Inspection·June 30, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some intervention was a chair alarm. R40's EHR Fall Investigation dated 3/10/23 documents R40 had a fall, and her intervention was a floor mat. R40's EHR Fall Investigation dated 3/4/23 documents R40 had a fall from her wheelchair. R40 had a hematoma to forehead/abrasion cut to the cheekbone. R40's intervention was to obtain a urine C/S (culture and sensitivity). R40's EHR Fall Investigation dated 1/18/23 documents an unwitnessed fall. R40's intervention was transfer to ER for evaluation of fall. R40's EHR Fall Investigation dated12/20/22 documents R40 had a fall with laceration to right forehead. R40 did not have an intervention for this fall. R40's EHR Fall Investigation dated 12/17/22 documents R40 fell on the mat, and her intervention was to remove the floor mat. R40's EHR Fall Investigation dated 10/29/22 documents R40 Fell in her bedroom, and her intervention was a low bed. R40's EHR Fall Investigation dated 9/25/22documents R40 had a fall. R40 sat on floor, and the intervention was anti roll backs. R40's EHR Fall Investigation dated 9/5/22 documents R40 had a fall, and her intervention was Restorative Program for transfers and AROM (Active Range of Motion). R40's EHR Fall Investigation dated 7/3/22 documents R40 had a fall from bed. R40's fall intervention was to be placed by nurses' station while restless. R40's EHR Fall Investigation dated 6/11/23 and Fall investigation dated 5/26/22 have the exact same fall intervention which was Ativan 0.5mg. R40's MDS dated [DATE] documents R40 is an extensive assistance of two staff persons. R40's MDS dated [DATE] also documents R40 is not stable only able to stabilize with staff assistance for surface to surface, transfer on and off the toilet and sitting to standing. R40's Fall Care plan dated 5/1/23 did not document progressive interventions. R40's Quarterly Fall assessment dated [DATE] documents R40 is at risk for falls. On 06/29/23 01:12 PM V26 (CNA) entered R40's room and told R40 she was going to lay her down. R40 said OK. V26 turned her chair around, towards the bed and locked the wheelchair. V26 placed a gait belt around R40's waist and asked R40 to hug her and stand up tall. R40 pivoted and turned to the bed and set down. V26 then laid her in the bed. She removed R40's shoes and made her comfortable. 3. R44's EHR/Fall Investigation dated 5/26/23 documents noted on floor, and her fall intervention was (non-slip material) to the floor. R44's EHR Fall Investigation dated 5/18/23 documents R44 fell out of her chair. R44's intervention was Anti-Tippers to w/c (wheelchair). R44's EHR Fall Investigation dated 4/2/23 documents a fall from W/C, and her Intervention was a psych (psychiatric) eval (evaluation). R44's EHR Fall Investigation dated 3/26/23 documents R44 had a fall, and her intervention was a psych consult. R44's EHR Fall Investigation dated 2/17/23 documents R44 slid to floor, and her intervention was UTI (Urinary Tract Infection), and antibiotics were ordered. R44's EHR Fall Investigation dated 2/16/23 documents R44 put self on floor, and her intervention were labs and urinalysis. R44's EHR Fall Investigation dated 2/9/23 documents R44 was found on floor, and her intervention, resident to be out of the room when awake. R44's EHR 1/11/23 dated documents an unwitnessed fall, and her fall intervention was not found. R44's EHR Fall Investigation dated 11/22/22 documents slid form w/c, and her intervention was tilted w/c. R44's EHR Fall Investigation, dated 9/7/22 documents scooted on bottom out to her doorway, and her intervention, was care plan updated. R44's EHR dated 8/19/22 documents R44 slid out of w/c, and her intervention was an Anti-thrust cushion. R44's EHR Fall Investigation dated 5/2/22 documents R44 was lowered to floor, and her intervention, was move closer to nurses' station. R44's EHR Fall Investigation dated 4/30/22 documents R44 fell walking down the hallway, and her intervention was obtaining a UA C&S (Culture and Sensitivity) and an antibiotic was started. R44's MDS dated [DATE] documents limited assist of one person for transfers and bed mobility. MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 2 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 dated [DATE] extensive assist of one person for transfers and bed mobility. For R44's surface to surface transfer and moving on and off the toilet R44's, balance is unsteady, only able to stabilize with staff assistance Fall Care Plan dated12/16/21 does not document fall interventions for every fall. Residents Affected - Some R44's Quarterly Fall assessment dated [DATE] determines the resident is at risk for falls. 