Health inspection·June 23, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to implement hand hygiene and apply new gloves between dirty to clean wound dressing changes and failed to apply pressure ulcer treatments as ordered by the physician for one of three residents (R1) reviewed for pressure ulcers in the sample of 38. Residents Affected - Few Findings include: The facility's Wound Care policy and procedure dated 11/9/19 documents the following guidelines for wound care, 1. Verify Order. 2. Explain procedure to the residents. 3. Gather equipment. 4. Place items on a clean surface. 5. Hand hygiene. 6. DON (put on) PPE (Personal Protective Equipment). 7. Remove dressing to be changed and discard. 8. Remove gloves and discard, (perform) hand hygiene. DON new gloves. 9. Clean wound bed per order. 10. Remove gloves and discharge. 11. Place new dressing. 12. Remove gloves and discard. Hand hygiene. 13. Reposition resident and bed covers. 14. Call light within reach. 15. Remove unused supplies from overbed table and place in appropriate place. 16. Document treatment. The facility's Skin Prevention, Assessment, and Treatment policy and procedure dated 10/23 documents, The goals of wound treatment are to protect the ulcer from contamination. The facility's Weekly Wound Tracking Log dated 6/13/25 documents R1 was admitted to the facility with a stage three pressure ulcers to the right thigh and right heel. R1's Physician's Order Sheets and Treatment Administration Records dated 6/1/25 to 6/20/25 document, Start date 5/9/25 cleanse right heel with normal saline Dakin's (wound disinfectant) wet to dry dressing to be changed BID (twice daily) and PRN (as needed) every shift for right heel wound. Start date 4/7/24 cleanse right posterior thigh with normal saline or wound cleanser, apply Dakin's moistened flat gauze to wound bed, cover with abdominal pad and change BID and PRN every shift to promote wound healing. R1's Treatment Administration Record dated 6/1/25 to 6/20/25 document R1's physician's ordered treatments to the right heel and right posterior thigh were not completed on the evening shifts on 6/9/25 and 6/10/25. On 6/20/25 at 10:01 AM R1 was sitting on the side of her bed in her room. R1 had a boot observed to her right foot. R1's dressings were dated for 6/20/25 to her right heel and right thigh. R1 stated, (V4/RN/Registered Nurse) and night shift nurses do not do my wound treatments at times. On 6/20/25 at 1:35 PM V8/Registered Nurse prepared wound treatment for R1's right upper thigh wound Page 1 of 14 146080 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and right heel wound. V8/RN donned gloves and a gown and set up treatment supplies on a treatment cart. V8 removed all R1's old wound dressings to all R1's wounds at this time. V8 then removed her gloves and without washing her hands placed new gloves on. V8 then took gauze and normal saline and cleansed R1's right heel. V8 then (without washing her hands or changing gloves) grabbed clean gauze and soaked it in Dakin's solution and packed R1's right heel wound. V8 then placed dry gauze over the top. Without changing gloves or washing her hands, V8 then placed rolled gauze around the dry dressing and secured it with tape. V8 then removed her gloves and without washing her hands donned new gloves on. V8 then cleansed the right thigh wound with gauze soaked in normal saline and then threw the gauze away. Without changing her gloves or washing her hands, V8 applied clean gauze soaked in Dakin's solution and applied it to the wound. V8 then covered R1's right thigh wound with clean gauze over the top and then secured it with a border gauze. V8 never washed/sanitized her hands throughout the entire wound treatments between dirty to clean dressings, or between each wound treatment. 6/20/25 at 3:01 PM V8/RN confirmed she should have changed gloves and hand sanitized in between touching clean and dirty dressings and between each wound treatment. On 6/21/25 at 11:10 AM V2/Director of Nursing confirmed R1's wound treatments weren't signed out for night shift on June 9th and June 10th indicating R1's wound treatments were not completed. 