Inspection·September 26, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure the POA (power of attorney) was notified for change of condition for 1 of 3 residents (R19) reviewed for notification in the sample of 34. Findings include: R19's Physician Order Sheet for September 2025 documents a diagnosis of acute respiratory failure, unspecified whether with hypoxia or hypercapnia, sepsis, unspecified protein-calorie malnutrition, vitamin deficiency; hypo-osmolality and hyponatremia; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; unspecified chronic conjunctivitis, right eye; non-st elevation myocardial infarction; pneumonia, pneumonitis due to inhalation of food and vomit; acute respiratory distress syndrome; repeated falls, urinary tract infection.R19's Minimum Data Set (MDS) quarterly assessment dated [DATE] document R2's cognition was not assessed. R19 MDS document R19 needs assistance with most ADL's (activities of daily living); she has impairments on both her upper and lower extremities and uses a wheelchair. R19's Care Plan with a revision date of 8/23/2025 documents (R19) is dependent on staff for meeting emotional, intellectual, physical, and social needs. (R19) has immobility and physical limitations. R19's Face sheet documents V12 is the POA (Power of Attorney) and V13 is the alternate contact. On 9/23/2025 at 2:32 PM, V12 (Family of R19/POA) I just met with the (Facility) yesterday and we had a Care Plan Meeting. I told them I was the POA and if there are any issues, please make sure I am notified. Back in June when my mom fell, they did not even notify me that she fell. They notified my brother, and he is the alternate contact. I am the POA and I am the one that makes decisions for my mom's care. If they could not get ahold of me, I would understand but they never contacted me.R19's Progress Notes dated 5/31/2025 at 6:12 AM, Resident was found on the floor and this nurse per nursing judgement is sending resident for further evaluation and treatment. The resident is nonverbal and cannot let nurse know if she has any pain. Resident has no visible injuries, EMS (emergency medical services) has been called and to transport with lights and sirens. POA was notified and he said to send to hospital. Awaiting for EMS to arrive.R19's Progress Notes dated 5/31/2025 at 8:32 AM, Note Text: POA/daughter called this nurse and voiced her concerns as to how her mom fell out of bed and if mom had any injuries. Daughter also informed this nurse that she was upset because she was not informed. This nurse informed daughter that resident did not have any injuries but was sent to hospital for precautions because resident is nonverbal. This nurse apologized to daughter about not being notified. This nurse informed daughter that her brother was informed about the fall and brother stated to send her to hospital. POA would like this nurse to report to other nurses that she's to be contacted first. Nurse will remind all nurse to call daughter first with any updates about resident.On 9/24/2025 at 3:01 PM, V14 (MDS/Care Plan Coordinator) stated, We did have a Care Plan meeting over the phone yesterday. The POA did not mention anything related to notification. I would expect all POA's to be notified for any change of condition. For (R19) V12 is listed for her POA and should always be notified first. If they cannot reach V12, then they should be notifying the alternate contact V13.The Change of Condition Policy dated 7/1/2025 documents, To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, effective manner. Event ID: Facility ID: 145620 If continuation sheet Page 2 of 13 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 09/26/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure abuse did not occur for 2 of 3 residents (R5 and R23) reviewed for abuse in the sample of 34. Findings include: 1-R23's Physician Order Sheet (POS) dated December 2024 documents a diagnosis of depression, acute on chronic heart disease, heart failure, acute respiratory failure with hypoxia. R23's Minimum Data Set (MDS) dated [DATE] document she was cognitively intact for decision making of activities of daily living. R23 uses a wheelchair and has impairments on both sides of her lower extremities. For sitting to standing she needs substantial to maximal assistance from staff. The Facility failed to provide a Care Plan for R19 that addresses abuse. On 9/25/2025 at 9:42 AM, R23 stated she did get into it with another resident over the remote and she scratched him because he grabbed the remote out of her hands.R23's Initial Report dated 12/9/2024 documents, Resident (R23) was watching television in main dining room. Resident (R5) came over to her and wanted the remote. He grabbed for the remote and sustained a skin tear to his arm from (R23's) fingernail. (R23's) finger was swollen but x-ray revealed no fracture. Residents separated and treated accordingly. Investigation started. Final summary to follow. 