4. R58's EHR Fall investigation dated 3/15/23 documents R58 had a fall, and his fall intervention was to lay down after lunch. R58's EHR Fall Investigation dated 3/12/23 documents R58 had a fall, and his intervention was to apply (non-slip material) to w/c. R58's EHR Fall Investigation dated 1/27/23 documents R58 had a fall, and his intervention was a high back w/c. R58's EHR dated 1/16/23 documents R58 had a fall, and he did not have an intervention for this fall. R58's EHR Fall Investigation dated 1/16/23 documents R58 had a fall, and this fall did not have an intervention. R5's EHR Fall Investigation dated 12/31/22 documents R58 had a fall, and he did not have an intervention for this fall. R58's EHR Fall Investigation dated 11/29/22 documents R58 had a fall and there weren't any interventions for this fall. R58's EHR Fall Investigation dated 10/7/22 documents R58 had a fall, and his intervention was a tilted w/c. R58's MDS, dated [DATE] documents R58 is an extensive assist of one staff person for transfers and bed mobility. R58's balance is not steady and only able to stabilize with staff assistance. R58's Fall Care Plan dated 4/5/23 did not document progressive interventions for all falls. R58's admission Fall Risk assessment dated [DATE] determines the resident is at risk for falls. On 6/30/23 at 9:45 AM V3 (Director of Nurses) stated, yes, I would expect all falls to have progressive interventions, and I will be correcting that. 5. R2's Physician Order dated 02/21/22 documents repeated falls. R2's Care Plan dated 03/28/19 documents Problem: At risk for falls due to decreased strength and balance, decreased safety. Is independent with bed mobility, transfers, ambulation, locomotion, uses her rollator walker, educated on wearing non-skid socks. Res (resident) has been educated from staff to use call light and ask for help prior to walking in room and res refuses to use call light and ask for help. 6/9/22 fall no injuries, R2 refuses to wear non-skid slippers. Son stated he will be in on 6/10 to bring up new non-skid sole slippers/shoes. 6/10/22 fall educated to press call light and wait for assistance. 7/11/22 slid while trying to stand. Intervention: R2 was educated multiple times from staff to use call light for assistance, wear gripper socks. 4/17/23 res found on floor in front of toilet, no injuries noted. Tennis shoes on but, came off during fall. Resident is non-compliant with all safety interventions. 5/29/23 Res found sitting on floor in front of bathroom door, shearing noted to buttock. Intervention, educated to use call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 3 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 - Some R2's Care Plan dated 03/28/19 documents Problem: Continued, resident is at risk for falls d/t (due to) decreased strength, balance and decreased safety awareness. 8/23/22 R2 slid out of bed onto the floor no injuries. Intervention R2 re-educated on use of call light for assistance. 8/29/22 R2 slid out her recliner and on to her bottom. No injuries, wearing regular socks at this time. Intervention R2 was re-educated on proper footwear of gripper socks, or non-skid footwear. 9/19/2022 resident fall, intervention CBC and BMP ordered. 9/20/2022 UA and CNS ordered. 10/29/22 unwitnessed fall in bathroom, no injuries, R2 was not wearing non-skid socks at time. Intervention R2 re-educated on wearing non-skid footwear. 11/5/22 slid out of chair on to floor, no injuries. Intervention re-educated on wearing gripper socks, and shoes. 11/7/22 resident slid out of chair onto floor, no injuries. Intervention educated R2 on importance of proper footwear and calling for and waiting for assistance. R2 is refusing to have the (nonskid material), in her chair which is an intervention for a fall. 11/18/22 slid out of recliner, no injuries. Intervention staff re-educated R2 on importance of using call light and waiting for assistance and proper footwear. 11/19/22 found on floor no injuries, did not have shoes on. Intervention staff re-educated about the importance of wearing shoes. 01/09/2023 resident found on the floor in her room in front of recliner, plain socks on. Resident educated regarding keeping tennis shoes on feet, fall had no injury. 01/21/23 slide off recliner onto the floor. Intervention education to keep shoes on until transfer complete. 01/25/23 slide off recliner onto the floor, plain socks. Continues to not follow instructions given by staff. 03/06/23 fall from recliner, slide out, no injuries. 03/30/23 found on floor in front of chair, no injuries. 04/2/23 found sitting on floor in front of recliner, no injuries. R2 continues to be non-compliant. R2's MDS (Minimum Data Set) dated 04/27/23 documents, a BIMS (Brief Interview of Mental Status) score 15 out of 15. Resident has no impairment. The MDS documents, that R2 is independent with setup help, only for bed mobility, transfer, walk in room, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Resident is not steady, but able to stabilize without staff assistance. R2's Fall Investigation dated, 07/10/22 documents, Resident fall. Spoke with resident concerning leaving (nonskid material) in her recliner and not covering it up with a blanket, also educated resident to use her call light and not to transfer without assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 4 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 - Some R2's Nursing Note dated, 07/11/22 at 4:22 PM documents, CNA (Certified Nurses Assistant), notified this nurse that resident was on the floor. When this nurse entered residents' room, resident observed sitting on her buttocks with her legs stretched out in front of her, reclining chair. When this nurse asked resident what happened, resident states, she slipped, when she got out of her chair, to go to the bathroom. Resident denies hitting head. ROM (range of motion), WNL (within normal limits). Denies pain with ROM. 0 (no) shortening or rotation noted to BLE (bilateral lower extremities) 0 injuries noted at this time. Resident assisted to her feet by this nurse and 2 CNAs. Resident encouraged to have on gripper socks or shoes when self-transferring, and to utilize call light for assistance. Resident expressed understanding, resident observed in bathroom an hr. (hour) later and resident had