Inspection·July 29, 2025

F 0690 Level of Harm - Actual harm Residents Affected - Few stated that I am a man. Who wants to live like that. R3 stated that he felt it was demeaning and disrespectful too. R3 stated that he doesn't deserve that. R3 stated that he felt like he doesn't matter and less than a man. R3 stated that he was treated like a caged animal. R3 stated that he was treated less than a dog. On 7/28/2025 at 11:55 AM V5, R3's friend, stated that she has been at the facility on multiple occasions when R3 had to wait 45 minutes. V5 stated that she was told by the staff that there is only 1 staff on the hall at that time. V5 stated that R3 shouldn't have sit in filth that long that is ridiculous. V5 stated that R3 was embarrassed that he was wet and that she had to say something for the staff to respond. On 7/28/2025 at 1:17 PM, V6, Licensed Practical Nurse, LPN, stated that she entered R3's room around 8:00 PM and gave R3 his medication. V6 stated at that time R3 said he had an accident and needed to be cleaned. V6 stated that she notified the CNA and was told that she was the only one down on the hall and would have to wait to get someone to help with cleaning up R3. V6 stated that she notified another staff and was informed that they could not go in the room with R3. V6 stated that R3 did call the police. V6 stated that she is not sure of what time approximately 8:15 PM but not for sure. V6 stated that the police did come. V6 stated that she was not sure when the police got to the facility, V6 stated that the police spoke with the resident and the CNA. V6 stated that then the Officer told her that R3 had a bowel movement and needed to be changed. V6 stated that R3 was changed at that time. On 7/28/2025 at 1:54 PM V7, CNA, stated that she was the aide assigned to R3. V7 stated that she is an agency with this being her first time at the facility. Upon entering the facility, she was informed what hall she was on and that she would get help at 6pm from oncoming staff. V7 stated that she was informed to not provide care to R3 alone or you will get in trouble. V7 stated that she did clean R3 prior to supper before 5pm. V7 stated that R3 was incontinent of bowel. V7 stated that she was then informed to feed in the dining room, and she did and stayed in there until about 7:10 PM. V7 stated that she checked her hall, and no lights were on, and she went to lunch returning around 7:40 PM. V7 stated that when she returned the light to R3's room was on. V7 stated that R3 was incontinent of bowel with stool up his side. V7 stated that she left the room to find the other aide that was supposed to have arrived at 6 PM. V7 stated that she was informed that no one came in and no one was scheduled. V7 stated that she could not change R3 at that time because she didn't have help, so she went and helped another resident. V7 stated that by the time someone came to help the police were there. V7 stated that she was interviewed by the police and informed him that she was the only one on the hall. V7 stated that she informed the police that she was informed that she would have help on the hall, but this was not case. V7 stated that she cannot care for R3 alone and had to wait for someone to help her. V7 stated that she was informed that R3 is continent and can ask for help. V7 stated that it is possible that he pushed his button, and it was turned off. V7 stated that she was the only one on the hall and stated that someone could have turned it off and not returned. V7 stated that she was not on the hall from 5:00 PM to 7:40 PM. V7 stated that R3 is alert and oriented and can speak for himself. V7 stated that she would have helped R3 before, but she didn't have any help. On 7/29/2025 at 12:20 PM V2, Director of Nursing, stated that it is the expectation of the staff to round at least every 2 hours and more frequent if needed. V2 stated that if the staff identifies a resident is incontinent, they are to address it immediately. V2 stated that R3 requires 2 CNAs to be in room when providing care. V2 stated that this is to give the staff a witness for allegations. V2 stated that the CNA is to respond to the call light, go ask for help then start gathering supplies and start the process while the other staff is coming. V1 stated that this should take no more than 5 minutes. The facility's Incontinence Policy, dated 6/17/25, documents that the purpose is to prevent excoriation and skin breakdown, discomfort and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145555 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 145555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025 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 0690 Level of Harm - Actual harm maintain dignity. Guidelines: Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provide perineal and genital care after each episode. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145555 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 145555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff to assist residents with incontinent needs to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for 1 of 3 (R3) reviewed for staffing in a sample of 3. This failure resulted in a delay in incontinent care for R3 causing him to feel embarrassment, ashamed, demeaned, disrespected, and unwanted. Findings include:R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and bowel, and requires Partial/moderate assistance with toileting. The Police Report, dated 7/2025, documents on 7-20-25 at 7:38 PM V9, Police officer, responded to facility in reference to patient R3 calling the police to get the nursing staff to help him. Upon arrival met with V10, Charge Nurse. V10 stated that R3 is a problem patient and falsely calls for help and uses up resources even though he doesn't need help. V9 explained to V10 why he was called. V10 stated that her staff will get to R3 when