Health inspection·September 16, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide enough licensed nursing staff to adequately meet the needs for 4 of 4 (R3, R10, R12, and R13) residents reviewed for staffing in the sample of 13. These failures have the potential to affect all residents residing at the facility. Findings include:1.R3's face sheet, print date of 9/15/25, documented R3 has diagnoses including pneumonia, anemia, hyperlipidemia, generalized anxiety disorder, insomnia, chronic pain, hypertension, paroxysmal atrial fibrillation, heart failure, hemiplegia and hemiparesis following cerebral infarction, unspecified convulsions, and COPD (chronic obstructive pulmonary disease). R3's MDS (Minimum Data Set), dated 7/7/25, documented R3 is cognitively intact.On 9/16/25 at 8:18 AM R3 stated her evening shift medications are often administered late and the nurses must wake her up so she can take them. Surveyor asked R3 if she has experienced increase pain due to her scheduled Tylenol not being administered as ordered every 4 hours and R3 replied sometimes I have had pain from not getting it on time. Surveyor asked R3 if she feels the facility has enough nurses and R3 replied no, they don't.2. R10's face sheet, print date of 9/16/25, documented R10 has diagnoses including wedge compression of first lumbar vertebra, insomnia, hypertensive heart disease, primary pulmonary hypertension, paroxysmal atrial fibrillation, altered mental status, hyperlipidemia, major depressive disorder, generalized anxiety disorder, and hypertension.R10's MDS, dated [DATE], documented R10 is cognitively impaired although at time of interview R10 was alert and oriented. On 9/16/25 at 6:03 AM R10 stated last night she did not receive her 8 PM meds until after 10 PM and the night before it was after midnight. Surveyor asked R10 if she knows why and she replied, they don't have enough nurses.3. R12's face sheet, print date of 9/16/25, documented R12 has diagnoses including fracture of right humerus, pain, insomnia, anxiety disorder, COPD, anemia, hypertension, major depressive disorder, and hyponatremia. R12's MDS, dated [DATE], documented R12 is cognitively intact. On 9/16/25 at 6:50 AM R12 stated she is the [NAME] President of the Resident Council and at the last meeting it was all about evening medications being administered late. R12 stated a whole lot of residents were upset because 3 nurses are not enough to pass medications so many residents are receiving their 8 PM medications late. R12 stated she and other residents have had their 8 PM medications administered at midnight or after.4. R13's face sheet, print date of 9/16/25, documented R13 has diagnoses including hypertension, diabetes mellitus, hyponatremia, infection, and inflammatory reaction due to internal right hip prosthesis, Marfan syndrome, pain, depression, bipolar disorder, and glaucoma. R13's MDS, dated [DATE], documented R13 is cognitively intact. On 9/16/25 at 6:58 AM R13 stated she has been getting her 8 PM medications late due to the facility being short staffed. R13 stated there have been a few times when she did not receive her 8 PM medications until after midnight. R13 stated she gets pain medications in the evening, and she has experienced increased pain due to the medications being administered late. On 9/16/25 at 5:17 AM V15 LPN (Licensed Practical Nurse) stated the 8 PM medication pass is Page 1 of 5 145555 145555 09/16/2025 Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some rough with just 3 nurses, meds are sometimes late, 3 nurses must share the D hall med cart because the residents are split between the 3 nurses. V15 stated this company cut the 4th nurse from 6 PM to 10 PM to save money.On 9/16/25 at 5:25 AM V16 LPN stated nurse staffing is not sufficient from 6 PM to 10 PM, used to have 4 nurses then the owner cut the 4th nurse from 6 PM to 10 PM. V16 stated (R12) has complained about her meds being late. On 9/16/25 at 5:30 AM V17 LPN stated they really need 4 nurses for the 6pm to 10pm med pass to ensure quality of care. On 9/16/25 at 6:10 AM V18 Wound Care Nurse stated 3 nurses from 6 PM to 10 PM is not enough nurses. On 9/16/25 at 7:37 AM V1 Administrator stated some residents were upset in the last Resident Council meeting about receiving their medications late on the evening shift. Surveyor asked V1 if she expects the facility nurses to sign their medications off as they administer them and V1 replied yes. Surveyor asked if she believes the medications were administered late when the evening shift nurses sign the medications off as charted late and V1 replied yes.On 9/16/25 at 9:27 AM V2 DON stated it is difficult for the nurses to complete all tasks with 3 nurses from 6 PM to 10 PM.The facility's Resident Council Memorandum, dated 8/4/25, documented issue: waiting till after 11 PM for meds. Residents getting very upset about it. DON (Director of Nursing) is aware of this issue. Response by V2 DON: will review staffing with (V1 Administrator) and (owner) to see if we can increase nursing staff at night to include 4 nurses until 10 PM to ensure residents are getting their meds in a timely manner. The facility's Resident Council Memorandum, dated 9/8/25, documented issue: nursing, meds are not getting to residents at right times, said nurses are getting angry at night. Call lights not being answered in a timely manner. The facility's staffing policy, undated, documented it is the policy of Evercare Skilled Nursing LLC to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and director of Nursing as specified by the Illinois Department of Public Health. The division of nursing needs by shift will be calculated based on the resident census and needs. The facility's Daily Census Report, dated 9/16/25, documented there are 100 residents residing at the facility. 