not utilized call light for assistance or put on shoes for transfer. MD (Medical Director), Family, and DON (Director of Nursing) notified of INC (incident). R2's Fall Investigation dated, 07/11/22 documents, spoke with resident concerning wearing the shoes, that are non-slip that her son bought for her, resident voiced understanding. R2's Nursing Note dated 08/03/22 at 2:22 AM documents, CNA notified this nurse, that resident was on the floor. When this nurse entered residents' room, resident observed sitting on her buttocks with her legs stretched out in front of her, in front of her reclining chair with W/W (wheeled walker) at feet. When this nurse asked resident what happened, resident states, she slipped, when she got out of her chair to go to the bathroom. Resident denies hitting head, ROM WNL. Denies pain with ROM, 0 shortening or rotation noted to BLE. 0 injuries noted at this time, resident assisted to her feet by this nurse and 1 CNA. Resident had tennis shoes on at the time of fall. Resident encouraged to utilize call light for assistance, resident expressed understanding. MD, Family, and DON notified of INC. R2's Fall Investigation dated, 08/03/22 documents Unwitnessed fall without injury, intervention in place, continue current care plan. R2's Nursing Note dated, 08/23/23 at 7:10 PM documents, CNA notified writer that resident was in room on floor. Upon entering room writer found resident sitting in room upright on coccyx with back against bed and leg stretched out in front of her and arms to her side. Staff assisted resident up off ground and back onto her bed. When asked how the fall occurred resident stated, I was attempting to get up off bed when my foot slipped from under me, and I fell onto my bottom. Resident denies any pain at this time, no injuries or bruising found at this time residents ROM is WNL per her baseline. Resident's Son notified of fall and call placed to (V33) exchange to make aware of fall. R2's Fall Investigation dated, 08/23/22 documents, Fall in bedroom, resident slid off of the side of the bed to the floor. No injuries, educated to utilize call light when needing assistance. Care plan updated and continued. R2's Nursing Note dated, 08/29/22 at 3:38 PM documents, CNA notified, this nurse that resident is on the floor, upon entering, resident was on the floor on her buttocks, resident stated, that she slid from her recliner when she was trying to get up, resident had plain socks on her feet, nurse educated resident to wear gripper socks or shoes before she transfer, resident stated, she did not hit her head, denies for any pain or discomfort, no injury noted, helped resident onto her chair, made aware to resident son and NP (V30). R2's Fall Investigation dated, 08/29/22 documents, Fall from recliner, no injury. Investigation completed, resident slid out of recliner onto her bottom, no injuries. Resident was wearing plain socks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 5 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 at the time. Educated to wear gripper socks or non-skid footwear, Care plan updated and continued. Level of Harm - Minimal harm or potential for actual harm R2's Nursing Note dated, 09/19/22 at 2:07 PM documents, Resident found on the floor in her room, on the floor by her recliner. Resident stated that she fell while attempting to go to the restroom. ROM completed and WNL, proper footwear in place. Resident assisted from the floor and back into her recliner, no injury apparent. Resident currently resting quietly in recliner with call light in place. Scheduled pain medication as well as Tylenol administered and tolerated well. No current c/o, (complaint of), pain or discomfort voiced, and no acute s/s, (signs and symptoms), of distress noted, monitor for change. Residents Affected - Some R2's Fall Investigation dated, 09/19/22 documents, Fall in bedroom. Investigation completed, resident slid down from recliner to bottom when attempting to transfer, no injuries. Intervention, decrease Tramadol and U/A. Continue current care plan. R2's Nursing Note dated, 09/20/22 at 4:08 AM documents, This nurse was doing rounds and resident call light was on. Upon entering room, resident was noted sitting on buttocks, in front of recliner with pants down. Assessed resident immediately, no injuries noted, no c/o pain or discomfort when asked. Resident stated that she was trying to go to the bathroom and had pulled pants down before going. She stated that she lost her balance when trying to pull pants up. Resident was wearing regular socks and wheeled walker wasn't locked. Resident educated on using call light when needing assistance and spoke with resident about transitioning to a wheelchair vs wheeled walker, due to recent falls, resident agreed, and stated son suggested that she do the same. Resident was assisted off the floor and into bed by this nurse. NP (V30), DON, and son made aware. R2's Fall Investigation dated, 09/20/22 documents Fall in bedroom. Investigation completed; resident slid down to bottom when attempting to get out of her recliner. No injuries. Intervention: Labs. R2's Nursing Note dated, 10/29/22 at 9:17 AM documents, CNA notified, (V22), that resident was on the floor in her bathroom at 8:30am. Resident was transferring self-off of the toilet & slipped onto her bottom. Resident noted to be in regular socks with no shoes. VS (vital signs), BP (blood pressure), 110/68, HR (heart rate) 70, RR (respiration rate) 16, O2 (oxygen saturation) 