Inspection·September 25, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R36's MDS, dated [DATE], documents, that R36 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. On 9/18/23 at 10:30 AM, V34, Certified Nurses Aid, (CNA), stated R36 requires redirection frequently because he wanders through the unit. V34 stated R36 will grab onto staff and you must redirect him to get him to let go of you. On 9/18/23 at 1:15 PM, R36 is observed walking up behind V35, CNA, and grabbing her sides. It appeared R36 was trying to pick V35 up. On 9/18/23 at 1:15 PM, V35 was telling R36 to let go of her and trying to redirect him. R36 did let V35 go, and he was redirected down the hall. On 9/19/23 at 10:50 AM, V16, Registered Nurse, stated, (R36) is inappropriate for the Memory Unit because of his behaviors. He is physically aggressive and sexually inappropriate with staff. He really hasn't hurt any residents, but he will grab them. V16 stated, I am very worried for the residents safety when I am not here because of him. On 9/19/23 at 11:30 AM, V1, Administrator, stated he is new here, but from what I have seen of (R36), (R36) is not your typical Dementia patient. I believe he has something else going on, but again I have only been here a few days and haven't really got into him yet. I am trying to find other placement for (R36) because (R36) would be better suited for a quieter place. V1 stated R36 does ambulate through the unit, and he will grab onto staff and other residents. On 9/19/23 at 12:45 PM, V3, RN/Memory Unit Manager, stated, (R36) is aggressive and sexually inappropriate with staff. (R36) will grab onto staff, and he has to be redirected to get him to let go. V3 stated he has had physical altercations with residents, but he is not sexually inappropriate with residents. V3 stated R36 reminds her of someone that is on the Autism Spectrum. He has the behaviors of someone who is Autistic, he is very tactile, and will stare off like he is not even looking at you. (R36) is basically nonverbal. 2. R17's Face Sheet, print date of 9/19/23, documents R17 was admitted on [DATE] and has diagnoses of Anxiety and Dementia. R17's MDS, dated [DATE], documents, that R17 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. The facility Abuse Investigation, undated, documents, Upon investigation through chart reviews, surveillance, and staff interview, on February 8, 2023, at approximately 4:00 PM, (R36) was walking around dining room where her walked up to (R17) who was coloring to observe her work. (R36) reached out to pick up a crayon at the same time (R17) reached out to pick up another crayon and (R36) grabbed onto (R17's) right arm instead. (R17) attempted to pull her right arm back creating a skin tear to her right forearm. (R17) then responded by contacting (R36's) arms with her left hand. 3. R208's Face Sheet, print date of 9/20/23, documents R208 was admitted on [DATE] and has diagnosis of Dementia. R208's MDS, dated [DATE], documents R208 is severely cognitively impaired and is independent with ambulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 2 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R208's Care Plan, dated 6/2023, documents, Mental Wellness. I have a diagnosis of Dementia with behavioral disturbances. I have behaviors of exit seeking, combative and resistive to care, banging on exit doors, pacing and looking for my truck. The facility Abuse investigation, undated, documents, Upon investigation through chart reviews, staff interviews, and surveillance, on April 30, 2023, at approximately 5 PM, (R36) was sitting in the lounge area and (R208) was at a dining table waiting for mal trays. (R208) received his meal tray and staff walked over to (R36) to direct him to a dining table on the other side of the room. As (R36) walked past (R208), he saw a container of ice cream and quickly picked it up. (R208) reacted by striking (R36). Additional staff members responded, and the residents were immediately separated. No injuries occurred for either resident. 4. R33's Face Sheet, print date of 9/20/23, documents R33 was admitted on [DATE] and has a diagnosis of Dementia. R33's MDS, dated [DATE], documents R33 is severely cognitively impaired and that R33 requires extensive assistance of one staff member for locomotion and that he uses a wheelchair. R33's September Behavior Tracking documents multiple entries of R33 wandering. R19's Face Sheet, print date of 9/18/23, documents R19 was admitted on [DATE] and has diagnoses of Dementia and Anxiety. R19's MDS, dated [DATE], documents R19 is severely cognitively impaired. The facility Resident Incident Report, dated 9/17/23, documents, reported per CNA that this res (R33) and male peer (R36) had gone into female's peer's (R19) room. (R33) had a hold of (R19's) elbow while (R36) had a hold of (R19's) right wrist and fingers. CNA able to redirect (R33) and he let go. (R19) peer then reached up and slapped (R36). 