Inspection·May 23, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few and told her that R2 had a scratch on his leg and when R2 got home, his leg wound was much more extensive than a scratch. V1 stated that V5 did state that R2 scratches himself when he is anxious, but this was much worse than a scratch. V1 stated that they reviewed R2's Medication Administration Record (MAR) and that R2 did not receive any of his PRN anxiety medications while he was in the facility. V1 stated that V5 was very unhappy about R2's condition and V1 stated she understands why and that R2's care was unacceptable. V1 stated that she talked to the CNA who was responsible for cleaning R2 prior to discharge and ended up terminating his employment because of R2's condition at discharge. V1 stated she then disciplined the nurses, one nurse for documenting R2's wound as a scratch, when it was much worse, and the other nurse who was responsible for R2 the day of his discharge. V1 stated that they also talked to the Hospice Nurse about R2's stay and they concurred with V5's description of R2's leg wound. V1 stated that best practice was not followed, and she was embarrassed about the situation. V1 stated that this was not what she would expect from her nurses and CNAs. On 5/9/24 at 11:15 AM, V2 (DON) stated that she spoke with the Hospice Nurse who explained the concerns with R2's condition at discharge. V2 stated that the daughter was told of a scratch on R2's leg and was not told of the extent of the injury. V2 stated she called V5 yesterday (5/8/24) and V5 described things to her that she felt was not best practice and not what a normal nurse would do. V2 stated that the bedrails go halfway down the bed, so R2 was able to bend his legs up and, being restless, was able to hit his legs on the siderails, causing his injury. V2 stated that she suspended the two nurses and will be reeducating them, and all staff, when they return. On 5/9/24 at 1:10 PM, R8 (R2's previous roommate) stated that R2 was always talking, yelling, and was restless in his bed. On 5/9/24 at 1:18 PM, V7 (CNA) stated that she took care of R2, and he would only answer questions with a one-word answer. V7 stated that R2 would yell while in his bed and it was usually about pancakes. On 5/9/24 at 3:08 PM, V6 (Hospice Nurse) stated (R2) arrived at the facility on Thursday (5/2/24) and I went in to do an assessment on him. (R2) was in good spirits, was calm, in no distress, and had no skin issues. I went over his orders for his Respite stay with the nurse. On Monday (5/6/24) V5 (R2's daughter) came home from out of town early because she received a phone call from the nurse at the facility that (R2) had scratched his leg. (V5) called me and asked me if I would go see (R2) so I did. When I got to the facility, (R2) had an area to his left leg that was reddened, he was very anxious and restless, so I asked the nurse to give him a dose of his PRN medication, so she did, and I called (V5) and updated her. His order was for Ativan 0.5 MG every four hours PRN, and normally gets Ativan three times per day at home. (R2) got back home on Tuesday (5/7/24) and (V5) notified me that he got home and had dried stool on him and had marks on his legs. The facility was given a case of (nutritional supplement drink) to give to (R2) because he usually drinks five to six of them a day, there was only two of them missing out of the case. (V5) asked me to follow-up on what happened at the facility, so I called the facility and spoke with V2 (DON), who looked in (R2's) chart and said that (R2) hit his leg on a bedrail. I updated (V5), my managers, and let (R2's) Practitioner know and received orders to treat (R2's) leg. (R2) had several scabs on his right leg from his knee down to his ankle and had a large, reddened area to his right knee and hip. (R2's) right leg had an 8 CM long reddened area to his left shin with open areas of blood and Serosanguineous fluid, it appeared similar to a sheering injury where a few layers of skin were sheared off. We are cleaning the wound and applying (name brand of a dressing) and wrapping with (gauze wrap) every two to three days and PRN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 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 0684 R2's Braden Scale Assessment, dated 5/2/24, documented that R2 was a High Risk for skin impairments. Level of Harm - Actual harm R2's Skilled Nursing Assessment, dated 5/7/24, documented, Behavioral Symptoms-Short tempered/easily annoyed: Yes, and Behavioral Symptoms-Fidgety or restless: Yes. Residents Affected - Few R2's Nursing Note, dated 5/2/24 at 10:22 AM, documented, admitted to