2-R5's POS for December 2024 documents a diagnosis of heart failure, arthritis, chronic atrial fibrillation, type 2 diabetes mellitus, pain, anemia, essential hypertension, and bradycardia.R5's MDS dated [DATE] document R5 was cognitively intact for decision making of activities of daily living. He is in a wheelchair, has no impairments and requires substantial/maximal assistance with most activities.R5's Care Plan with a revision date of 5/17/2025 documents, The resident is/has potential to be verbally aggressive r/t (related to) Poor impulse control, resident yells at staff, cusses at staff, yells at residents, resident made statement that I wish I wish I was dead but stated that he had no plan to harm self.R23 and R5's Final Report documents, On 12/9/2024 at approximately 6:10 PM, (R23) was sitting in the dining/activity area watching television. (R5) had been sitting there previously but had moved away. (R5) came back to the area and requested (R23) turn the television off. When she refused (R5) attempted to snatch the remote control from the table in front of her. In the process of trying to get control of the remote (R5) grabbed (R23's) right hand, squeezing it. (R23) then reached out and scratched (R5's) left hand causing a skin tear. Investigation initiated and concluded. (R23) has swelling and pain to her right hand 2nd digit. An x-ray was completed in house and results determined osteopenia and moderate arthritis changes without acute fractures.On 9/25/2025 at 9:41 AM, R5 was sitting in the dining room having breakfast. On 9/5/2025 at 9:42 AM, R5 stated, I did get into with another resident because I wanted the TV on and she would not turn it on so I tried to grab the remote and she dug her nails into me because she did not want me to turn on the TV and I grabbed her hand to get the remote.On 9/5/2025 at 9:43 AM, R5's left arm near the wrist has a scar on it in a strange shape approximately 6 cm (centimeters) x 3 cm.On 9/26/2025 at 1:11 PM, V1 (Administrator) stated (R5) and (R23) got into an argument over the remote but nobody was hurt, and it was not anything serious and no resident was injured. The Facility's Abuse Prevention and Prohibition Program reviewed 6/1/2025, document's purpose: to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to protect residents and to ensure a standardized methodology for the prevention of abuse. Resident to resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain. The facility protects residents from any harm that could result from abuse. Event ID: Facility ID: 145620 If continuation sheet Page 3 of 13 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 09/26/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for an indwelling catheter for 1 of 3 (R7) residents investigated for a catheter in a sample of 34.Findings include:R7's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R7's EMR dated 7/11/25 documents a diagnosis of obstructive and reflux uropathy, unspecified.R7's MDS (Minimum Data Set) dated 7/6/25 documents a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident has an indwelling catheter.R7's Physician Order dated 7/15/25 documents Foley catheter: 18Fr/10ml balloon: change monthly; every night shift starting on the 15th and ending on the 15th every month.There was no care plan noted for the Catheter.The facility was unable to provide a care plan for the catheter.On 9/24/25 at 11:55 AM, R7 stated that he does have an indwelling catheter.On 9/25/25 at 2:15 PM, V14 (MDS/Care Plan Coordinator) stated she is new to the MDS/Care Planning position, started in June 2025 and is still learning. Facility's policy Care Planning dated 9/2/25 documents To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. Event ID: Facility ID: 145620 If continuation sheet Page 4 of 13 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 09/26/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clean and maintain a C-Pap (Continuous Positive Airway Pressure) and change oxygen tubing/humidifier in 2 of 2 residents (R16, R35) reviewed for respiratory care in the sample of 34.Findings Include: Residents Affected - Few 1.) On 9/23/25 at 9:40 AM, R16 was observed with oxygen on at 3.5 liters/minute/nasal cannula. The oxygen tubing/cannula was not dated when it had last been changed. R16's Face Sheet, undated, documents