5. R17's Face Sheet, print date of 9/19/23, documents R17 was admitted on [DATE] and has diagnoses of Anxiety and Dementia. R17's MDS, dated [DATE], documents R17 is severely cognitively impaired, requires extensive assist of 2 staff members for transfers and extensive assistance of 1 staff member for ambulating. R19's Face Sheet, print date of 9/18/23, documents R19 was admitted on [DATE] and has diagnoses of Dementia and Anxiety. R19's MDS, dated [DATE], documents R19 is severely cognitively impaired. R17's Resident Incident Report, dated 9/15/23 at 4:20 PM, documents, (R19) had swung at (R17) over peer attempting to use the crayons. (R17) then grabbed (R19's) arm causing scratches and skin tears. 5 cm, (centimeters), scratch x 2 left forearm 1 cm scratch and 5 cm scratch left forearm and .2 cm skin tears left forearm. The Abuse Prevention- Illinois Only policy, dated 11/17/23, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 3 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Definitions: a) abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. Event ID: Facility ID: 145519 If continuation sheet Page 4 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, observation, and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 2 residents (R18, R36) reviewed for abuse in the sample of 58. Residents Affected - Few Findings include: On 9/19/23 at 10:50 AM, V16, Registered Nurse, stated, (R36) is inappropriate for the Memory Unit, because of his behaviors. He is physically aggressive and sexually inappropriate with staff. He really hasn't hurt any residents, but he will grab them. V16 stated, I am very worried for the residents, safety when I am not here, because of him. A night nurse (V17, Licensed Practical Nurse, (LPN)) has told me that she caught (R36) in the bed of his roommate (R18) rubbing his chest and stuff. (V17) told me it has happened a few times. I guess it started around May. V16 stated she did not know if V17 had reported the incident to the Administrator. V16 was questioned if she had reported it to the Administration, V16 stated, No, it was hearsay. I never saw (R36) do anything, sexually inappropriate to any resident. That's why. I was friends with (R18's) daughter and she has passed away. All I think of is she is up in heaven saying, '(V16) why are you not protecting my Dad?' On 9/18/23 and 9/19/23, R36's Nurses Notes were reviewed, and there was no documentation of an incident between R36 and R18. On 9/19/23 at 1:30 PM to 2:30 PM, the abuse investigations involving R36 were reviewed. An abuse investigation involving R38 and R18 was not available for review. R38's abuse investigations did not document any sexually inappropriate behavior. On 9/19/23 at 2:40 PM, V1, Administrator, V2, Director of Nursing, and V27, Regional Nurse Consultant, all were notified of the allegation of abuse between R36 and R18. All three denied knowing about the allegation. V1 stated he will start an investigation immediately. V1 stated any staff member that sees, hears of, or suspects any type of abuse, must report it to him immediately. On 9/20/23 at 9:00 AM, V1, stated he has interviewed V16, and she had stated she did not report it, because it was hearsay. (V17) was interviewed and she has told different stories which I cannot make any sense out of. She told me that she had documented, it in the Nurses' Notes. I have gone back and reviewed his entire record of Nurses Notes and there was one very vague note, dated back in June, that I had found of hers documenting, that he is physically aggressive toward staff and sexually inappropriate as witnessed/experienced and reported. The note did not elaborate on anything else. I have one Certified Nurse Aide, (CNA), that said she had overheard (V16) and (V17) talking about it. All of the other staff members that I have interviewed have never observed or heard about (R36) being sexually inappropriate with other residents. On 9/21/23 at 8:20 AM, V2 stated all of R36's Nurses Notes are missing at this time. On 9/21/23 at 9:30 AM, V1 stated, (V17) has not given me consistent or reliable information. She has changed her story and dates three times. I have reviewed (R18's) Medical Record and there is nothing in his chart either, related to this. I have spoken to (V28, fomer Administrator), and she had no idea of what I was talking about. She told me that an allegation of sexual abuse was never reported to her. I also, have spoken to (V5, Interim Administrator). She began on July 10, 2023, and