146080 Page 2 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review the facility failed to ensure mechanical lift machines used to transfer dependent residents were safe and in good repair for five of five residents (R1, R4, R27, R38, and R39) reviewed for accidents in the sample of 38. Findings include: The Manufacturer's User Instruction Manual for the (Mechanical Lift) HPL700 dated 2024 documents, 9. Maintenance Schedule and Daily Checklist-Operate the hand control to confirm the boom raises and lowers satisfactorily. The Manufacturer's User Manual for the (Mechanical Lift) 450/600 dated 2022 documents, Caster Base: Inspect monthly for missing hardware. Inspect casters and axle bolts for tightness. Inspect casters for a smooth swivel and roll. On 6/21/25 at 11:30 AM V2 (Director of Nursing) provided a list of residents who use a mechanical lift for transfers which included R1, R4, R27, R38, and R39. ` On 6/21/25 at 9:50 AM V18 (CNA/Certified Nursing Assistant) was transferring R1 from the wheelchair to the bed using a mechanical lift model number HPL700. During this transfer, the mechanical lift was wobbling from one leg to the other leg. R1 stated, This lift squeaks and wobbles. It gets a little scary at times. On 6/21/25 at 10:00 AM V18 (CNA) demonstrated using the model HPL700 mechanical lift without a resident. This mechanical lift's casters were not rolling smoothly, and the lift was wobbling back and forth from one leg to the other leg. There was a bolt at the bottom right-side axle of the mechanical lift that had been altered with a bolt that did not fit correctly and was not a bolt used by this lift's manufacturer. V18 then demonstrated using the remote on the mechanical lift model 450/600. This remote stopped working during the demonstration and V18 wiggled the cord to get the remote to work. On 6/21/25 at 10:15 AM V18 (CNA) stated, 'Both mechanical lifts we use here are not good. The (HPL700) lift wobbles back and forth and the rollers (casters) do not roll right. The bolt at the bottom (axle) was replaced a while ago and is not even a bolt that is the right size for the mechanical lift. The other mechanical lift's remote (450/600) quits sometimes mid-air whenever we are transferring the residents. The remote must be wiggled to get it to work. The wiring for the remote is bad. On 6/21/25 at 11:00 AM V21 (Maintenance) stated, I just started coming to this building to help out. I work at the other building most of the time. This building does not have a maintenance supervisor. No one has told me the (mechanical lifts) were broke. On 6/21/25 at 12:15 PM V14 (Regional Administrator) stated, Staff should have reported the (mechanical lifts) being broke. The lifts need to be taken out of commission. 146080 Page 3 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

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. Based on observation, interview, and record review the facility failed to ensure medications were stored in their original packaging until administered for 18 of 18 residents (R1, R2, and R8-R23) reviewed for medication storage in the sample of 38. Findings include: The facility's Administering Medication Policy and Procedure dated 10/15/2023 documents, Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Medications may not be prepared in advance. Medications that are removed from their original packaging and not immediately administered must be destroyed in accordance with facility policy. The facility's Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication dated 11-9-21 documents, Purpose: To ensure that medications and biologicals are stored in a safe, secure storage and safe handling. Medications will be stored in the containers in which they are received. Transfer between containers is performed only by the issuing pharmacy. R1's Order Summary Report and MAR (Medication Administration Record), dated June 1st through June 20th, 2025, document R1 receives the following medications at 8:00 AM daily: Ferrous Fumarate 325 mg (milligrams) one tablet, Multivitamin with Minerals one tablet, Oxybutynin Chloride Extended Release 24 hour 15 mg one tablet, Potassium Chloride Extended Release 10 meq (milliequivalents) two tablets, Protonix 40 mg one tablet, and Wellbutrin Extended Release 24 hour 150 mg one tablet. R8's Order Summary Report and MAR dated June 1st through June 20th, 2025, document R8 receives the following medications at 8:00 AM daily: Chlorpromazine HCL (Hydrochloride) 25 mg one tablet, Chlorpromazine HCL 200 mg one tablet, Chlorpromazine HCL 10 mg one tablet, Prochlorperazine Maleate 10 mg one tablet, Clonidine HCL 0.2 mg one tablet, Levetiraceta 750 mg one tablet, Topiramate 50 mg one tablet, Gabapentin 300 mg one capsule, and Hydroxyzine HCL 25 mg one tablet. R9's Order Summary Report and MAR dated June 1st through June 20th, 2025, document R9 receives the following medications at 8:00 