97%, RA (room air), T (temperature) 97.6, PERRLA (pupils equal, round, reactive to light, accommodation) and no new complaints of pain, related to fall. Reported to NP (V30), NNO (no new orders). POA (Power of Attorney) notified as well and (V18) (on-call) notified. Resident educated on importance of asking for help with transfers and either gripper socks or shoes at all times. Resident voiced understanding, however, is noncompliant & unaware of safety guidelines & needs. Resident resting in her recliner at this time with call light within reach, no other concerns at this time. R2's Fall Investigation, 10/29/22 documents, Unwitnessed fall, resident fell while in the bathroom. Resident had plain socks on, no shoes or gripper socks. Resident educated on proper footwear and voiced understanding. R2's Nursing Note dated, 11/05/23 at 10:44 PM documents, resident turned on call light and CNA went to answer, and resident was on floor in front of her chair. R2 stated just slipped out of chair, CNA help her back up in chair, nurse went down to assess. Resident stated, did not hit head & no bumps or red areas seen. PERRL, BP 134/82, T 97.3, P 100, R 18, O2 sats 96%. Stated, did not hurt anything just twisted her neck a little no red/open areas noted. Resident remains up in chair with call light within reach, POA called & made aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 6 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 No fall investigation for fall on 11/05/22. Level of Harm - Minimal harm or potential for actual harm R2's Nursing Note dated, 11/07/22 at 10:13 AM documents, CNA informed this nurse, that resident was on floor, upon observation resident was sitting in front of the bed with legs outstretched in front of her. Resident informed this nurse that she slid out of recliner, resident noted to have plain socks on with no shoes or gripper socks. Resident informed of the importance of proper footwear, to stop further incidents or injuries. Resident assessed to have ROM to all extremities without difficulty, no other injury noted, resident denies hitting head. VS assessed, T 97.6, P 94, R 18, 02 99% on room air; Resident assisted back to recliner and proper footwear put in place. (V30) NP notified of incidents; no new orders; son notified of new incident. Residents Affected - Some No fall investigation noted for fall on 11/07/22. R2's Nursing Note dated, 11/18/22 at 10:23 PM documents, Staff was answering residents call light at 9:50PM, resident sitting on buttock on the floor stated, to staff that she slid off recliner and landed on her bottom. Denies hitting head or injuries. Tennis shoes were off and in front of resident. Resident states, that they came off when she slid down. Resident was assisted back off the floor by staff and into recliner. (V30) NP for (V33) notified, son was notified, and ADON was notified. R2's Fall Investigation dated, 11/18/22 documents Slid off chair in room. Resident slid out of chair while returning from the restroom, reminded resident to wear shoes and socks and push call light for help. R2's Nursing Note dated, 11/19/22 at 4:41PM documents, resident picked up off floor, no injuries noted. Denies hitting her head, VS, WNL, help into bed after assessment. Made sure call light within reach, resident was not wearing shoe. Reminded to put shoes on for all transfers, POA call & left message. (V30) NP, made aware with no new orders. R2's Fall Investigation dated, 11/19/22 documents, Fall from bed, Therapy referral. R2's Nursing Note dated, 01/09/23 at 7:20PM documents, Answered resident's call light and resident was noted on the floor sitting on her buttocks, in front of her recliner. Resident was assessed immediately, no injuries noted, no c/o pain or discomfort when asked. Asked resident what happened, and she stated, she was trying to pull her pants up and slipped. Resident had on regular socks only, no shoes on before she slipped. Resident educated on putting shoes on before standing and using call light if needing assistance. Resident understood and stated, she didn't hit her head. Son, NP (V30), and (V15) made aware. R2's Fall Investigation dated 01/09/22 documents unwitnessed fall in room. Found on the floor in front of her recliner. Resident had taken her tennis shoes off and only had her plain socks on. [NAME] was in front of resident. Attempted to place (nonskid material) to the floor in front of resident's recliner but, resident removes it off the floor. Intervention is resident teaching; resident is alert and responsive oriented to know that she needs to leave her shoes on. Despite all safety measures taken and in place, resident continues to remove her tennis shoes and walk around her room in plain socks. R2's Nursing Note dated, 01/21/23 at 1:18PM documents, Resident had an unwitnessed slide in room. Resident was found sitting on bottom leaning against recliner. Resident did not have gripper socks on, resident had normal black socks on. Call light in use, alarm on. CNA answered light and informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 7 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 - Some this nurse that resident was on the floor. Resident was assessed, no injuries noted, no s/s of shock. VS: T:97.8, R: 20, P:96, BP:154/81, O2:98% RA, Pain: 0, Resident denies any pain. Resident is A&O x4 able to make needs known. When asking resident what happened she stated, I was trying to get out of my recliner and slide onto the floor. When asking