facility from home for five-day Respite Care. Transported by ambulance from home. Remains on service with (Hospice Company). Bedbound, reported by EMT's (Emergency Medical Technician) resident has not been in w/c (wheelchair) since February. Non-weight bearing. Alert and oriented to self. May respond with yes or no, but no conversation. Inc. (incontinent) of B&B (bowel and bladder). Total care needed. Meds brought by EMT's. Dr. notified of respite admit. R2's Nursing Note, dated 5/4/24 at 11:48 PM, documented, Skin check complete. Upper extremities and body are clear of any concerns. BLE (bilateral lower extremity) have abrasions and discoloration. Left shin has a clean, dry, and intact dressing. 2nd left toe have (sic) 2 scabs. Right greater toe have (sic) one small scab. Right malleolus have (sic) a old scab noted. R2's Nursing Note, dated 5/4/24 at 12:09 PM, documented, This nurse noted resident's leg was rubbing against bed rails causing skin abrasion measuring 8.5 CM (centimeter) x 6 CM; no bleeding noted; area was cleansed and tx (treatment) in place; made aware to hospice nurse and resident's daughter. R2's Physician Order (PO), dated 5/2/24, documented, Lorazepam 0.5 MG (milligram) Q (every) 4 hrs (hours) PRN. R2's PO, dated 5/2/24, documented, Clonazepam 0.5 MG Q 6 hrs PRN. R2's PO, dated 5/2/24, documented, Quetiapine 50 MG BID (twice daily) 8:00 AM and 4:00 PM. R2's PO, dated 5/2/24, documented, Olopatadine 1 drop to each affected eye Q 6 hrs PRN. R2's PO, dated 5/6/24, documented, Cleanse left leg shin with wound cleanser, then apply double layer (name brand of a dressing) then wrap with (gauze wrap); change daily and PRN. R2's Event Report, dated 5/4/24, documented, Description: Skin abrasion. Event Details: Skin Tear/Laceration. Activity during skin tear/laceration occurrence: Friction in bedrails. Interventions: Cleansed with wound cleanser, apply (name brand of a dressing) or hydrogel and wrap with (gauze wrap) (no skin flap). Evaluation: Event still open. The facility's investigation into R2, dated 5/9/24, documented, During our investigation, (V5) called the Administrator and talked about concerns. She stated that the nurse who called about the abrasions on the legs did not adequately describe what she witnessed upon the resident returning home. She also stated that when she spoke with the nurse, (V16), she let her know that (R2) gets anxious and that there were medications ordered to take care of anxiety. Upon reviewing the MAR (Medication Administration Record), it was noted that one dose of Lorazepam was given throughout his stay for anxiety. (V16) stated that when she took care of him, that he did not appear in any distress and that she did not feel he was displaying signs of anxiety. (V5) also stated that (R2) now had pink eye and that his PRN medications for eyes were not given. In reviewing the progress notes and orders, it appears that (R2) has order for Natural Tears and an antihistamine eye drop. There is no indication in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145620 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few the notes that the resident required this PRN medication during his stay. (V5) alleged that (R2) was soiled upon return home. Resident was incontinent of bowel and bladder, and we feel it would be difficult to determine when this incontinence occurred. The progress notes revealed skin assessments and events. A treatment was put into place and the measurements were documented. It is also noted that sheets were applied to the bedrail and pillows were placed between the rail and mattress to attempt prevention of skin issues. While reviewing documentation, (R2) did not have any decreases in cognition during stay and he had no symptoms of pain or distress. Administrator, DON, and ADON (Assistant Director of Nurses), interviewed CNA (V17), LPN (V16), and LPN (V18). Disciplinary actions were taken at the discretion of the facility. Because (V5) felt as if the expectation of her father's care was not met, the facility determined disciplinary action was necessary to stress the importance of customer satisfaction. The Facility's Respite Care Policy, dated 11/2023, documented, 1. It is the facility's responsibility to provide medical care when needed in the absence of family. It continues, 6. The residents may bring in their own medications to be used during their stay at (the facility) if the stay is for 14 days or less. Respite stays beyond 14 days will require medications be ordered from (the facility's) pharmacy. The Nursing staff at (the facility) will dispense all medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 4 of 4