R16 has a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). R16's Care Plan, dated 9/24/25, documents R16 has impaired gas exchange. There was no documentation in R16's record as to when the oxygen tubing/cannula had been changed last. On 9/25/25 at 11:05 AM V2 (Director of Nurses) stated they are to change the oxygen tubing and humidifiers weekly. The Oxygen Administration Policy, dated 8/1/25, documents all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly. 2.) R35's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R35's EMR dated 7/8/25 documents a diagnosis of obstructive sleep apnea. R35's Physician Order dated 7/9/25 documents BiPap (Bilevel Positive Airway Pressure) at night for sleep apnea; at bedtime. R35's MDS (Minimum Data Set) dated 8/6/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident that uses a CPAP. No care plan noted for R35's CPAP. The facility was unable to provide a care plan for R35's CPAP. Manufacture's Manual dated 4/4/22 documents that the water tank should be hand washed daily to prevent mold and bacteria growth. The hose should be washed weekly. The mask should be wiped off daily and cleaned with water and mild detergent weekly. On 9/23/25 at 9:24 AM, R35 stated that no one has cleaned her CPAP equipment since she was admitted in July. She stated that at home she cleans her own equipment but did not even think about since she has been at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 5 of 13 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 09/26/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/24/25 at 8:43 AM, V6 (Licensed Practical Nurse) stated that nurse that takes the resident's CPAP/BiPAP off is supposed to clean it. She stated that the facility has no set schedule for cleaning resident's CPAP/BiPAP. On 9/25/25 at 11:06 AM, V2 (Director of Nursing) stated that the nurse should wipe the mask and replace the hose if they have extras. She stated that all respiratory equipment is taken care of on Wednesdays. On 9/25/25 at 11:22 AM, observation of (name brand) CPAP machine sitting on R35's nightstand with hose and mask attached and lying on nightstand uncovered. Facility's policy CPAP Therapy dated 9/1/25 documents Continuous Positive Airway Pressure is used to treat obstructive sleep apnea. The goals of this therapy include; improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance. Cleaning and Maintenance 1.b. remove the headgear from the mask or nasal pillows shell. Disconnect the mask or shell, swivel, and tubing. C. With a soft cloth, gently wash the mask or pillows with a solution of warm water, and a mild clear liquid detergent. D. Rinse thoroughly. If the mask still feels oily, repeat step C. E. Allow the mask or pillows to air dry. Do not place any supplies in the dryer. Once air dried place in plastic bag. F. Washing tubing as necessary with a solution of warm water, and a mild clear liquid detergent. Rinse thoroughly, and allow to air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 6 of 13 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 09/26/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to ensure there was an adequate number of CNAs (Certified Nursing Assistants) working to provide care to the residents. This failure has the potential to affect all 85 residents residing in the facility.Findings Include:On 9/23/25 at 9:24 AM, R35 stated that the facility is short staffed. On 9/23/25 at 9:40 AM, R28 stated that the facility is short staffed for CNAs. She stated that sometimes R28 has to wait 2 hours for her call light to be answered.On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they have cut down on staff. R75 stated within the past 2 weeks, unsure of exact date, he had to wait 3 hours to get his call light answered because they don't have enough.The Facility Assessment, with a review date of 1/16/25, documents the following staffing plan for the number of licensed nurses and CNAs per shift per day: Licensed nurses - 4/4/3 and CNAs 8-10/8-10/5-7. The CNA/Nurse Schedules document the following: 9/6/25 - 3 nurses and 3 CNAs; 9/7/25 - 1 nurse and 4 CNAs; and 9/13/25 - 3 nurses and 3 CNAs.On 6/30/25 R20 filed a grievance due to the new company works the employees too hard and the facility is short staffed. Staffing Policy, undated, documents it is the policy of the facility 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. 