resident if she hit her head she stated, no, I did not hit my head. Resident was transferred off the floor with two staff members, using gait belt into recliner per resident's request. Intervention was put into place, gripper socks applied and rest. Neuro checks initiated; resident is currently sitting in recliner with call light in place. NP contacted, note was made in 24hr nursing report to call POA in the AM. On call nurse contacted, statements made. No fall investigation noted, for fall on 01/21/23 R2's Nursing Note dated, 01/25/23 at 3:25 PM documents, Was notified by staff that resident had a fall. Resident was sitting on buttocks in front of recliner. She stated that she was trying to stand and slid to the floor. No injuries noted, no c/o pain or discomfort. Educated resident on using call light and waiting for staff assistance, when needing to stand during the night, she stated she would. NP (V30), DON and family made aware. R2's Fall Investigation dated, 01/26/23 documents Fall investigation, resident slipped while transferring self from recliner chair. Resident very non-complaint with safety devices/interventions. Resident given night light for safety. R2's Nursing Note dated, 03/06/23 at 1:22AM documents, Resident had an unwitnessed fall; found on floor on bottom by CNA. Resident A&O (alert and oriented) X3; able to make needs known. Resident stated she slid out of her reclining chair attempting to go to the restroom. Resident stated, she did not hit her head and was not in pain. 0 s/s of distress or discomfort, VS WNL; BP 137/82, P 77, RR 12, O2 at 98%, room air, T 97. Resident assessed by this nurse and reoriented on importance of call light use. Resident is resting in bed at this time call light within reach, will continue to monitor during shift. R2's Fall Investigation dated, 03/06/23 documents, Fall investigation. Resident slid to floor from chair with no injuries. Resident remains non-complaint with safety devices/inventions. R2's Nursing Note dated, 03/06/23 at 7:42PM documents, Resident had an unwitnessed fall at 7pm. Resident was found on the floor next to bed. Resident said she fell while getting off the toilet. VS, T 97.6, P 83, R 20, O2 96%, RA, BP 122/63. A&O x4, she reached for her walker and the walker breaks were not locked in place, the walker went the opposite direction and the resident slid and fell. The resident denies hitting her head, when the nurse first assessed the fall, the resident said, she was in pain and hurting; she was on the floor crying, and she appeared to be in distress. When the nurse discussed the possibility of her going to the ER r/t (related to) 2 falls in one day, the resident began to deny pain and plead not to be sent to the hospital. No signs of bleeding noted, no changes in skin condition. NP (V30) contacted, NP suggest we ask the POA for instruction r/t hospital and to begin Neurological Checks. The nurse contacted POA son, POA chose not to send resident to the ER stating, if she says she's not in pain, she not in pain. I know it may seem concerning, but I'm ok with her not going to the hospital. The nurse will initiate Neuro-checks. Resident last seen in recliner, call light in reach. R2's Fall Investigation dated, 03/06/23 documents, Unwitnessed fall. Incorrect documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 8 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 - Some R2's Nursing Note dated, 03/30/23 at 9:10PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttocks, in front of her chair. She stated, she slid trying to get up to hold on to walker, and she didn't fall or hit her head. Resident did have shoes on. Resident was assessed immediately, no injuries, no c/o pain or discomfort. Educated resident on using call light when needing assistance, she stated she would. Family, NP (V30), and on-call nurse (V15) made aware. R2's Fall Investigation dated, Fall investigation. Resident fall, attempting to transfer from recliner chair, no injury. Resident remains non-complaint with safety interventions. R2's Nursing Note dated, 04/02/23 at 10:30PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttock, in front of her recliner. When asked what happened resident stated, she was trying to get up and go to the bathroom and slid out of her recliner. Resident educated on using her call light when needing help, resident agreed and stated, I know I am just embarrassed to ask for help. Resident was assessed immediately, ROM WNL, hand grips strong, no injuries noted, denies having pain. Resident had shoes on, lighting in room was adequate, floor was dry, no items in pathway. Call light and personal belongings within reach. POA, on call nurse (V18) and NP (V30) notified. Resident was assisted to the bathroom and is currently resting in bed with call light within reach. R2's Fall Investigation dated, 04/02/23 documents, Fall investigation. Resident fall, attempting to transfer from recliner chair, no injury. Resident remains non-complaint with safety interventions, continues to remove (Nonskid material) from chair. R2's Nursing Note dated, 04/14/23 at 10:04PM documents, Resident had an unwitnessed fall. Resident was observed on the floor, sitting on bottom in front of chair. Resident states, I was trying to get up to use the bathroom and my feet slipped from under me. [NAME] breaks were not locked prior to fall, call light was within reach, tennis shoes and non-slip socks were on. VS, T 98, P 78, R 16, BP 102/77, O2 98% RA. Resident denies hitting head