145555 Page 2 of 5 145555 09/16/2025 Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer medications at the scheduled times for 4 of 4 (R3, R10, R12, and R13) residents reviewed for medication administration in the sample of 13. These failures have the potential to affect all residents residing at the facility. Findings include:1.R3's face sheet, print date of 9/15/25, documented R3 has diagnoses including pneumonia, anemia, hyperlipidemia, generalized anxiety disorder, insomnia, chronic pain, hypertension, paroxysmal atrial fibrillation, heart failure, hemiplegia and hemiparesis following cerebral infarction, unspecified convulsions, and COPD (chronic obstructive pulmonary disease). R3's MDS (Minimum Data Set), dated 7/7/25, documented R3 is cognitively intact.R3's care plan, undated, documented R3 has chronic pain with interventions including administer analgesia as per orders. R3's 9/1/25 - 9/16/25 MAR (medication administration record) documented R3 has an order for acetaminophen 325 mg (milligrams), 2 tabs, every 4 hours. This MAR documented R3's scheduled 8 PM acetaminophen was signed off as late administration: charted late on 9/1/25 at 11:41 PM, on 9/3/25 at 1:58 AM on 9/4/25, on 9/4/25 at 9:56 PM, on 9/8/25 at 10:14 PM, on 9/11/25 at 1:56 AM on 9/12/25, on 9/13/25 at 4:39 AM on 9/14/25, on 9/14/25 at 11:20 PM, and on 9/15/25 at 10:06 PM.On 9/16/25 at 8:18 AM R3 stated her evening shift medications are often administered late and the nurses must wake her up so she can take them. Surveyor asked R3 if she has experienced increase pain due to her scheduled Tylenol not being administered as ordered every 4 hours and R3 replied sometimes I have had pain from not getting it on time. Surveyor asked R3 if she feels the facility has enough nurses and R3 replied no, they don't.2. R10's face sheet, print date of 9/16/25, documented R10 has diagnoses including wedge compression of first lumbar vertebra, insomnia, hypertensive heart disease, primary pulmonary hypertension, paroxysmal atrial fibrillation, altered mental status, hyperlipidemia, major depressive disorder, generalized anxiety disorder, and hypertension.R10's MDS, dated [DATE], documented R10 is cognitively impaired although at time of interview R10 was alert and oriented. R10's care plan, undated, documented R10 has diagnoses of hypertension, cardiomegaly, atrial fibrillation, hypertension, and hyperlipidemia with interventions including administer medications as ordered. R10's MAR, dated 9/1/25 - 9/15/24, documented R10 has an order for a beta-blocker medication carvedilol 12.5 mg twice a day between 6 AM and 9 AM and between 7 PM and 10 PM. This MAR documented R10's evening carvedilol was signed off as late administration: charted late on 9/3/25 at 12:56 AM on 9/4/25, 9/6/25 at 11:16 PM, 9/11/25 at 12:50 AM on 9/12/25, 9/13/25 at 4:37 AM on 9/14/25 and 9/14/25 at 11:17 PM. On 9/16/25 at 6:03 AM R10 stated last night she did not receive her 8 pm meds until after 10 pm and the night before it was after midnight. Surveyor asked R10 if she knows why and she replied, they don't have enough nurses.3. R12's face sheet, print date of 9/16/25, documented R12 has diagnoses including fracture of right humerus, pain, insomnia, anxiety disorder, COPD, anemia, hypertension, major depressive disorder, and hyponatremia. R12's MDS, dated [DATE], documented R12 is cognitively intact. R12's care plan, undated, documented R12 has acute pain related to a fracture of her arm prior to admission with interventions including administer analgesia as per orders. R12's MAR, dated 9/1/25 - 9/15/25, documented an order for oxycodone 5 mg 3 times a day at 6 AM, 12 PM, and 6 PM. This MAR documented R12's 6 PM oxycodone as late administration: charted late on 9/7/25 at 8:40 PM, and on 9/12/25 at 8:08 PM. R12's MAR, dated 9/1/25 - 9/15/25, documented an order for trazadone 50 mg at 8 PM. This MAR documented R12's trazadone as late administration: charted late on 9/3/25 at 10 PM, on 9/4/25 at 9:52 PM, on 9/10/25 at 9:14 PM, and on 9/13/25 at 9:30 PM. On 9/16/25 at 6:50 AM R12 stated she is the [NAME] President of the Resident Council and at the last meeting it was all about evening medications being administered late. R12 stated a whole lot of residents were upset Residents Affected - Some 145555 Page 3 of 5 145555 09/16/2025 Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because 3 nurses are not enough to pass medications so many residents are receiving their 8 PM medications late. R12 stated she and other residents have had their 8 PM medications administered at midnight or after.On 9/16/25 at 10:57 AM R12 stated she has chronic pain from a shoulder fracture that was not operable, and she has had to wait for a long time for a pain pill on the evening shift due to the facility not having enough nurses. R12 stated her pain reached a level of 8 to 10 during the times her pain medication was late. R12 stated this just became an issue about 2 to 3 months ago. V12 stated she also takes trazadone to help her sleep and there have been times when she did not receive her trazadone until midnight. 