AM daily: Aspirin 81 mg one tablet, Dapagliflozin Propanediol 10 mg one tablet, Famotidine 40 mg one tablet, Jardiance 25 mg, Levothyroxine Sodium 175 mcg (micrograms) one tablet, Losartan Potassium Hydrochlorithizide50-12.5 mg one tablet, Plavix 75 mg one tablet, Venlafaxine HCL Extended Release 150 mg one capsule, Calcium Carbonate 500 mg one tablet, Carvedilol 12.5 mg one tablet, Glipizide 10 mg two tablets, and Pregabalin 100 mg one capsule. R10's Order Summary Report and MAR dated June 1st through June 20th, 2025, document R10 receives the following medications at 8:00 AM daily: Aspirin 81 mg one tablet, Atenolol 25 mg one tablet, Clozapine 100 mg one tablet, Escitalopram 20 mg one tablet, Folic Acid 1 mg one tablet, Januvia 100 mg one tablet, Jardiance 25 mg one tablet, Omeprazole 20 mg one capsule, Pioglitazone 45 mg one tablet, Vitamin D3 50 mcg one tablet, and Metformin 1000 mg one tablet. R11's Order Summary Report and MAR dated June 1st through June 20th, 2025, document R11 receives the following medications at 8:00 AM daily: Vitamin D3 10 mcg one tablet, Amlodipine 5 mg one tablet, Aspirin 81 mg one tablet, Cerovite Senior one tablet, Citalopram Hydrobromide 40 mg one tablet, 146080 Page 4 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0761 Level of Harm - Minimal harm or potential for actual harm Folic Acid 1 mg one tablet, Levothyroxine 150 mcg one tablet, Oyster Shell 500 mg three tablets, Sodium Chloride 1 GM (Gram) one tablet, and Phenytoin 100 mg one capsule. R12's Order Summary Report and MAR dated June 1st through June 20th, 2025, document R12 receives the following medication at 8:00 AM daily: Metformin 500 mg one tablet. Residents Affected - Some On 6/20/25 at 8:40 AM V4 (RN/Registered Nurse) opened the top drawer of the B/C Hallways medication cart. In the top drawer of this cart was six medication cups with loose medication tablets/capsules inside the cups and resident names (R1, R8-R12) written in marker on the outside of the cups. V4 verified at this time R1's Ferrous Fumarate 325 mg one tablet, Multivitamin with Minerals one tablet, Oxybutynin Chloride Extended Release 24 hour 15 mg one tablet, Potassium Chloride Extended Release 10 meq two tablets, Protonix 40 mg one tablet, and Wellbutrin Extended Release 24 hour 150 mg one tablet, R8's Chlorpromazine HCL 25 mg one tablet, Chlorpromazine HCL 200 mg one tablet, Chlorpromazine HCL 10 mg one tablet, Prochlorperazine Maleate 10 mg one tablet, Clonidine HCL 0.2 mg one tablet, Levetiraceta 750 mg one tablet, Topiramate 50 mg one tablet, Gabapentin 300 mg one capsule, and Hydroxyzine HCL 25 mg one tablet, R9's Aspirin 81 mg one tablet, Dapagliflozin Propanediol 10 mg one tablet, Famotidine 40 mg one tablet, Jardiance 25 mg, Levothyroxine Sodium 175 mcg one tablet, Losartan Potassium Hydrochlorithizide50-12.5 mg one tablet, Plavix 75 mg one tablet, Venlafaxine HCL Extended Release 150 mg one capsule, Calcium Carbonate 500 mg one tablet, Carvedilol 12.5 mg one tablet, Glipizide 10 mg two tablets, and Pregabalin 100 mg one capsule, R10's Aspirin 81 mg one tablet, Atenolol 25 mg one tablet, Clozapine 100 mg one tablet, Escitalopram 20 mg one tablet, Folic Acid 1 mg one tablet, Januvia 100 mg one tablet, Jardiance 25 mg one tablet, Omeprazole 20 mg one capsule, Pioglitazone 45 mg one tablet, Vitamin D3 50 mcg one tablet, and Metformin 1000 mg one tablet, R11's Vitamin D3 10 mcg one tablet, Amlodipine 5 mg one tablet, Aspirin 81 mg one tablet, Cerovite Senior one tablet, Citalopram Hydrobromide 40 mg one tablet, Folic Acid 1 mg one tablet, Levothyroxine 150 mcg one tablet, Oyster Shell 500 mg three tablets, Sodium Chloride 1 GM one tablet, and Phenytoin 100 mg one capsule, and R12's Metformin 500 mg one tablet) were removed from their original packaging and placed in the medication cups to be administered at a later time. On 6/20/25 at 8:50 AM V4 (RN) stated, I pulled these residents (R1, R8-R12) morning medications out of their original packaging and put them in medication cups. I labeled the medication cups with (R1, R8-R12's) names on the cups. It is quicker to give (R1, R8-R12) their medications if I just pull them up early and give the medications to the residents when I see them. I know I am not supposed to do it that way. On 6/20/25 at 9:30 AM V2 (Director of Nursing) stated, The nurses have been told numerous times that they are not to pull medications up and out of their original packaging ahead of time. They (nurse) know better. R2's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R2 