Countryside Care Center

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

would do nothing but sit at the nursing station and watch movies on (V8's) phone, and that they never saw (V8) take the medication cart up and down the hallway for the heavy 6:00 am medication pass or passing medications. I think that (V8) was very strategic with certain Resident's depending on their cognition as far as not giving medications. I told V1 (Administrator), V19 (Former Director of Nursing/DON), V5 (Assistant Director of Nursing/ADON) multiple times about (V8) not doing the job, then I would come on shift and have to clean everything up and deal with it. (V8) should have given medications and sent out (Resident R4) and (Resident R9) to

the hospital way before us first shift nurses got in. Those poor Residents sat there for hours without (V8) monitoring or helping them.On 8/30/25 at 11:44 am, V8 (Agency Registered Nurse/RN) stated They came to me about (Resident R9) not breathing well, but (Resident R9) had COPD for gosh sakes, so (Resident R9) was not going to be breathing well. I did give (Resident R9) a nebulizer that morning, but I did not sign it out. (Resident R4) was so confused, did anyone take into consideration that (Resident R4) probably does not remember getting his medications. Honestly, does it really matter on medications if a dose, here or there, does get missed. As far as I am concerned, if I signed it, I gave it.On 9/2/25 at 9:54 am, V4 (Ombudsman) stated, I heard they had problems with a night shift nurse over there, from the Residents. Something with medications and not sending people out to the hospital.On 8/29/25 at 11:10 am, V5 (Assistant Director of Nursing/ADON) stated, I did hear the staff and Residents complaining about (V8) not doing his job. We needed our third shifts covered and needed him still to come in. I am not quite sure if (V19/Former DON) was still working here or not, so I am not sure who really took care of the issues. (V8) was in charge of the entire building on night shift, since there was only one nurse on duty. I would hear that he would leave sometimes for lunch and that definitely was not allowed. We ended up terminating (V8) through the Agency due to all of these issues.On 8/29/25 at 10:10 am, V1 (Administrator) stated, (V8) was employed through an Agency and because we were aware that (V8) was not performing the job duties, so we ‘DNR'd/Do Not Rehire. (V8), so basically (V8) was terminated.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

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 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the corner of the mat to keep it flat. It lasted a couple of days then it rolled back up again.On 8/28/25 at 4:45 PM V4/Ombudsman stated that she had come into the facility and saw Resident R1's face was bruised under both eyes and across Resident R1's nose. Resident R1 told V4 that she (Resident R1) had tripped over a rug. V4 also stated that she was told by Resident R2/Resident Council President that management was made aware of the rug being a trip hazard

before Resident R1 fell.On 8/29/25 at 10:05 AM, V1/Administrator stated that there was a nine foot long by four-foot-wide nonskid mat in front of the entry door. The mat extended past the front of the staff breakroom.

The weekend before Resident R1 fell on Tuesday 8/5/25 the residents had complained to V13/Registered Nurse that

the rug was in disrepair and needed replaced. V13 told V1 about the residents' complaints. A new mat was ordered on 8/4/25 but the worn mat was not removed until after Resident R1 tripped and hit her head on the staff breakroom door. After Resident R1's injury on 8/5/25 the rug was removed to prevent any other accidents.On 8/29/25 at 11:36 AM, V14/Maintenance stated that a few days before Resident R1 tripped they (staff) had talked about removing the rug. They were saying Someone is going to trip over it then (Resident R1) did. I carried it (the mat) to

the dumpster the same day that (Resident R1) fell.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

co-workers and that V6's contract was not going to be renewed.On 8/29/25 1:50 pm, V5 (Assistant Director of Nursing/ADON) stated (V19/Former Director of Nursing) put her notice in and I think her last day was 6/10/25, then we went without a Director of Nursing for a while. (V6) was on a thirteen-week contract, but (V6) got terminated for multiple reasons. (V6) was not documenting falls and medications, although (V6) was asked to several times. I know there was an issue with (Resident R5's) Morphine because almost a whole bottle went missing on V6's shift and the Morphine was not documented by (V6), they never found the narcotic count sheet or the bottle of Morphine. I am not sure who investigated that, I never heard much more about it.On 8/30/25 at 10:30 am, V23 (Corporate Nurse) stated, (V6/Contracted LPN) was a contracted employee

on a 13-week contract, but we terminated the contract on 8/11/25. We did not do an entire investigation on

this missing Morphine. I cannot see where Pharmacy, Physician, Residents or other employees were interviewed. We never found the empty bottle of Morphine either.

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If continuation sheet