09/25/2025 12:20 PM V1 (Administrator) stated the residents always think we need more staff but according to the numbers, they aren't. V1 stated they run with the 4 nurses and 8 CNAs on day shift, 4 nurses and 7 CNAs on evening shift, and 2 nurses and 4 CNAs on night sift. V1 stated they fill any vacancies or call offs with agency staff. The CMS (Centers for Medicare & Medicaid Services) form 671, dated 9/23/25, documents there are 85 residents residing in the facility. Event ID: Facility ID: 145620 If continuation sheet Page 7 of 13 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 09/26/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure insulin pens and stock medication have legible expiration dates for 2 (R35 and R32) residents in a sample of 34. Findings include: 1.)R35's Physician's Order Sheet (POS) dated 9/2025 documents Humalog KwikPen, inject 10 units subcutaneously three times a day for DM (diabetes) and Glargine insulin, inject 42 units subcutaneously at bedtime for DM. On [DATE] at 12:45 PM R35's Humalog Kwik insulin pen was not dated. R35's Glargine insulin pen was also not dated. 2.)R32's POS, dated 9/2025 documents insulin Aspart, inject per sliding scale three times a day for diabetes. On [DATE] at 12:48 PM R32's Aspart insulin pen wasn't dated. 3.)On [DATE] at 12:50 PM the 400 hall medication cart had a stock medication, sodium chloride 1,000 mg bottle, the expiration month was not readable and the year was 2025. On [DATE] at 12:53 PM V6 (Licensed Practical Nurse) opened the 400 hall medication cart. V6 stated all the insulin pens should be dated with the date they are opened so staff know when they are to throw them away because they expire 30 days after opening. On [DATE] at 1:18 PM V2 (Director of Nurses) stated all insulin pens should be dated with the date of expiration, so staff know when they are to throw away the insulin pens. Some insulin pens expire in 30 days and some expire in 45 days. V2 also stated she expected staff to be able to read the expiration dates on all stock medications and if the stock medication date is not readable or rubbed off the nurse should throw that medication away. The Facility's Medication Storage Policy, revised [DATE] documents purpose: to ensure proper labeling and expiration dates of medications. Facility should ensure that medications have an expired date on the label. Event ID: Facility ID: 145620 If continuation sheet Page 8 of 13 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 09/26/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to serve palatable, timely meals to 3 of 4 residents (R16, R68, R75) reviewed for nutritive value/appearance/palatable/preferred temperature in the sample of 34.Findings Include:On 9/23/25 at 9:40 AM, R16 stated the food tastes horrible, they took away our soda and snacks. R16 stated they don't offer any snacks throughout the day or in the evening time. R16 stated sometimes she gets so hungry, she has to eat the food even though it tastes bad. R16's MDS (Minimum Data Set), dated 9/10/25, documents R16 is cognitively intact. On 9/23/25 at 9:18 AM, R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. the food is worse than it was before, you get smaller portions. Breakfast is late, it should have been served at 8:00 AM today but it wasn't served until 8:45AM. R68's MDS, dated [DATE], documents R68 has moderate cognitive impairment. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they cut out their soda, fruit drinks at breakfast and evening snacks. R75 stated about the only thing he likes is the hot dogs and he is getting tired of hot dogs. R75's MDS, dated [DATE], documents R75 is cognitively intact. The Resident Council Minutes, dated 9/26/24, 10/28/24, 12/20/24, and 8/26/25 document complaints of the meals being served late. On 9/25/25 at 1:33 PM V1 (Administrator) stated they don't have the smorgasbord of food like we had before, but the quality hasn't changed. This is one of the biggest complaints I have from the residents. The Food Preparation: Taste Testing Policy, undated, documents food items will not be served unless palatable and pleasing to the eye. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 9 of 13 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 09/26/2025 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer snacks to the residents. This failure has the potential to affect all 85 residents residing in the facility.Findings Include:On 9/23/25 at 9:18 AM R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. R68's MDS (Minimum Data Set), dated 8/19/25, documents he has moderate cognitive impairment. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they cut out their soda, fruit drinks at breakfast and evening snacks. R75 stated they don't offer any snacks. R75 stated about the only thing he likes is the hot dogs and he is getting tired of hot dogs. R75's MDS, dated [DATE], documents R75 is cognitively intact. On 9/23/25 at 9:40 AM, R16 stated the food tastes horrible, they took away our soda and snacks. R16 stated they don't offer any snacks throughout the day or in the evening time. R16 stated sometimes she gets so hungry, she has to eat the food even though it tastes bad. R16's MDS, dated [DATE], documents R16 is cognitively intact. On 9/23/25 at 9:35 AM, R1 stated the facility does not offer snacks, her daughter has to provide her snacks. R1's MDS, dated [DATE], documents R1 is cognitively intact. On 9/24/25 at 11:14 AM, R45, President of Resident Council stated, since the new owners took over there have been a lot of changes, especially in the food department. The new owners took away hot chocolate, soda and snacks. They no longer give out any snacks. They said they don't have to give out any snacks anymore. If I lived at home and wanted a snack I could go and get a snack. Now, we have no snacks. Why is that and is that any fair. I used to get a hot chocolate at night and now they tell me there is no more hot chocolate. At first, I thought they just ran out, and but no, they said they can't get any more hot chocolate. R45's MDS, dated [DATE], documents R45 is cognitively intact. On 9/24/25 at 11:18 AM, R74 stated he gets hungry, especially at nighttime, and the facility has never offered him any snacks at night, and he has never seen any snacks at night available for him to just take and/or eat. I think they should offer snacks because sometimes I am just not hungry at dinner but then I am hungry later and I have to wait for breakfast unless my family brings me something and I know not everyone here is lucky enough to have family bring them stuff. R74's MDS, dated [DATE], documents R74 is cognitively intact. On 9/24/25 at 11:22 AM, R35 stated they have never offered her snacks and/or told her she could get any snacks since she has been here, and she has been here since July. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 10 of 13 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 09/26/2025 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 0809 R35's MDS, dated [DATE], documents R35 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm On 9/24/25 at 8:32 AM, no snacks were observed in the dry storage area. There were no cookies, no pudding, no graham crackers, no fruit cups, no fresh fruit, no peanut butter, no bread. Residents Affected - Many On 9/24/25 at 8:33 AM, the refrigerator did not contain any fresh fruit, there were 9 cups of yogurt, no other snacks were observed in the refrigerator. On 9/24/25 at 8:34 AM, there was one loaf of bread near the toaster in the kitchen. On 9/25/25 at 3:39 PM, a tour of the medication storage room was completed with 2 bags of potatoes chips, 6 prewrapped cookies, 6 puddings, and 12 small cartons of juice. On 9/24/25 at 8:35 AM, V4 (Dietary Manager) stated, I was not working last night so you will have to ask (V5, Dietary Aid), she was the one working last night. It is what it is. I am on a strict budget, and I just don't have the budget for snacks, and I order things, but they get removed and I have no control of the food anymore. On 9/24/25 at 8:38 AM, V5 (Dietary Aid) stated, I did work last night, but I did not send out any snacks because honestly, we don't have anything here to give out as snacks. There are no snacks to pass out. 09/25/2025 1:33 PM V1 (Administrator) stated we don't have a policy on snacks, we aren't required to offer a snack unless they have an order for it, if they want something, they have stuff at the nurse's station. On 9/25/25 at 3:32 PM, V7 (Licensed Practical Nurse/LPN), stated they used to bring a cart out from the kitchen with snacks, but I am not sure why, but they no longer do that. I do not have any snacks here at the nurse's station for residents. On 9/25/25 at 3:34 PM, V6 (LPN) stated I keep a few snacks in the locked medication room because I need the pudding and applesauce for medication pass. There is not a lot in there. The CMS (Centers for Medicare & Medicaid Services) form 671,dated 9/23/25, documents there are 85 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 11 of 13 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 09/26/2025 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 develop, promote, and implement a facility-wide system to monitor the use of antibiotics for 3 out of 5 residents (R106, R55 and R34) sampled for antibiotic use. Findings include:1. R106's Hospital After Visit Summary, dated 6/24/2025 documents R106 was diagnosed with a urinary tract infection (UTI) and prescribed an antibiotic Levofloxacin. The Facility's Infection Surveillance Log, dated 6/24/2025 documented R106 symptoms decreased level of consciousness and confusion and treatment an antibiotic levofloxacin. No organism was documented on the log. R106's Hospital Records, dated 6/26/2025 urine culture documents multiple organisms present, probable contamination, suggest repeat culture. R106's Physician's Order Sheet (POS) dated 6/24/2025 Levofloxacin 750 mg 1 tablet by mouth every other day for 10 days. R106's Medication Administration Record (MAR) dated 6/2025 staff documented Levofloxacin was administered per physician's orders. R106's Electronic Medical Record (EMR) no documentation of organism for urine. 