receives the following medications at 12:00 PM: Glipizide 5mg (milligram) tablet and Hydrocodone/Acetaminophen 7.5-325 mg tablet. These same documents indicate R2 receives the following medications at 5:00 PM: Pregabalin 75mg tablet, Risperidone 0.25mg (3 tablets), Glipizide 5mg tablet, Hydrocodone/Acetaminophen 7.5-325mg tablet, Cranberry 500mg tablet, Lorazepam 0.5mg tablet, and Metformin 500mg tablet. R13's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R13 receives the following medications at 12:00 PM: Buspar 10mg tablet, Carbidopa-Levodopa 25-100mg tablet, Gabapentin 300mg tablet, and Tylenol Extra Strength 500mg tablet. These same documents indicate R13 receives the following medications at 5:00 PM: Atorvastatin Calcium Oral 40mg tablet. 146080 Page 5 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R14's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R14 receives the following medications at 12:00 PM: Gabapentin 300mg capsule, Tylenol Extra Strength 500mg tablet, and Gas Relief 80mg tablet. These same documents indicate R14 receives the following medications at 5:00 PM: Tylenol Extra Strength 500mg tab and Gas Relief 80mg tablet. R15's Order Summary Report and MAR, dated June 1st through June 20th, 2025, documents R15 receives the following medications Lasix 40mg tablet and Glipizide 10mg tablet at 11:00 AM and Ascorbic Acid tablet 500mg, Multivitamin tablet, and Dapagliflozin Propanediol 10mg tablet at 12:00 PM. These same documents indicate R15 receives the following medications at 5:00 PM: Escitalopram Oxalate 20mg tablet and Simvastatin 20mg tablet. R16's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R16 receives the following medication at 12:00 PM: Ativan 0.5 mg tablet. These same documents indicate R16 receives the following medication at 5:00 PM: Ativan 0.5mg tablet. R17's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R17 receives the following medication at 12:00 PM: Tylenol Extra Strength 500mg tablet. These same documents indicate R17 receives the following medications at 5:00 PM: Buspar 10mg tablet and Tylenol Extra Strength 500mg tablet. R18's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R18 receives the following medications at 12:00 PM: Tylenol Extra Strength 500mg. R19's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R19 receives the following medications at 12:00 PM: Augmentin 500-125mg tablet and Oxybutynin Chloride 5mg tablet. These same documents indicate R19 receives the medications at 5:00 PM: Oxybutynin Chloride 5mg tablet and Atorvastatin 40mg tablet. R20's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R20 receives the following medications at 12:00 PM: Tylenol Extra Strength 500mg tablet (2 tablets) and Lorazepam 2mg tablet. R21's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R21 receives the following medications at 12:00 PM: Gabapentin 300mg capsule, Tramadol 50mg tablet, and Acetaminophen 650mg tablet. These same documents indicate R21 receives the following medications at 5:00 PM: Acetaminophen 650mg tablet and Metformin 1000mg tablet. R22's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R22 receives the following medication at 12:00 PM: Gabapentin 400mg capsule. These same documents indicate R22 receives the following medication at 5:00 PM: Metformin 1000mg tablet. R23's Order Summary Report and MAR, dated June 1st through June 20th, 2025, document R23 receives the following medication at 12:00 PM: Carbamazepine 200mg (2 tablets). These same documents indicate R23 receives the following medications at 5:00 PM: Clonidine 0.3mg (Give 0.45mg) and Metformin 500mg. On 6/20/25 at 8:55 AM, V8/RN (Registered Nurse) was standing at the A/C medication cart. V8 opened the top drawer, where 12 cups of medication were set up for administration for R2, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, and R23 labeled for 12:00 PM. V9 verified at this time R2's 12 PM 146080 Page 6 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Glipizide 5mg tablet and Hydrocodone/Acetaminophen 7.5-325 mg tablet, R13's Buspar 10mg tablet, Carbidopa-Levodopa 25-100mg tablet, Gabapentin 300mg tablet, and Tylenol Extra Strength 500mg tablet, R14's Gabapentin 300mg capsule, Tylenol Extra Strength 500mg tablet, and Gas Relief 80mg tablet, R15's Lasix 40mg tablet, Glipizide 10mg tablet, Ascorbic Acid 500mg tablet, Multivitamin tablet, and Dapagliflozin Propanediol 10mg tablet, R16's Ativan 0.5 mg tablet, R17's Tylenol Extra Strength 500mg tablet, R18's Tylenol Extra Strength 500mg, R19's