Health inspection·March 21, 2025

F 0684 hold the medication of R1 due to a report from facility nursing staff that it was a possibility that R1 was being double or tripled dose by V5, her daughter. Level of Harm - Actual harm Residents Affected - Few On 3/20/25 at 9:37 AM V16 Licensed Practical Nurse ( LPN) stated she was the one that was passing medications to R1 when she requested her new pill. As she (V16) was explaining to her that she did not have a new pill. R1 kept repeating that she had a new pill. R1 called her daughter (V5) and the conversation between the two of them was (R1) telling (V5) her daughter that she was not being given the new pill. (V5) R1's daughter came to the facility with a bottle of medicine and wanted it to be given to her mother. (V5) was advised that we could not give the medicine and we would need to obtain an order for the medication. On 3/20/25 at 11:31 AM V17 Nurse Practitioner stated she was on vacation for 2 weeks and V7 Psychiatric Nurse Practitioner (NP) was covering for her. V17 stated she was aware that (R1) was being followed by specialists but do not have any interactions with the specialists. V17 stated she was unaware of the labs ordered by the nephrologist. When she returned from vacation she did have an email from V7 advising that there was a possibility that R1 was receiving double dosages of a medicine thought to be an antibiotic. The move to hold the medication was based on not having any information as to why R1 was on any medication besides what was prescribed. V17 stated the expectation was for the specialist to contact us if they have any concerns. If she had any concerns she would contact them. On 3/20/25 at 11:43 AM V7 Psychiatric Nurse Practitioner stated she was not the regular provider for (R1). The nurse practitioner (V17) was on vacation and she (V7) was just covering for (V17). V7 stated she went with the information that was provided from the staff. The staff assumed (R1) was receiving double or triple doses of some type of medication. She (V7) did not know what the medication was and the staff did not specify the medication because they did not know. What was reported was (V5) the daughter was providing the medication to her mother (R1). On 3/20/25 at 12:25 V4 Social Service Director stated when (V5) daughter of R1 returned her mother (R1) to the facility she (V5) did not bring the medication or share that her mother was on a prescribed medication. We became aware of some medication only after the mother (R1) began asking about her new pill. On 3/20/25 at 4:20 PM V2 Director of Nursing stated we did what we were supposed to do. The staff continued to give prescribed medication until able to contact a provider. The order was via email dated 3/14/25 to Hold medications and to monitor (R1). Staff continued to monitor R1 until she was sent to the emergency room 3/17/25. R1's medical records from a local hospital dated 3/17/25 documents residents seizure medications were stopped few days ago per the order of nursing home staff after they had negative interactions with (V5) patient's daughter . While in Triage patient had a tonic seizure lasting less than 1 minute. Patient was postictal and had a nasal trumpet inserted. On 3/21/25 at 10:26 AM V22 Medical Director stated the Nurse Practitioner's should be having contact with the specialist. On 3/21/25 at 2:30 PM V26 pharmacist stated the nurse practitioner dropped the ball, the nurse practitioner should have reviewed the medication before 3 days. It is definitely concerning because Lacosamide has a half-life of 13 hrs and Keppra has a half life of 6-8 hrs. Those meds are significant, while overdosing might be a concern, review of the medication and further assessment was warranted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 2 of 5 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 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 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 0684 Do not feel the facility was at fault, the problem lies with the nurse practitioner as a provider not reviewing or assessing the resident sooner. Level of Harm - Actual harm The facility did not have a policy on Continuity of Care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 3 of 5 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 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a diagnosis of epilepsy/seizures received their anti-convulsant medications as ordered by the physician for 1 of 3 (R14) residents reviewed for medications in the sample of 3. This failure resulted in R14 missing 10 doses of his anti-convulsant medication and requiring evaluation and treatment in the emergency room (ER) following seizure activity. Residents Affected - Few Findings include: R14's facesheet dated 4/29/25 documents his diagnosis to include epilepsy, unspecified, intractable, without status epilepticus and localization-related (focal) (partial) symptomatic epilepsy, epileptic syndromes with complex partial seizures, intractable, without status epilepticus, and other seizures. R14's care plan dated 4/29/25 documents The resident has a seizure disorder. Interventions for this care plan include give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. R14's medication