was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 5 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that position until September 13, 2023. I took over on the 14th. (V5) told me that she did not know anything about an allegation of sexual abuse, and nothing was reported to her. On 9/21/23 at 10:17 AM, V17, stated, There was an incident involving (R36 and R18). I was summoned into (R36's) room by 2 CNA's. I do not remember who they were. I saw (R18) lying on his back in his bed. He did not have a gown on, only an incontinent brief. (R36) had his pajama pants, down around his ankles and his incontinent brief on. (R36) was on his knees straddling (R18) and he was rubbing (R18's) chest, breast like you would a woman. It took all three of us to get (R36) off of (R18). (R18) did not seem to be traumatized by this behavior; I think he was enjoying it. I placed (R36) on one-to-one supervision. I contacted the Executive Director, (V28) and notified the Director of Nursing at that time who is (V3). I never actually spoke with (V28). I just left a message. She never reached out to me about it. So, I documented it on a paper Nurses Note. At that time, we had to do paper charting, because our computer system was hacked. We had to paper chart, from July 9th until the 17th. I did not write a note in (R18's) chart. (V3) told me that she would contact (R36's) Power of Attorney and explain it to her. I tried to contact (R18's wife), but she did not answer. (V3) told me she would tell (R18's wife) when she came to visit today. When I came to work on 9/19/23 (V1 and V2) questioned me about the incident, between (R36 and R18). I told them what had happened, that I had reported it and I charted it in (R36's) chart. (V1 and V2) both stated that they had reviewed the chart and could not find the note. (V1) handed me all (R36's) notes to review. I looked and I couldn't find it. After they left, I was thinking about it, and I knew that what they gave me for review could not have been all the notes. (V16) came up that night and we went and got his chart to look for my notes. My note was in the chart. (V16) took all the notes up to the office and made copies. I wanted a copy of my notes for myself. We put the notes back in his chart. V17 was asked what new intervention was put into place since she reported the incident, V17 stated, (V3) said we are getting rid of him. That's what we are going to do. On 9/21/23 at 11:20 AM, V3 stated she was never told about an incident between R36 and R18, and she never said they were getting rid of R36. On 9/21/23 at 11:25 AM, V2 stated she reviewed all of R36's computer notes and his paper Nurse Note right after they were told of the allegation. V2 stated there was not a paper Nurses Note, about the alleged incident between R36 and R18. On 9/21/23 at 11:30 AM, V1 stated, he reached out to IT (Information Technology) to find out when the computer system was down, and he was told it was only one day and it was July 7, 2023. On 9/21/23 at 3:10 PM, V5, Administrator from July 10, 2023, until September 13,2023, stated she was never told of an allegation of sexual abuse, between R36 and R18. On 9/22/23 at 9:19 AM, V28, former Administrator, stated V17 never told her about a sexual abuse, between R36 and R18. The Abuse Prevention - Illinois Only policy, dated 11/17/23, documents, Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual. Definitions: a) abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 6 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. c) Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault or non-consensual sexual contact of any type with a resident. prevention: Staff members, volunteers, are to report and family members and others must report incidents of abuse. Identification: the Administrator must be immediately notified of suspected abuse or incident of abuse. If such incidents occur or are discovered after hours, the Administrator must be called at home or must be paged and informed of such incident. Event ID: Facility ID: 145519 If continuation sheet Page 7 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete injury report, investigate an injury, and implement identified interventions for one of five residents (R20) reviewed for falls in the sample of 58. Finding include: 1. R20's face sheet, dated 8/28/2022, documents a history of falling. R20's Minimum Data Set, (MDS), dated [DATE], documents R20 requires extensive assistance and one-person physical assistance for bed mobility and transfers. R20's fall risk assessment, dated 8/3/2023, documents a score of 75, with a score of 46 or greater being high risk for falls. R20's Resident incident report, dated 9/17/2023 at 5:30PM, documents, resident