Augmentin 500-125mg tablet and Oxybutynin Chloride 5mg tablet, R20's Tylenol Extra Strength 500mg tablet (2 tablets) and Lorazepam 2mg tablet, R21's Gabapentin 300mg capsule, Tramadol 50mg tablet, and Acetaminophen 650mg tablet, R22's Gabapentin 400mg capsule, and R23's Carbamazepine 200mg (2 tablets) were removed from their original packaging and placed in the medication cups to be administered at 12:00 PM. In the top of the A/C medication cart 10 other cups of medication were set up for administration for R2, R13, R14, R15, R16, R17, R19, R21, R22, and R23 labeled for 5:00 PM. V9 verified at this time R2's Pregabalin 75mg tablet, Risperidone 0.25mg (3 tablets), Glipizide 5mg tablet, Hydrocodone/Acetaminophen 7.5-325mg tablet, Cranberry 500mg tablet, Lorazepam 0.5mg tablet, and Metformin 500mg tablet, R13's Atorvastatin Calcium Oral 40mg tablet, R14's Gabapentin 300mg capsule, Tylenol Extra Strength 500mg tablet, and Gas Relief 80mg tablet, R15's Escitalopram Oxalate 20mg tablet and Simvastatin 20mg tablet, R16's Ativan 0.5mg tablet, R17's Buspar 10mg tablet and Tylenol Extra Strength 500mg tablet, R19's Oxybutynin Chloride 5mg tablet and Atorvastatin 40mg tablet, R21's Acetaminophen 650mg tablet and Metformin 1000mg tablet, R22's Metformin 1000mg tablet, and R23's Clonidine 0.3mg (Give 0.45mg) and Metformin 500mg were removed from their original packaging and placed in the medication cups to be administered at 5:00 PM. V8/RN stated, I typically prepare all of my medications ahead of time for the whole day and keep them in the top of the medication cart for each resident in individual medication cups. Sometimes I must leave the facility, so I like to have all my medications already popped out and ready to go in the medication cups. I give my keys to the nursing managers if I must leave the building so they would have access to my medication cart. I know I shouldn't prepare and pop medications out of ahead of time. 146080 Page 7 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to prepare and serve palatable food. This failure has the potential to affect all 47 residents residing in the facility. Residents Affected - Many Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's [NAME] Job Description, undated, documents, Job Summary: The primary purpose of this position is to prepare, serve, and maintain food safety with current federal, state, and local standards, guidelines, and regulations, facility established policies and procedures, and as directed by the dietary manager, to ensure on-going program of food safety and to assist with resident food preferences. Main Duties: Prepare foods in a safe and palatable manner that meets the appearance, taste, and quality expectations of the residents. The facility's 4/3/25 Resident Council Minutes document, Resident say the food is getting worse (eggs are burnt food is watery, food under/overcooked). On 6/20/25 between 11:50 AM through 12:30 PM the residents were served tuna patties. The bottom of the tuna patties was hard and overdone. On 6/20/25 at 9:50 AM R1 stated, The food we get here is burned 30 percent of the time. Most of the time the chicken, tuna patties, and eggs are burned so bad that you cannot eat them. On 6/20/25 at 2:00 PM V12 (CNA/Certified Nursing Assistant) stated, The food is burned almost every other day. On 6/20/25 at 1:55 PM R6 stated, The food is usually burnt when I get it. On 6/20/25 at 2:55 PM R2 stated, The eggs are always burnt. On 6/20/25 at 3:00 PM R21 stated, At least once a day I get served something that is burnt. On 6/20/25 at 3:10 PM R22 stated, The eggs are burnt every day. The food is just terrible. The tuna patty today was like eating a hockey puck. On 6/20/25 at 3:15 R36 stated, The food is always burnt. On 6/20/25 at 8:45 PM V20 (CNA) stated, I have worked at the facility for four to five months and I work second and third shift. The residents do not get offered a bedtime snack every day. On 6/21/25 at 9:45 AM V22 (Dietary Manager) stated, Ever since before this company took over in November 2024, the regulators in the ovens do not work and the oven burns the food. On 6/21/25 at 10:00 AM V25 (Cook) stated, The oven here has burned the food ever since I have worked here. I have been here for over 30 days. 146080 Page 8 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0804 On 6/21/25 at 10:20 AM V18 (CNA) stated, The food served here is usually burnt. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 146080 Page 9 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on record review and interview the facility failed to offer bedtime snacks daily. This failure has the potential to affect all 47 residents residing in the facility. Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's Frequency of Meals policy and procedure dated 12/30/24 documents, Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment. On 6/20/25 at 3:30 PM V2 (Director of Nursing) provided a list of residents with the diagnoses of Diabetes which included R2, R5, R6, R9, R10, R12, R13, R15, R18, R19, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, and R34. On 6/20/25 at 9:50 AM R1 stated, Staff do not offer me a bedtime snack. On 6/20/25 at 1:55 PM R6 stated, I would like a snack at bedtime. I never get one. On 6/20/25 at 2:55 PM R2 stated, I don't get a snack at bedtime. I am diabetic and want one. On 6/20/25 at 3:00 PM R21 stated, I never get offered a snack at bedtime. I have diabetes. On 6/20/25 at 3:10 PM R22 stated he never gets a bedtime snack. On 6/20/25 at 3:15 R36 and R37 both stated they do not get offered snacks at bedtime. R37 stated she has diabetes and never gets a bedtime snack. On 6/20/25 at 3:45 PM V14 (Regional Administrator) stated, All residents should get offered a bedtime snack. On 6/20/25 at 8:45 PM V20 (CNA/Certified Nursing Assistant) stated, I have worked at the facility for four to five months and I work second and third shift. The residents do not get offered a bedtime snack every day. 146080 Page 10 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBPs) and failed to change gloves and complete handwashing after performing catheter care for one of four residents (R1) reviewed for infection control practices in a sample of 38. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions Policy, date 10/28/24, documents Policy: It is this Facilities policy that EBPs are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are a strategy in nursing homes to decrease transmission of CDC (Centers for Disease Control and Prevention)-targeted and epidemiologically important MDRO's (Multidrug-Resistant Organisms) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device, regardless of MDRO status, in addition to residents who have an infection or colonization with CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. Facilities may have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents. Definition: High-contact resident care activities include but are not limited to: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care; any skin opening requiring a dressing. Indwelling medical device- Examples include but are not limited to, central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral inserted central catheter is not considered an indwelling medical device for the purpose of EBP. Procedure: Personal Protective Equipment: 2. Gowns- Staff will wear a clean, non-sterile gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood or bodily fluids, secretions, or excretions and during specific high-contact resident care activities. The facility's Indwelling Catheter Policy, dated 12/23/25, documents Purpose: To provide for and maintain constant urinary drainage, to monitor the kidney functions of the seriously ill resident, and to obtain a urine specimen for diagnostic purposes. Catheter Care: 7. Perform perineal/incontinence per facility policy prior to catheter care. The facility's Perineal/Incontinence Care Policy, dated 9/11/2020, documents Purpose: to provide cleanliness and comfort to the resident, prevent infections and skin irritation, and observe the resident's skin condition. Procedure: 9. Use a clean area of cloth for each area cleansed. Use multiple cloths, if necessary, to maintain infection control practices. 10. Assure all areas affected by incontinence have been cleansed. 14. Remove gloves and perform hand hygiene. 15. Apply clean brief and reapply clothing. R1's admission Record, dated 6/20/25, documents R1 is a [AGE] year-old female who was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Spina Bifida, Paraplegia, Retention of Urine, and Overactive Bladder. R1's Order Summary Report, dated 6/20/25, documents R1 has a Physician ordered Suprapubic Catheter 16fr (French)/10 ml (milliliter). This same Order Summary Report documents, Infection Precautions: Enhanced barrier: staff wear gown/gloves when in direct patient contact every shift. Signage on door. Gown and gloves required for the following high-contact care activities: Dressing, 146080 Page 11 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Bathing/Showering, Transfer, Changing