and pain, no injuries noted. POA notified, NP (V30) notified, no new orders at this time. Resident is currently laying down in bed resting, call light in reach. R2's Fall Investigation dated, 04/14/23 documents, Fall investigation. Fall during self-transfer from recliner chair. Wheeled walker brakes not locked, no injury. Resident educated/reminded to lock brakes before transferring. Resident continues to remove, (nonskid material), from recliner chair. Resident remains non-complaint with safety interventions/devices. R2's Nursing Note dated, 04/17/23 at 8:52AM documents, This nurse was going to the 200 hall and heard voice calling for help; upon entering in the room, observed resident on the floor on her buttocks in front of the toilet; resident states she slipped when she was trying to get up from commode; resident denies hitting her head; no injury noted; denies for any pain or discomfort; ROM, WNL; walker breaks were not locked; resident stated, she did had tennis shoes on but, when she slipped her shoes came off; bp 145/84, temp 98.3, pulse 90, resp 20; POA notified; NP (V30) notified, no new order received. R2's Fall Investigation dated, 04/17/23 documents, Fall investigation. Resident stated, she fell when shoes fell off during transfer from commode. Brakes to rollator not engaged. Resident non-complaint with safety devices/interventions. Refuses to ask for assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 9 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 - Some R2's Nursing Note dated, 05/29/23 at 9:30PM documents, Was notified by staff that resident was on the floor. Upon entering room resident was noted sitting on her buttock in front of the bathroom door. When asked what happened resident stated, I was coming out of the bathroom and slid. Resident educated on the risks and benefits of using call light when needing assistance, resident stated, I know baby. Resident was assessed immediately. VS: T 97.3, B/P 116/68, P 73, R 18, O2, 96% RA. Shearing noted on buttock; SWM nurse made aware, resident to be evaluated. ROM, WNL, hand grips strong, denies having pain, resident had shoes on prior to fall, lighting in room was adequate, floor was dry, no items in pathway. POA, DON (V2), and NP (V30), notified. Resident currently resting in bed, call light in reach. R2's Fall Investigation dated, 05/29/23 documents, Fall investigation. Resident fall when leaving bathroom, no injury. Resident remains non-complaint with safety interventions. Will not use call light for assistance. R2's Nursing Note dated, 06/03/23 at 11:30PM documents, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 10 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to provide a Registered Nurse (RN) for eight consecutive hours in a day. This failure has the potential to affect all 66 residents in the facility. Residents Affected - Many The facility Nursing Schedule dated, Monday June 12th through June 29th documents. The facility has three RNs (V4, V10, and V25.) The facility did not have a RN for eight consecutive hours in a day on June 16th, 24th, 25th. On 6/29/23 at 11:00 AM V3 Director of Nursing stated our night nurse just walked in and resigned. We just don't have the RN coverage. The facility policy entitled, Direct Care Staffing dated, 12/2012 documents, the facility will comply with staffing requirements set forth by the State and Federal requirements to meet the needs of its residents. The Residents Census and Conditions of Residents Form dated, 6/27/23 documents the facility has a census of 66. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 11 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 66 residents living in the facility. Findings include: On 6/27/23 at 7:58 AM, on the bottom shelf of the preparation table, beside the large steam table, there were 4 clear containers with various dry cereals that were not labeled or dated. On 6/27/23 at 8:08 AM, in the standing freezer, there was a brown paper bag containing an unknown food. The bag was sealed, but not labeled or dated. There was a bag of snicker doodle cookies, inside a cardboard box. The plastic bag inside the cardboard box had been opened, but was not resealed or dated, and the cookies were open to air. There were two trays of individual ice cream cups covered with sheets of wax paper, but not sealed. The wax paper was labeled ice cream and 6/27/23 in black marker. On 6/27/23 at 8:07 AM, in the walk-in refrigerator, there was a bag of shredded yellow cheese and a bag of parmesan cheese that were previously opened and resealed but were not dated. On 6/27/23 at 8:12 AM, in the dry storage room, there was a dented 108 ounce can of pinto beans on the rack. There was a plastic bag containing an opened box of baking soda on a shelf that was not sealed up or dated. There were two bins, each approximately three feet high, containing white powdery substances, labeled sugar and flour that were not dated. On 6/27/23 at 8:23 AM, V7 (Cook) was serving food from the small steam table. The entire scoop and handle of the scoop fell into the scrambled eggs. On 6/27/23 at 8:25 AM, V7 (Cook) served toast using the tongs that were used for the bacon. On 6/27/23 at 8:26 AM, V7 (Cook) resumed serving scrambled eggs with the scoop that was inside the bin on top of the food. On 6/27/23 at 8:28 AM, V6 (Cook) and V8 (Dietary Aid) were serving food at the larger steam table. V6 was wearing a loose, unzipped sweatshirt that brushed the inside of the scrambled egg container when she reached forward to place the plate on the counter to be served. V8 had a mustache and goatee approximately one inch long and was not wearing a beard net. V8 used the tongs for the French toast, then the tongs fell into the French toast container. V6 then used the tongs that were in the sausage and bacon container for the French toast. On 6/27/23 at 8:30 AM V6 touched the French toast with her bare hand while reaching for the tongs inside the container. On 6/27/23 at 8:33 AM, V9 (Dietary Aid) was running the dish machine. He stated, he has been working in the facility for 1 or 2 months and has never tested the dish machine. He stated, he was never told he should be testing the machine. During the final rinse, the final rinse temperature dial did not move from 0 degrees Fahrenheit (F). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 12 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 6/27/23 at 8:39 AM, V5 (Dietary Supervisor) stated, they check the dish machine twice weekly and asked if she should be testing it more often. V5 removed a test strip from a plastic bag. The text on the test strip stated, If center is black then correct temperature has been achieved. V5 placed a test strip on a coffee cup, placed the cup in the dish machine, and started the dish cycle. After the cycle was complete, the test strip remained white and did not change color. V5 stated, when the machine is tested, it usually takes a few cycles to get to the correct temperature, but she will be contacting the person who maintains the dishwasher. On 6/27/23 at 8:37 AM, after the last resident tray was served, the pureed sausage, from the assisted dining room steam table measured 94.4 degrees Fahrenheit on a metal calibrated thermometer. V7 (Cook) stated, It should have been on the hot plate. On 6/29/23 at 7:55 AM, V7 stated, the pureed food on her steam table is used for all pureed diets in the facility. The Facility's Resident Orders for Dietary documents, R4, R9, R10, R19, R30, R32, R39, R40, R52, R54, and R56 have pureed diets. On 6/30/23 at 8:19 AM, V1 (Administrator) stated, she expects staff to follow all of the Facility's food service and sanitation policies. The Facility's Food Storage Policy revised 8/2017 documents, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled. Food should be dated as it is placed on the shelves. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. All foods should be covered, labeled and dated for refrigerated and frozen foods. The Facility's Food Safety and Sanitation Policy dated 2017 documents, All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary department of food and nutrition services. All staff will be in good health, will have clean personal habits and will use safe food handling practices. Beard nets are required when facial hair is visible. When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. The Facility's Cleaning Dishes/Dish Machine dated 2017 documents, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Prior to use, verify proper temperatures and machine function. Note: Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot but, cannot verify actual temperatures. The Facility's Resident Census and Conditions Form (CMS-672) dated 6/27/23 documents there are 66 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 13 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to establish and implement an infection control program which analyzed trends of infection. This has the potential to affect all 66 residents living in the facility. Residents Affected - Many Findings include: 1. R3 was listed on the undated Infection Control Log for a Urinary Tract Infection (UTI). The Infection Control Log documented; a urine specimen was collected 01/26/23. No organisms were listed but, the antibiotic Macrobid (Nitrofurantoin) was prescribed. On 6/29/23 at 3:30 PM, V3 (Director of Nurses) presented Lab results dated, 5/11/23 documenting, the organisms as (1) Escherichia Coli ESBL >100,000 CFU/mL (2) Mixed Skin Flora, no sens, (Sensitivity), done >100,000CFU/ml. The Prescription Order Sheet dated, 5/17/23 documents, Macrobid 100 mg, 1 tab twice a day between 7:00 AM-10:00 AM and 7:00-10:00 PM. Start date documented as 5/16/23 and end date 5/21/23. Electronic Medical Record, (eMAR), dated, May 2023 documents, R3 received a dose of Macrobid at 4:00 PM and the order was discontinued. Another prescription order was issued on 5/17/23 with a start date of 5/17/23 and end date of 5/21/23. On 6/30/23 at 8:45 AM V3 Director of Nursing stated, charts are audited to ensure accuracy of orders to eliminate any medication errors. It is her expectation that staff will adhere to the facility's policy and procedures. 2. R8 is on the undated Infection Control Log for Urinary Tract Infection (UTI), no test was listed; no test results were listed, and no antibiotics were listed. On 6/29/23 at 3:30 PM V3 provided lab results dated 5/11/23 which documents, lab results as (1) Escherichia Coli > 100,000 CFU/mL (2) Mixed Skin Floras, no sens done 50-60,000 CFU/ml. The facility received an order for Macrobid 1 tab by mouth twice a day by mouth for 7 days. Start date documented, as 5/16/2023 and end date documented, as 5/23/2023. (eMAR) dated, May 2023 documents. On 5/16/23 R8 was given a dose of Macrobid at 4:00 PM. On 5/17/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/18/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/19/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/20/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. On 5/21/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 14 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0881 On 5/22/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM and Level of Harm - Minimal harm or potential for actual harm On 5/23/23 R8 was given a dose of Macrobid at 8:00 AM and 4:00 PM. Instead of 14 doses of Macrobid received 15 doses. Residents Affected - Many On 6/29/23 at 3;30 PM V3 also provided Labs results dated, 6/7/23 documents a urine specimen was collected, and the organisms were documented, (1) Escherichia Coli >100,000 CFU/mL and (2) Mixed Skin Flora, no sens done 40-50,000 CFU/mL and no antibiotics were started. 