) was notified of the Immediate Jeopardy on 7/26/24 at 10:30 AM. The Facility's Facility Reported Incident dated 6/23/24 documents (R1) was eating and began choking. CNA alerted nurse, she came to resident's side and told CNA to call 911. Resident transported to (Emergency Department) where received an x-ray. Investigation completed. R1's discharge papers dated 6/23/24 from the local hospital document that R1 was evaluated after a choking episode at the facility. The paperwork indicated that R1 had a chest x-ray done with no abnormalities and sent back to the facility. R1's admission diet order dated 5/22/24 documents Controlled Carbohydrate Diet, mechanical soft, thin liquids, ground up meat with gravy on all meats. R1's MDS (Minimum Data Set) dated 06/04/24 documents a BIMS (Brief Interview for Mental Status) score of 4 out of possible 15 indicating severe cognitive impairment. R1's MDS also documents inattention, disorganized thinking and altered level of consciousness. The MDS documents that R1 requires Extensive Assist of one person. On 7/24/24 at 11:30 AM V3 (Licensed Practical Nurse) stated the level of assistance R1 requires while eating varies depending on the day. Most days he will physically feed himself with a lot of verbal cueing. He does not like to be in the dining room so he will try to rush through meals and wheel himself out. Throughout the survey R1 did not answer any questions appropriately and did not seem to understand what was being said. On 7/24/24 at 11:00 AM V5 (Dietary Aide) stated I served (R1) a pork fritter type piece of meat. I did not grind it or put any gravy on it. When (V6/Certified Nurse Aid) requested gravy and chopped meat I cut up the meat with a knife and told her to use some other condiment on it to soften it up because I did not have any gravy. V5 stated I have not been trained on any of this, I am doing the best I can. I was in the kitchen by myself, so a housekeeper and a CNA came in to help sling trays. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146080 If continuation sheet Page 3 of 4 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 146080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Care Center 400 West Grant Street Macomb, IL 61455 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 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few do remember (V6/CNA) telling me that it was the wrong diet, I fixed it the best I knew how to. V5 stated that he did not know if a pork fritter/pork chop would be consistent with a mechanical soft diet. V5 stated I guess that means, so they (residents) don't have to chew up tough meat or something. V5 stated that he did not know who had altered diets in the facility until V4 (Dietary Manager) took over on 7/1/24. Once (V4) took over, I realized how wrong I was doing some stuff. I didn't mean to; I was just doing the best I knew. But (V4) follows the menus, gives me recipes to follow and showed me how to cook. (V7/Previous Dietary Manager) would not answer questions and didn't follow the menu or order the right groceries, so I came in on that night (6/23/24) and figured it out myself what I was making for supper. On 7/25/24 at 8:00 AM V1 (Administrator in Training) provided a dietary schedule for the night of 6/23/24 based on timecard punches. This information confirmed that V5 (Dietary Aide) was working alone on 6/23/24. On 7/24/24 at 10:30 AM V6 (Certified Nurse Aid) stated, (V5/Dietary Aid) gave me a regular diet for (R1) which I knew was wrong. (R1) was a mechanical soft diet with minced meat with gravy. I told (V5) that and he just cut up the meat and told me to use something else for the gravy. V5 had no idea what he was doing, and we were so short staffed and busy, I just took it. On 7/24/24 at 10:30 AM V6 (Certified Nurse Aid) stated I sat the tray in front of (R1) and continued to pass trays. All of us (Staff) were busy and not paying attention, when I happened to look over, he was putting a piece of meat in his mouth. He immediately began choking. V6 stated that R1 usually required supervision to eat. V6 stated, We had not even passed silverware yet, so I didn't think he would try to eat it. V6 confirmed that R1 very confused and can only follow simple instructions. On 7/24/24 at 11:30 AM V8 (Licensed Practical Nurse) stated On 6/23/24 (R1) was served the wrong diet. That is why he choked. He is supposed to have mechanical soft with ground meat and gravy on all meats. When he was choking, I smacked him on the back several times and then positioned him to do the Heimlich and he coughed up about 120 ccs (Cubic Centimeters) of chewed up meat. This surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 07/26/24. 1. On 7/26/24 at 10:45 AM V4 (Dietary Manager) stated she monitors all meals while she is in the facility and checks with second shift nurses and weekend managers to see how other meals are going. 2. Dietary Schedule for 07/01/24 - 07/31/24 documents at least two dietary staff on the schedule for every meal. 3. R1, R2 and R3 were the only residents in the facility to receive an altered texture diet. Their meal cards were correct and in the kitchen. Their dietary orders were posted next to the steam table/serving window. 4. V4 (Dietary Manager) provided a seating chart that had residents requiring assistance seated together in the middle of the dining room. There were no previous seating charts to compare to. 5. R1, R2 and R3's care plans all reflected the correct diet texture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146080 If continuation sheet Page 4 of 4