Health inspection·September 16, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete from the facility on 8/21/2025 for safety reasons.On 9/9/2025 at 11:25 AM V10's background checks were requestedOn 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed.On 9/11/2025 at approximately 1:30 PM V1 stated that she is responsible for the background checks. V1 stated that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that the background checks are to be completed upon hire and should have been completed.The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A. The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people. Event ID: Facility ID: 145438 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 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. The Immediate Jeopardy began on 9/30/2024. The survey team validated the abatement on 9/15/2025 at 10:46 AM. The facility remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan. R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively intact.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that R4 reported that a few weeks ago, kitchen staff member used inappropriate language towards him. R4's Serious Injury Incident and Communicable Disease Report, dated 6/24/2025, documents that on 6/20/25 V1, Administrator, R4 stated that a few weeks ago, kitchen staff member used inappropriate language towards R4. V10, Cook, immediately suspended per protocol. It continues to document that (R4) was initially interviewed and stated that he was in the dining room rear the kitchen doors when (V10), who was in the kitchen, used inappropriate language towards him. (R4) could not recall the date but stated it was a few weeks ago. (R4) could not recall if anyone was else heard the language. On 6/24/25(R4) was interviewed again. (R4) still could not recall if anyone else heard the language or when the incident happened. When asked if anything else was said during the conversation with (V10), (R4) could not recall anything. When asked if he could have misunderstood what (V10) said because of the noise that is in the kitchen, he agreed that it was possible. In conclusion, the facility was unable to substantiate the allegation of verbal abuse. Due to the noisy environment of the kitchen, this was a misunderstanding of words spoken. On 9/9/2025 at 1:10 PM R4 stated that this occurred sometime ago around April, May or June. R4 stated that R4 was in the dining room. R4 stated that that he complained about his food being cold and (V10) said that (V10) was going to whoop R4's ass. R4 stated that he had so many feelings from anger to fear. R4 stated that he was startled, embarrassed and ashamed being talk to that way. R4 stated that he feared he would have to fight V10. R4 stated that he would if he had to but why should he have to. R4 stated that it's hard to be on pins and needles every day. R4 stated that he didn't want to come out of his room while V10 worked at the facility. R4 stated that when he learned that V10 had gotten fired he felt relieved and safe. R4 stated that the facility did ask question about the incident, but they don't believe him. R4 stated that he knows what he heard and how he felt. On 9/9/2025 at 11:25 AM asked V1 for V10's background checks. On 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed or if there were any offenses.On 9/10/2025 at 11:43 AM asked V1 for V12, Dietary Aide, V17, Housekeeper, V18, Maintenance, V19, Cook, and V20, Cook, healthcare worker registry and background checks. As of 9/11/2025 at 4:00 PM the facility had not provided V10's registry and background checks.On 9/11/2025 at approximately 1:30 PM V1 stated that under the previous ownership the background check facility stopped servicing the facility due to nonpayment and no one followed up. V1 stated that V17's, and V19's Healthcare worker registry checks and background checks were not completed timely. V1 stated that V12's, V18's, and V19's Healthcare Worker Registry and Background checks had not been completed at all. V1 stated that she is responsible for the background checks. V1 stated Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 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 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that after finding that V10's background checks were not completed V1 then checked other hires. V1 stated that on 9/9/2025 and 9/10/2025 she ran background checks for employees hired in June and July as they were not done. V1 stated that V6's, CNA, and V16's, CNA, Healthcare worker registry checks and background checks were not completed. V1 stated that V6, V12, V16, V17, V18, V19 and V20 all have direct access to the resident and checks should have been done. V1 stated that prior to performing the Healthcare Worker Registry and Background checks herself on 9/9/2025 and 9/10/2025 she was not aware of any offenses that each employee had or if they were eligible to work in the facility. V1 stated that the background checks are to be completed upon hire and should have been completed.On 9/11/2025 at 2:44 PM V21, Medical Director, stated that he would expect the staff to follow the policy and guidelines set forth by the state regarding Healthcare Worker Registry and Background checks. V21 stated that the residents in the facility are vulnerable and need protection. V21 stated that it is imperative that the background checks are done and timely because you never know who is or will harm someone. V21 stated that the background checks should have been done. The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A. The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.On 9/9/2025 the facility provided a facility matrix and room roster identifying 79 people residing in the facility. The Immediate Jeopardy that began on 9/30/2024 was removed 9/15/2025, when the facility took the following actions to remove the immediacy:A) Administrator was in-serviced by the VP (Vice President) of clinical services on background checks & the need to run prior to staff member working on 9/15/2025.B) Administrator will in-service department heads on ensuring that staff will not work without background check being completed on 9/15/2025.2. A) All staff members that are currently on the working schedule have had a background check completed & are eligible to work in a skilled facility. Completed 9/15/2025.B) Initial audit completed for all current employees, that a background check has been completed. Completed 9/15/2025.C) Review of current policy and procedure to reflect current practices. Completed 9/15/2025.1. No staff will work before having a background check. On-going2. A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to 1st working day. Administrator and department manager. On going. 3. Root Cause Analysis Completed for background checks. Deficiency: Failed to run background checks on new employees prior to them working their 1st shift. Event ID: Facility ID: 145438 If continuation sheet Page 4 of 4