4. R13's face sheet, print date of 9/16/25, documented R13 has diagnoses including hypertension, diabetes mellitus, hyponatremia, infection, and inflammatory reaction due to internal right hip prosthesis, Marfan syndrome, pain, depression, bipolar disorder, and glaucoma. R13's MDS, dated [DATE], documented R13 is cognitively intact. R13's care plan, undated, documented R13 has chronic pain with interventions including administer analgesia as per orders. R13's MAR, dated 9/1/25 - 9/15/25, documented an order for hydromorphone 6 mg four times a day for pain. This MAR documented R13's 7 PM to 9 PM hydromorphone was charted as late administration: charted late on 9/1/25 at 4:54 AM on 9/2/25, on 9/4/25 at 10:34 PM, on 9/5/25 at 10:58 PM, on 9/7/25 at 12:38 AM on 9/8/25, on 9/10/25 at 3:58 AM o 9/11/25, on 9/11/25 at 1:03 AM on 9/12/25, on 9/13/25 at 4:40 AM on 9/14/25, on 9/14/25 at 10:59 PM, and on 9/15/25 at 10:08 PM. On 9/16/25 at 6:58 AM R13 stated she has been getting her 8 PM medications late due to the facility being short staffed. R13 stated there have been a few times when she did not receive her 8 PM medications until after midnight. R13 stated she gets pain medications in the evening, and she has experienced increased pain due to the medications being administered late. On 9/16/25 at 5:17 AM V15 LPN (Licensed Practical Nurse) stated the 8 PM medication pass is rough with just 3 nurses, meds are sometimes late, 3 nurses must share the D hall med cart because the residents are split between the 3 nurses. V15 stated this company cut the 4th nurse from 6 PM to 10 PM to save money.On 9/16/25 at 5:25 AM V16 LPN stated nurse staffing is not sufficient from 6 PM to 10 PM, used to have 4 nurses then the owner cut the 4th nurse from 6 PM to 10 PM. V16 stated (R12) has complained about her meds being late. On 9/16/25 at 5:30 AM V17 LPN stated they really need 4 nurses for the 6pm to 10pm med pass to ensure quality of care. On 9/16/25 at 6:10 AM V18 Wound Care Nurse stated 3 nurses from 6 PM to 10 PM is not enough nurses. On 9/16/25 at 7:37 AM V1 Administrator stated some residents were upset in the last Resident Council meeting about receiving their medications late on the evening shift. Surveyor asked V1 if she expects the facility nurses to sign their medications off as they administer them and V1 replied yes. Surveyor asked if she believes the medications were administered late when the evening shift nurses sign the medications off as charted late and V1 replied yes.On 9/16/25 at 9:27 AM V2 DON stated it is difficult for the nurses to complete all tasks with 3 nurses from 6 PM to 10 PM.The facility's Resident Council Memorandum, dated 8/4/25, documented issue: waiting till after 11 PM for meds. Residents getting very upset about it. DON (Director of Nursing) is aware of this issue. Response by V2 DON: will review staffing with (V1 Administrator) and (owner) to see if we can increase nursing staff at night to include 4 nurses until 10 PM to ensure residents are getting their meds in a timely manner. The facility's Resident Council Memorandum, dated 9/8/25, documented issue: nursing, meds are not getting to residents at right times, said nurses are getting angry at night. Call lights not being answered in a timely manner. The facility's Medication Administration policy, dated 6/1/25, documented Purpose: To provide practice standards for safe administration of medications for residents in the facility. Policy: 1. Medication will be administered by a Licensed Nurse per the order of an attending physician or licensed independent practitioner or as consistent with state law. 2. No medication will be used 145555 Page 4 of 5 145555 09/16/2025 Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for any resident other than the resident for whom it was prescribed. It continues, 5. Medications may be administered one hour before or after the scheduled medication administration time. It continues, Procedure: 1. Assemble the necessary equipment. 2. Wash hands before and after medication administration. 3. Gloves will be worn to administer medication when contact with blood or potentially infectious body fluid is anticipated. 4. Nursing staff will keep in mind the 7 rights of medication when administering medications: A. The right medication. B. The right amount. C. The right resident. D. The right time. E. the right route. F. Right indication. G. Right outcome. It continues, 15. Administer the medication to the resident. 17. The licensed nurse will chart the drug. Time administered and initial his/her name with each medication administration. The facility's Daily Census Report, dated 9/16/25, documented there are 100 residents residing at the facility. 145555 Page 5 of 5