Health inspection·July 7, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's rooms are maintained at comfortable temperature for 2 out of 3 residents (R1 and R2) reviewed for homelike and comfortable environment in a sample of 4. Findings Include: 1. R2's Face Sheet, print date of 07/07/25, documented he has diagnoses of but not limited to Chronic obstructive pulmonary disease, obstructive sleep apnea, and Ischemic Cardiomyopathy. R2's Minimum Data Set (MDS), dated [DATE], documented he is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he is dependent on staff or requires substantial/maximal assistance with his activities of daily living (ADLs). On 07/02/25 at 1:40 PM, R2 was lying in bed with just a sheet on the lower half of his body. He did not have on any clothing on the upper half of his body. He had a small osculating fan sitting on his over the bed table blowing directly on him. The room was warm and stuffy. R2's room did not have any air conditioning vents in it and there was no individual air unit of any kind in his room. On 07/02/25 at 1:40 PM, R2 said they have been having problems with the air in the facility for the last four or five days. He said it has been getting hot in his room and the only air vents are out in the hallway, and he doesn't have any in his room. R2 said they have been checking the temperatures in the hallway, but they haven't checked the temperature in his room. R2 said he has heart problems and doesn't tolerate the heat very well. He said when the Certified Nursing Assistants (CNAs) come in and do patient care and they shut the door it gets even hotter. He said the CNAs are sweating and he even starts to sweat. He said sometimes it feels like it is over 100 degrees in there. On 07/02/25 at 2:50 PM, R2 stated they came in and offer to move him to another room after this surveyor had left the room. He said they had never offered before that. He said they also came in and temped his room and they had never done that before either. R2 said they didn't tell him what the temperature was after they took it. This surveyor took a calibrated thermometer into R2's room and asked if I could test and see how hot it was in his room, and he agreed. This surveyor laid the thermometer on the over the bed table with nothing touching it. This surveyor stayed in the room and talked with R2 and after five minutes of lying on the table the thermometer read 79 degrees. This surveyor continued to speak with R2 and after another five minutes the thermometer was checked again and it still read at 79 degrees. This surveyor was just standing in the room with R2 and had sweat on my forehead. R2 said the room even gets hotter than it was now especially between 10:00 AM and 11:00 AM Page 1 of 3 145410 145410 07/07/2025 Evercare of Breese 1155 North First Street Breese, IL 62230

F 0584 when the sun is directly over his part of the building. Level of Harm - Minimal harm or potential for actual harm 2. R1's Face Sheet, print date of 07/07/25, documented R1 has diagnoses of but not limited to Chronic Embolism and Thrombosis of unspecified vein, urinary tract infection, and disorder of the bone. Residents Affected - Few R1's MDS, dated [DATE], documented R1 is cognitively intact with a BIMS of 15 out of 15 and she requires substantial/maximal assistance to dependent on staff for her ADLs. On 07/02/25 at 1:30 PM, R1 said they have been having an issue with the air conditioner. She said the first night it was out she sit up for four hours because it was so hot, and she was unable to sleep. She said finally one of the nurses got her a fan and she was able to get some rest. She said sometimes the heat in the room gets bad and it is miserable in there. R1 said they are waiting on a part for the air conditioner. On 07/02/25 at 1:30 PM, V4, CNA said it has been hot on the hallway and the air hasn't been working for a few days. She said she knows they have been trying to get someone to come in and look at it. V4 said they gave the residents box fans to help with the heat but trying to work in the heat was miserable. On 07/02/25 at 1:50 PM, V5, Licensed Practical Nurse (LPN) said it was the weekend before this last weekend is when the air went out. She said she knows because she was working that weekend. V5 said she call management and told them what was going on, but they didn't do anything. She said they told them to close the blinds and to turn off the lights. V5 said all the residents were miserable. V5 said they didn't offer to move any of the residents that she is aware of. She said the nurse's stations doesn't have any air conditioning vents in the hallways are the only vents there are the residents don't have vents in their rooms. V5 said they had their maintenance guy look at it and the regional maintenance director came in and said it's hotter than Satan's Breath in here. On 07/02/25 at 1:50 PM, The east wing nurse's station was warm and muggy. On 07/02/25 at 2:15 PM, V7, CNA said they have been having an issue with the air not working right for a couple of weeks now. She said it has been miserable in the building for the residents and the workers especially during that hot spell they had not too long ago. On 07/07/25 at 9:40 AM, Room temperature (temps) log was reviewed and documented temps were taken on 07/03/25, 07/04/25, 07/05/25, 07/06/25, and 07/07/25 there were no room temps documented prior to 07/03/25. The temperatures were as follows: R2's room temperatures: 07/03/25 at 09:09 AM room was 76 degrees and at 12:42 PM room was 79 degrees. 07/04/25 at 10:07 AM room was 75 degrees. 07/05/25 at 11:41 AM room was 76 degrees. 07/06/25 at 08:23 AM room was 76 degrees. 07/07/25 at 08:15 AM room was 75 degrees. 145410 Page 2 of 3 145410 07/07/2025 Evercare of Breese 1155 North First Street Breese, IL 62230

F 0584 R1's room temperatures: Level of Harm - Minimal harm or potential for actual harm 07/03/25 at 09:09 AM room was 76 degrees and at 12:41 PM room was 78 degrees. 07/04/25 at 10:07 AM room was 75 degrees. Residents Affected - Few 07/05/25 at 11:41 AM room was 77 degrees. 07/06/25 at 08:22 AM room was 74 degrees. 07/07/25 at 08:15 AM room was 74.9 degrees. Facility grievance, dated 06/24/25, documented residents were wanting air conditioners in their rooms. The facility's policy Extreme Temperatures, with a review date of 06/30/25, documented Purpose To assure the comfort and safety of residents and to prevent heat stress of residents during periods of extreme heat. 145410 Page 3 of 3