Inspection·September 18, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wrong person in the group which included V10, Former LPN, after V10 replied with no to message her anymore she realized she text messaged the wrong person and stopped any further text messages regarding R5 and his medical care. V3 stated sending the text message to V10 was an accident and she knew better than to text message a resident's name and medical information but it was a weekend and she needed guidance on how to proceed with caring for R5. V3 stated V1 inserviced her on 9/8/2025 regarding not text messaging resident's names and medical information because it's not secure or encrypted and stated she won't text message resident information again. The Facility's HIPPA Policy and Procedure, dated 6/1/2025, documents this policy applies to all employees with access to personal health information (PHI.) This includes all administrative, clinical and support staff. Definition: PHI: any information recorded in any form, that relates to health, provision of health care that can be linked to an individual. Staff members will receive training on HIPAA policies and procedures, with additional training provided as rules and regulations evolve. This training includes but is not limited to privacy practices, security measures and breach notification procedures. Violations of this policy may result in disciplinary action. Event ID: Facility ID: 145410 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 145410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Breese 1155 North First Street Breese, IL 62230 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prescribe physician ordered medications upon admission for 2 (R1 and R3) of 3 residents reviewed for pharmacy services in a sample of 3. Findings include: 1. R1's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis including anxiety disorder, major depressive disorder, bipolar disorder and panic disorder. R1 was covered by Med A benefits. R1's Hospital Discharge Paperwork, dated 8/7/2025, documents continue these medications which included Austedo XR 24 milligrams (mg) take 48 mg by mouth daily for treatment of depression and Vraylar 3 mg 1 capsule by mouth daily for treatment of depression. R1's Physician's Summary Report, dated 8/7/2025 documented do not send on Austedo XR 24 milligrams (mg) 2 tablets by mouth a day for treatment of depression and Vraylar 3 mg give 1 capsule by mouth once a day for treatment of depression. R1's Medication Administration Record (MAR), dated 8/2025, documents no Austedo 48 mg daily for treatment of depression or Vraylar 3 mg daily for treatment of depression was documented administered. 2. R3's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] and diagnosis including diabetes mellitus due to underlying condition with diabetic polyneuropathy. R1 was covered by Med A benefits. R3's Hospital After Visit Summary, dated 7/18/2025 documents Ozempic 1 mg into the skin once a week for treatment of diabetes was marked out and a handwritten note documented, Not while at facility. R3's MAR dated 8/2025, no documentation staff administered the physician prescribed medication Ozempic 1 mg into the skin once a week for treatment of diabetes. On 9/12/2025 at 2:00 PM V9, Pharmacist stated he receives resident's medication list upon admission to the facility, and he fills the prescriptions he can. When a medication is over the facility $200 threshold per medication he completes a high cost form which shows the current medication and the cost of it and then he documents an alternative lower cost medication and the cost of it then he emails the form to administration at the facility and they forward it to the resident's provider to see what they want to do which is either order the high price medication or chose to prescribe the low cost medication. When he receives a resident's medication list and staff document do not send or not while at facility he doesn't fill or send those medications and doesn't complete a high cost form because staff are communicating not to send the medication and if in the future the facility requests those medications marked that and if they are high cost medications, he would then send the facility the high cost form with an alternative low cost so the resident's provider can approve either medication. V9 stated R3's hospital discharge medication list dated 8/17/2025 was sent to him to fill the medications and the medication Ozempic 1 mg to treat diabetes was documented not while at facility. V9 stated R3 was prescribed no other medication to treat diabetes while she resided at the facility. V9 stated R1's POS dated 8/7/2025 was sent to the pharmacy with handwritten documentation do not send on the medications Austdro 24 mg take 48 mg by mouth daily for depression and Vraylar 3 mg by mouth daily for depression. V9 stated he didn't know what staff documented not to send the medications, but he didn't question it. On 9/12/2025 at 2:25 PM V11, Pharmacy [NAME] Director stated the facility has a $200 threshold for each medication the facility fills, if the medications cost more than that threshold the pharmacy staff are instructed to complete a high cost medication form and documents a lower cost alternative medication on the form and email it to the facility then the provider decides what medication they want to prescribe and the facility sends it back to the pharmacy and the medication is filled. V11 stated R3's Ozempic 1 mg medication to treat diabetes was an injectable and they are always expensive, V11 stated Ozempic is a high-cost medication and cost around $1500.00 a month. V11 stated R1's medication Austrdro 48 mg daily for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 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 145410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Breese 1155 North First Street Breese, IL 62230 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 depression is very expensive and costs $6,000.00 for a 14-day supply and Vraylar 3 mg for depression is also expensive as it cost $700.00 for a 14-day supply. V11 stated these medications for R1 and R3 were not filled from the pharmacy because staff handwrote a note on the medication list that stated, do not send or not while at facility. V11 stated she was the billing director, and she didn't know who documented not to send the medication on the resident's medication lists that were sent to the pharmacy. On 9/16/2025 at 10:00 AM V23, Nurse Practitioner stated she wasn't aware the facility wrote on R1's and R3's admission medication list that was sent to pharmacy with a handwritten note not to fill medications. V23 stated the facility staff don't have the authority to not fill physician prescribed medications and it most definitely should not be occurring. V23 stated R1 has multiple mental health diagnoses including major depressive disorder and abruptly stopping any of those medications including Austedo and Vraylar to treat her major depressive disorder could cause her to downward spiral into a deep depression and ultimately, she could be so depressed she commits suicide. V23 stated R3 had a diagnosis of diabetes and that's what the injectable medication, Ozempic 1 mg was prescribed to treat. V23 stated R3 wasn't prescribed any other medication to treat diabetes while at the facility and she wasn't aware facility staff put a handwritten note on R3's medication list sent to the pharmacy documented, Not while at the facility. V23 stated she should have known staff were making that decision to not treat R3's diabetes because she would have at least ordered staff to check R3's blood sugar a few times a day and if it was high she would've prescribed sliding scale insulin. V23 stated she knows why the facility isn't filling all the resident's medications, it's because residents on Med A have the facility is responsible for paying for their medications and the facility is always harping her to prescribe lower cost medications and she can't sometimes. On 9/17/2025 at 11:00 AM V1 Administrator, V3 Assistant Director of Nurses and V24 Regional Nurse Consultant stated they were not aware of facility staff writing on resident medication lists that are sent to pharmacy with handwritten notes documenting do not send or not while at the facility. V1 stated pharmacy staff should've questioned that because they know facility staff do not have the authority to document a note like that and not to send the medication or notify her or V2, Interim Director of Nurse of what's going on so they can look into it. V1 stated the facility has a $200 per medication threshold and the pharmacy knows that so when there is a high cost medication the pharmacy emails her a high cost form that documents the current prescribed medication and an alternative lower cost medication and she forwards these forms to the provider, the provider ultimately decides what medication is to be prescribed and the facility will pay for it if the resident is on Med A. No staff stated they were aware of staff documenting handwritten notes on residents' medications lists and sending it to the pharmacy. On 9/18/2025 at 11:44 AM V1, Administrator responded to an email and stated, We do not have a formal policy, we request pharmacy provides alternatives and recommendations regarding medications over $200 that must still be approved by the resident physician. No one goes without medications, if there is no alternative to a high cost medication or the physician declines an alternative/generic, the medication is still provided to the resident.An Undated Physician's Orders Entering and Processing Policy, documents to provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and a physician's assistant.) Fax or call the orders to the appropriate pharmacy as needed. If pharmacy is integrated with EHR (Electronic Health Record), orders will be automatically transmitted. Notify the resident's physician (if not the prescribing physician), for verification if applicable. Event ID: Facility ID: 145410 If continuation sheet Page 4 of 4