they can, because of shift change and other nursing duties. V9 then found R3 in his room. Overwhelming smell of feces, R3 had feces leaking out of R3's diaper all over his waist area. R3 stated that he turns on the patient signal light for help, but staff comes and turns it off but do not help him. V7, CNA, was present in room helping another patient. V7 seemed overwhelmed and stated that she cannot change R3 by herself. When V7 started her shift, she was supposed to have help, but no one was coming to help her. Advising that the facility was understaffed. After approximately 15 minutes of V9 presence in the room, the staff arrived to help R3. On 7/28/2025 at 11:52 AM R3 stated that he received horrible care at the facility. R3 stated that he laid in urine for 45 minutes. R3 stated that a friend came to visit, and he smelled of strong urine. R3 stated that he was embarrassed and ashamed. R3 stated that he couldn't look his friend in the eyes. R3 stated that that he was sitting in his own crap for so long that he called the police for help. R3 stated he had a bowel movement. R3 stated that he put the light on and nothing. R3 stated that there have been multiple times that the staff come in and turn the light out and never come back. R3 stated that he was covered with bowel. R3 stated that I am a man. Who wants to live like that. R3 stated that he felt it was demeaning and disrespectful too. R3 stated that he doesn't deserve that. R3 stated that he felt like he doesn't matter and less than a man. R3 stated that he was treated like a caged animal. R3 stated that he was treated less than a dog. On 7/28/2025 at 11:55 AM V5, R3's friend, stated that she has been at the facility on multiple occasions when R3 had to wait 45 minutes. V5 stated that she was told by the staff that there is only 1 staff on the hall at that time. V5 stated that R3 shouldn't have sit in filth that long that is ridiculous. V5 stated that R3 was embarrassed that he was wet and that she had to say something for the staff to respond. On 7/28/2025 at 1:17 PM, V6 LPN, stated that she entered R3's room around 8:00 PM and gave R3 his medication. V6 stated at that time R3 said he had an accident and needed to be cleaned. V6 stated that she notified the CNA and was told that she was the only one down on the hall and would have to wait to get someone to help with cleaning up R3. V6 stated that she notified another staff and was informed that they could not go in the room with R3. V6 stated that R3 did call the police. V6 stated that she is not sure of what time approximately 8:15 PM but not for sure. V6 stated that the police did come. V6 stated that she was not sure when the police got to the facility, V6 stated that the police spoke with the resident and the CNA. V6 stated that then the Officer told her that R3 had a bowel movement and needed to be changed. V6 stated that R3 was changed at that time. On 7/28/2025 at 1:54 PM V7, CNA, stated that she was the aide assigned to R3. V7 stated that she is an agency with this being her first time at the facility. Upon entering the facility, she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145555 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 145555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025 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 0725 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete informed what hall she was on and that she would get help at 6pm from oncoming staff. V7 stated that she was informed to not provide care to R3 alone or you will get in trouble. V7 stated that she did clean R3 prior to supper before 5pm. V7 stated that R3 was incontinent of bowel. V7 stated that she was then informed to feed in the dining room, and she did and stayed in there until about 7:10 PM. V7 stated that she checked her hall, and no lights were on, and she went to lunch returning around 7:40 PM. V7 stated that when she returned the light to R3's room was on. V7 stated that R3 was incontinent of bowel with stool up his side. V7 stated that she left the room to find the other aide that was supposed to have arrived at 6 PM. V7 stated that she was informed that no one came in and no one was scheduled. V7 stated that she could not change R3 at that time because she didn't have help, so she went and helped another resident. V7 stated that by the time someone came to help the police were there. V7 stated that she was interviewed by the police and informed him that she was the only one on the hall. V7 stated that she informed the police that she was informed that she would have help on the hall, but this was not case. V7 stated that she cannot care for R3 alone and had to wait for someone to help her. V7 stated that she was informed that R3 is continent and can ask for help. V7 stated that it is possible that he pushed his button, and it was turned off. V7 stated that she was the only one on the hall and stated that someone could have turned it off and not returned. V7 stated that she was not on the hall from 5:00 PM to 7:40 PM. V7 stated that R3 is alert and oriented and can speak for himself. V7 stated that she would have helped R3 before, but she didn't have any help. On 7/29/2025 at 12:20 PM V2, Director of Nursing, stated that if the staff identifies a resident is incontinent, they are to address it immediately. V2 stated that R3 requires 2 CNAs to be in room when providing care. V2 stated that this is to give the staff a witness for allegations. V2 stated that the CNA is to respond to the call light, go ask for help then start gathering supplies and start the process while the other staff is coming. V1 stated that this should take no more than 5 minutes. The facility's Staffing Policy, not dated, documents that It is the policy of the (facility) to provide sufficient nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Event ID: Facility ID: 145555 If continuation sheet Page 5 of 5