was found on floor next to bed and noted purple and red area to right side of head. No open area or drainage noted. The report documents, immediate actions taken fall and a mats was put in place. The facility does not provide any witness statements in regard to R20's fall on 9/17/2023. On 09/18/23 at 11:00AM, V33, R20's wife, was in the dining room. V33 started crying and stated R20 had a fall a couple days ago, and R20 is not the same. V33 stated R20 cannot tell her where he got these bruises. V33 pointed to a bruise on top right side of V33's head and stated, (R20) has a bruise on his hip also. The facility called her and told me (R20) rolled out of bed and was fine. V33 stated R20 stated he did not have a mat beside his bed when he fell. On 9/21/23 11:37AM, V32, Registered Nurse, (RN), stated she was on call for the weekend of 9/16/2023. V32 stated she entered the facility on 9/17/2023 for a short period of time. V32 stated V33 was present at the facility and approached her, and reported to her R20 had fallen out of bed at 11:00PM the previous night. V32 stated V33 asked her if she had been notified as the on-call Nurse. V32 stated she initiated the injury report. The nurse who worked the night shift had notified the Physician, V33, and had started Neurological checks, but had not completed an injury report. V32 stated there were not fall mats in place, beside R20's bed, and she had to physically go find some to put in place. V32 stated R20 was to have fall mat beside his bed. On 9/21/2023 at 2:45PM, V2, Director of Nursing, (DON), stated she would expect staff to complete injury reports, investigate injuries and implement identified interventions for falls. The facility interdisciplinary fall reduction/injury prevention protocol, dated 7/12, documents, each fall is to be investigated as soon as possible post, fall, by all staff members working on that unit. The policy documents, an interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 8 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation, and record review, the facility failed to place a date on vial when a multi-use medication vial was opened, failed to maintain the medication refrigerator at the proper temperature, and failed to maintain a clean refrigerator and not store food in the medication refrigerator. This failure has the potential to affect 37 residents living in the Memory Unit. Findings include: On 9/20/23 at 10:00 AM, the Memory Unit Medication Room was observed. In the refrigerator there was 17 magic cup ice creams, the temperature was 32 degrees. The inside of the door had brown debris on the shelves, and there was an open undated bottle of Tubersol multi-dose vial. On 9/20/23 at 10:08 AM, V3, RN/Memory Unit Manager, stated food should not be kept in the medication refrigerator. They have been having trouble with the temperatures in that refrigerator, and any multi-use vial should be dated when opened. The policy Medication Storage, dated 1/15, documents, 18. Medications requiring refrigeration must be stored between 36 degrees F (Fahrenheit) and 46 degrees F in refrigerator. The policy Guidelines for Shortened Expiration Date, dated 11/10, documents, As a general rule, write the date opened on all multi-dose vials, ophthalmic, inhalers, nasal sprays and sublingual nitroglycerin tablets. Medication: Tubersol. Expiration Date after Opening: 30 days. The Resident Census and Conditions, CMS 672, dated 9/18/23, documents the facility has 37 residents on Memory Care Unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 9 of 10 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 145519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of White Hall 620 West Bridgeport White Hall, IL 62092 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 24 of 24 residents (R6, R9, R12, R13, R17, R19, R26, R32, R33, R34, R35, R39, R48, R56, R58, R63, R68, R71, R73, R77, R85, R91, R93, R207) reviewed for resident living space in the sample of 58. Findings include: On 9/21/23 at 8:50AM, the 8 three-bed resident rooms, (Rooms 51-58) all had three residents residing in each of these rooms. Each room was licensed and available for three residents per room. According to historical measurement data, these eight rooms only provide 77 square feet per resident bed. The following residents reside in these rooms: R6, R9, R12, R13, R17, R19, R26, R32, R33, R34, R35, R39, R48, R56, R58, R63, R68, R71, R73, R77, R85, R91, R93, R207. All eight of these three-bed resident rooms are Medicaid certified. On 9/21/23 at 9:15AM, V1, Administrator, stated the residents are assessed prior to going into these rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145519 If continuation sheet Page 10 of 10