Linens, Providing Hygiene, Changing Briefs/Assist with Toileting, Device Care/Use and/or Wound Care. On 6/20/25 at 10:26 AM V9/CNA (Certified Nursing Assistant) and V10/CNA were preparing to perform R1's Suprapubic catheter care. V9 put her supplies on R1's overbed table. V9 donned gloves and with a soapy rag began R1's catheter care. After V9 completed the washing, rinsing, and drying of the catheter tubing and R1's peri area, V9 (with the same gloves on), applied a new clean incontinence brief on R1, then rearranged R1 in the bed. V9 never changed her gloves or washed/sanitized her hands before applying R1's new incontinence brief or re-arranging R1 in bed. V9 also never wore a gown while performing R1's catheter care. On 6/20/25 at 2:57 PM V9/CNA verified she should have worn a gown during catheter care and should have changed gloves and washed/sanitized hands prior to applying R1's clean incontinence brief and rearranging R1 in bed. On 6/21/25 at 11:08 AM V2/Director of Nursing stated, Any staff member performing high contact care on a resident with an indwelling catheter should wear a gown. V2 stated V9/CNA should have worn a gown while performing R1's catheter care and should have washed her hands and changed her gloves after performing R1's catheter care and prior to applying R1's new incontinence brief. 146080 Page 12 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the kitchen ovens were maintained and in operating condition. This has the potential to affect all 47 residents residing in the facility. Residents Affected - Many Findings include: The facility's Daily Census dated 6/19/25 documents 47 residents currently reside within the facility. The facility's Maintenance Director Job Description, undated, documents, The primary purpose of this position is to maintain the orderly functioning of all equipment in the facility including the kitchen, laundry heating, air conditioning, and elevators as well as purchasing necessary supplies for repairs, maintenance, and emergencies within budgetary guidelines. Assure the proper maintenance and running condition of all equipment in the building including all kitchen appliances and machinery. Supervise repairs and routine maintenance of the building and all the departmental equipment. The facility's Equipment and Supplies policy and procedure dated 11/5/19 documents, Purpose: To ensure the facility provides and maintains routinely to meet the needs of the residents. Formulary supplies and equipment must be available and in good working condition for use at all times to meet the needs of the residents. Equipment in disrepair will be removed from service until in safe and proper working condition. The facility's Food Service Director Job Description, undated, documents, Main duties: Assure proper maintenance of all food service equipment in all kitchen areas in conjunction with the maintenance director. On 6/20/25 between 11:50 AM through 12:30 PM the residents were served tuna patties. The bottom of the tuna patties was hard and overdone. On 6/20/25 at 9:50 AM R1 stated, The food we get here is burned 30 percent of the time. Most of the time the chicken, tuna patties, and eggs are burned so bad that you cannot eat them. On 6/20/25 at 2:00 PM V12 (CNA/Certified Nursing Assistant) stated, The food is burned almost every other day. On 6/20/25 at 1:55 PM R6 stated, The food is usually burnt when I get it. On 6/20/25 at 2:55 PM R2 stated, The eggs are always burnt. On 6/20/25 at 3:00 PM R21 stated, At least once a day I get served something that is burnt. On 6/20/25 at 3:10 PM R22 stated, The eggs are burnt every day. The food is just terrible. The tuna patty today was like eating a hockey puck. On 6/20/25 at 3:15 R36 stated, The food is always burnt. On 6/21/25 at 9:45 AM V22 (Dietary Manager) stated, Ever since before this company took over in 146080 Page 13 of 14 146080 06/23/2025 Countryside Care Center 400 West Grant Street Macomb, IL 61455

F 0908 November 2024, the regulators in the ovens do not work and the oven burns the food. Level of Harm - Minimal harm or potential for actual harm On 6/21/25 at 10:00 AM V25 (Cook) stated, The oven here needs replaced. It does not work correctly. Residents Affected - Many On 6/21/25 at 11:00 AM V21 (Maintenance) stated, I just started coming to this building to help out. I work at the other building most of the time. This building does not have a maintenance supervisor. No one has told me the ovens do not work here. 146080 Page 14 of 14