2. R55's Hospital After Visit Summary, dated 9/15/2025 documents R55 was diagnosed with a UTI and prescribed an antibiotic Cephalexin. The Facility's Infection Surveillance Log, dated 9/15/2025, documented R55 symptoms not eating, lethargic and weak and treatment an antibiotic Cephalexin. No organism was documented on the log. R55'a POS, dated 9/15/2025 documents a physician order for Cephalexin 250 mg 1 tablet by mouth 4 times a day for infection until 9/22/2025. R55's Hospital Paperwork no documentation of a urine culture completed. R55's MAR dated 9/2025 staff documented Cephalexin was administered per physician's orders. R55's EMR no documentation of what organism for the UTI. 3. R34's Hospital After Visit Summary dated 6/8/2025, documents R34 was diagnosed altered mental status. The Facility's Infection Surveillance Log, dated 6/9/2025, documented R34 symptoms behaviors and treatment an antibiotic Cefdinir. No organism was documented on log. R34's POS, dated 6/8/2025 documents a physician's order for Cefdinir 300 mg by mouth two times a day for 6 doses. R34's MAR dated 6/2025 staff documented Cephalexin was administered per physician's orders for UTI. R34's Hospital Paperwork dated 6/8/2025 documents urine culture final report: growth indicates contamination with mixed bacterial flora. Please submit a new specimen with special attention given to the collections process and to prompt transport to the laboratory.R34's EMR no documentation of what organism for the UTI. On 9/25/2025 at 12:30 PM V3 (Assistant Director of Nursing) stated she is also the facility's Infection Control Preventionist (ICP) at the facility and is responsible for ensuring all residents on antibiotics for UTIs have a urine culture in their medical record, so the facility knows what organisms are in the facility at all times. V3 stated she called the hospital today to inquire about resident's urine cultures and she was waiting for the medical records to be sent over. On 9/26/2025 at 10:15 AM V2 (Director of Nurses) stated she knows the facility's infection surveillance log doesn't have the residents with UTIs organisms documented on there. V2 stated when a resident is readmitted to the facility with a physician's order for an antibiotic for a UTI she immediately contacts the medical records department at the hospital and requests the resident's urine culture be sent to the facility as soon as possible. V2 stated it is very challenging to get the hospital to send medical records including the urine culture and she requests it because she knows she needs it because she needs to know what organisms are in the building and if the antibiotic is resistant or sensitive to the prescribed antibiotic. V2 stated she is very frustrated because although she requests the urine cultures from the hospital she doesn't receive them and she knows she will receive a citation for not having the proper medical records. The Facility's Antibiotic Stewardship Program, updated 3/13/2025 documents this facility is dedicated to implementing an antibiotic/antimicrobial stewardship program to reduce the unnecessary use of antibiotics. This program help ensure that our residents get the right antibiotics at the right time for the right duration and can Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145620 If continuation sheet Page 12 of 13 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 09/26/2025 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete improve individual patient outcomes, slow antibiotic resistance and reduce healthcare costs. Laboratory will provide data on microbiology reports. Review the clinical record for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used to identify patterns of use and determine the impact of new stewardship interventions. The Facility's Long-Term Care Facility Application for Medicare and Medicaid documents a total of 85 residents. Event ID: Facility ID: 145620 If continuation sheet Page 13 of 13