administration record (MAR) dated 3/1/25-3/31/25 documents R14 did not receive his oxcarbazepine (anti-seizure medication) oral tablet 600 mg (milligrams) two tablets at 6:00 PM on 3/29/25 and at 8:00 AM on 3/30/25. R14's progress note dated 3/29/25 at 5:05 PM documents: orders-administration note oxcarbazepine oral table 600 mg give 2 tablets by mouth two times a day for epilepsy-awaiting med. R14's progress note dated 3/30/25 at 8:47 AM documents his oxcarbazepine was not available and reorder awaiting pharmacy. R14's [DATE]/30/35 at 8:39 AM documents R14's lacosamide oral tablet (anti-seizure medication) 100 mg give one tablet by mouth two times a day for epilepsy was not available, reordered awaiting pharmacy. R14's MAR dated 4/1/25-4/30/25 documents he did not receive his lacosamide on 4/3/25 (PM dose) 4/6/25 (PM dose) 4/7/25 (PM dose) and 4/8/25 (AM and PM dose). R14's Controlled Drug Receipt/Record/Disposition Form dated 3/22/25 documents he ran out of his lacosamide 100 mg tablets on 4/5/25 after PM dose. R14's Drug Receipt/Record/Disposition Form dated 4/9/25 documents he did not receive his next dose of lacosamide until 4/9/25 at 8:30 AM. There is no documentation on these count sheets of R14 receiving AM doses of lacosamide on 4/6/25 or 4/7/25 AM doses. R14's progress note date 4/1/25 at 4:45 PM documents Seizure activity noted in bed. Clonic episode lasting 2.5 minutes. Emesis noted. Resident placed in recovery position until seizure completion. EMS called. Post ictal phase noted with pupils dilated to 6. Walking around room without purpose and combative with staff. Unable to answer questions or respond appropriately. VS: 98.2, 88, 22, 131/74, and 95% on room air. No signs of pain or injury. Sent to (local hospital) for evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 4 of 5 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 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 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 0760 Level of Harm - Actual harm Residents Affected - Few On 4/29/25 at 12:50 PM V6 Nurse Practitioner stated she was first notified by staff to refill R14's lacosamide on 4/8/25. V6 stated she was reviewing R14's information from 4/6/25 and 4/7/25 and was not notified, but she would not know if staff reached out to another provider. V6 stated yes, it would be significant for R14 to receive anti-seizure medication since R14 has had seizures since the age of 9 and R14 is a difficult case and he needs to take his anti-seizure medications as ordered. On 4/29/25 at 1:50 PM V7 Pharmacy [NAME] Lead stated pharmacy was notified by fax on 4/8/25 at 7:21 PM requesting refill on R14's lacosamide. On 4/29/25 at 1:55 PM V8 Pharmacist stated lacosmide has a half-life of 13 hours, and R14 would have been sub therapeutic after 24-30 hours. V8 stated lacosamide was filled by pharmacy on 4/8/25 and started on 4/9/25. V8 stated R14 was sub therapeutic on 4/8/25 and 4/9/25 and was therapeutic by 4/10/25. V8 stated R14 was not therapeutic for 1 day and would not recommend doing this again. V8 stated R14 dodged a bullet that R14 did not have a seizure during that time. V8 stated he would consider this a significant medication error. V8 stated it is never recommended that a resident with a history of seizures misses any of their medication. On 4/29/25 at 1:22 PM V9 Registered Nurse (RN) stated she does not recall R14 ever being out of lacosamide, and if she pulled from pharmacies emergency stock of medication it would have been documented on a sheet. V9 stated she does not remember ever pulling a lacosamide for R14. V9 stated she is unsure of where she got R14's lacosamide doses on 4/625 and 4/27/25. On 4/29/25 at 2:20 PM V2 Director of Nursing (DON) stated as part of the plan of corrections she was auditing residents who took seizure medications. V2 stated if she saw a missed medication she would educate the nurse, and then should have documented everything in the resident's electronic medical record (EMR). V2 stated she went back and had to put late entries in some of the resident's progress notes related to missed medications. V2 acknowledged R14's controlled drug receipt/record/disposition form that stated R14 ran out of lacosamide after 4/5/25 PM and did not resume until 4/9/25 AM. V2 stated she has no idea how V9 RN would have gotten and documented lacosamide since the medication was not in the facility. V2 stated V11 Medical Doctor (MD) was called on 4/8/25 letting him know R14 needed a signed script for lacosamide. V2 unable to provide documentation of why R14's lacosamide was not refilled and available on 4/6/25. On 4/30/25 at 10:48 AM V2 stated lacosamide is not included in the emergency kit. The facilities policy revised 7/18/18 Emergency Pharmacy and Emergency Kits documents, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication kit/box or by special order from MAC Rx. MAC Rx supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the resident. The facilities policy undated policy Receiving Controlled Substances documents Procedures: H. Controlled substances are reordered when a four (4) day supply remains to allow for transmitted of the required written prescription to the pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 5 of 5