3. R39 is listed on the undated Infection Control Log with a Urinary Tract Infection. The Infection Control Log documents, a urine specimen was collected 10/24/22. In the test results column, the note documents, spoke with NP, hospital results received from Hospital, Macrobid ordered. eMAR dated, 10/2022 documents, Ciprofloxacin suspension microcapsule recon 500 mg/5 ml; amount to administer 5 mL oral daily. R39 was given 5 ml of Ciprofloxacin on 10/28/22. R39 was given 5mL of Ciprofloxacin on 10/29/22. R39 was given 5 mL of Ciprofloxacin on 10/31/22 and R39 was given 5 mL of Ciprofloxacin on 10/31/22. R39 was not listed on the undated Infection Control Log again but, an (eMAR) dated, November 11/2022 documents, an order for Macrobid 100 mg 1 tab twice a day with a start date of 11/6/22 and end date of 11/11/22 for a urinary tract infection. On 11/6/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/7/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/8/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/9/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/10/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 11/11/22 R39 was given 2 doses of Macrobid at 8:00 AM and 4:00 PM. On 6/30/23 at 8:45 AM V3 stated, she was the ICPC but does not have certification as an Infection Control Preventionist Program. 4. R58 was listed on the undated Infection Control log as having a Urinary Tract Infection. The specimen collection dated was documented, as 5/19/23 no organism(s) were documented, and the antibiotic Bactrim DS was ordered. On 6/29/23 at 3:30 PM supplied lab results dated, 5/15/23 documenting, the organisms as (1) Proteus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 15 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0881 Level of Harm - Minimal harm or potential for actual harm Mirabilis (2) Enterococcus Faecalis-Unable to isolate organism for definitive susceptibility due to swarming properties of Proteus. The organism was sensitive to Bactrim (<=0.5/9.5). eMAR dated 5/1/23-5/31/23 documents R58 was given Bactrim-DS 1 tab twice a day x 7 days. R58 was given Bactrim-DS on 5/22/23 at 4:00 PM. Residents Affected - Many R58 was given Bactrim-DS on 5/23/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/24/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/25/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/26/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/27/23 at 8:00 AM and 4:00 PM. R58 was given Bactrim-DS on 5/28/23 at 8:00 AM and 4:00 PM R58 did not receive a dose of Bactrim on 5/29/23 at 8:00 AM, however did a total of 13 doses instead of 14. The Facility's Policy and Procedure undated Mercy Rehab & Care Center Antibiotic Stewardship documents the policy establishes directives for antimicrobial stewardship at Mercy Rehab & Care Center to develop antibiotic use protocols and a system to monitor antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 16 of 17 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 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evervella of Swansea 100 Rosewood Village Drive Swansea, IL 62220 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to utilize the services of an Infection Preventionist (IP), at a minimum part time basis, to track facility infections and resident vaccinations in order to prevent the spread of infectious disease. This has the potential to affect all 66 residents living in the Facility. Findings include: On 06/30/23 at 9:00 AM, V1 (Administrator) stated, (V3) is our Infection Preventionist, but she is not certified. She is working on it but, has not completed the training. On 06/30/23 at 8:45 AM V3 (Director of Nursing) stated, I have been doing the job but, I am not certified. The Facility's Infection Control log undated but, covers the months June 2022 to June 2023 for Urinary Tract Infections, (UTI), have 12 entries with no organisms documented, as source of infection. Additionally, there are 6 residents with antibiotics with no organisms listed. The Facility's QAPI Meeting Attendees list does not document (V3) as the Infection Control Preventionist. The Facility's Policy and Procedures undated documents, The infection Preventionist, (IP), will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP's primary professional training is in nursing, medical technology, microbiology, or epistemology, or other related field. the IP is qualified by education, training, experience or certification and by November 28th, will have completed specialized training in infection prevention and control. The IP works at the facility full-time/part-time. Resident Census and Conditions of Resident form dated 6/27/23 document. The facility has a census of 66. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 17 of 17