Health inspection·September 1, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, interview and record review the facility failed to ensure residents with limited mobility were properly assessed for assistive devices for 1 of 1 (R135) resident reviewed for assistive devices in a sample of 32. The Findings Include: R135's resident face sheet documents an admit date of 8/25/23. This same document includes the following diagnosis: frontal lobe and executive function deficit following non traumatic intracerebral hemorrhage, alcohol dependence, bipolar disorder, major depressive disorder, generalized anxiety disorder, post traumatic disorder, epilepsy, and cerebral infarction due to cerebral venous thrombosis, and functional quadriplegia. R135 is alert to person, place, and time. R135's care plan documents that he has a BIMS (Brief Interview of Mental Status) of 15 indicating that R135 is fully cognitively intact. A problem area in R135's care plan with a start date of 8/31/23 documents that R135 is at risk for weakness or tiredness due to late effects of Cerebral Vascular Accident. The goal is for the resident to be out of bed daily and able to attend activities of choice daily as tolerated by next review date. The approaches for this problem area are as follows: call light within reach while in room and remind resident to call for assistance as needed, diet as ordered, encourage rest periods as needed, invite resident to daily activities of choice as tolerated, monitor appetite and weight, monitor lab work as available, observe resident for weakness and or tiredness, provide medication as ordered and observe effectiveness of medication, provide monthly activity calendar in room and to report excessive tiredness and weakness to the physician. A problem category in this same care plan with a start date of 8/31/23 documents: Activities of Daily Living status/rehabilitation potential. Goal for this problem area is discharge to community. I will have access to necessary services to promote adjustment to my new living environment and or post discharge from the facility. Approaches listed for this problem are as follows: Activities of Daily Living: I require assistance with oral care, grooming, eating, toileting, dressing and mobility (All dependent). I will need assistance to have my personal care needs met while supporting my strengths and personal goals. Safety: I will need to be monitored to prevent falling in my new environment. I will need assistance with bed/chair mobility, assistance with transfers, and assistance with locomotion. I use a mechanical lift and wheelchair and need safety reminders to use durable medical equipment safely. R135's current physician order sheet for August 2023 includes an order for: rehab physical therapy, occupational therapy, and speech therapy to evaluate and treat with a start date of 8/25/23. Restorative therapy program for active range of motion 6-7 times a week every shift and restorative therapy program for bed mobility 6-7 times a week every shift with a start date of 8/25/23. A Skilled occupational therapy 8 visits in a 30-day period to address therapeutic exercise, therapeutic activities, neuromuscular retraining, and self-care training with a start date of 8/26/23. Physical therapy evaluation and treatment for 6 visits in 4 weeks for therapy exercises, therapeutic activities, gait training, wheelchair management with a start date of 8/29/23. On August 29th, 2023, at 9:45AM, R135 was observed to be sitting in a standard wheelchair with a mechanical lift sling underneath him. The wheelchair had foot pedals and a cushion on the seat. R135 was positioned in front of the television and upon entering the room his head was found to be hanging back with no support. R135 attempted to lift his head up to speak but appeared to not have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 2 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few strength to lift his head completely up. R135 at this time stated that he was put in this chair by therapy and left alone and has no idea how long it has been but feels like forever. When asked if he was comfortable in this chair R135 stated (explicit) no, this is the first time I have been out of bed since I got here and I am uncomfortable and want to get back in bed. After turning on R135's call light V6 (Certified Nurse Assistant) and V13 (Physical Therapist) came in to assist R135 at 9:53 AM back to his bed by the mechanical lift. When asked at this time why R135 was left in a wheelchair that allowed his head to hang back due to no support V13 instructed V10 (Director of Therapy) to go get R135 a different wheelchair. V10 came back with a high back wheelchair. V10 told R135 at this time that when he was ready to get out of bed, they would place him in the wheelchair and determine if it was a better fit for him. On 8/30/23 at 11:00 AM, R135 was up in the high back wheelchair that V10 had changed out for him on 8/29/23. When asked if this chair was better than yesterday's chair, R135 stated that it was much better and that he had better support for his back and head. At this time R135 was observed to be sitting straight up in this chair, and his head was not hanging back with no support. On 8/31/23 at 1:30 PM, V9 (Certified Occupational Therapy Assistant) stated that she was the therapist on call this weekend that did his evaluation. V9 stated when she was here on 8/26/23 she did a telehealth evaluation with an Occupational Therapist to complete the evaluation. V9 stated that she assessed his recliner as being adequate for him to safely sit in it and recline. However, she did not place R135 in the standard wheelchair that she brought in for the staff to use. V9 stated that she put foot pedals on the wheelchair and a cushion to use on the seat but did not actually place him in the chair to determine if it was appropriate. V9 stated that she did not fit R135 in a wheelchair on the assessment on 8/26/23, she just grabbed a wheelchair that was available and left it in the room for R135 to use. V9 stated her expectation would be for the nursing staff to let her know if the wheelchair didn't appear to be properly fitted for residents. V9 stated that she just wanted to have a chair for him to be able to get up out of bed, go to the dining room to eat and be included in activities because she knew he would not be starting therapy yet. V9 went on to state that after the evaluation occurred, he would start therapy and that is when he would be able to select a wheelchair and they would assess it. V9 stated that she was unaware that the wheelchair was not fitting R135's needs until V10 told her on Tuesday 8/29/23 when she got him a wheelchair with a higher back. Occupational Therapy Treatment Encounter note dated 8/26/23 document a completion of a telehealth evaluation with Certified Occupational Therapy Assistant (COTA) was completed and assessment of bed mobility, bilateral upper extremities, self-feeding tasks and sitting balance was assessed. This note documented under functional skills assessment that R135 was dependent for toilet transfers, eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing and putting on/taking off footwear. On this same note it documents under the summary of skilled services that R135 required minimum/moderate assist to maintain posture on edge of bed. An occupational therapy evaluation and plan of care document dates 8/26/23 documents under the balance section that R135's sitting balance is poor and maintains balance with moderate assist and upper extremity support. This same document under functional skills assessment-mobility during activities of daily living regarding wheelchair mobility states detailed wheelchair mobility assessment= no. On 8/31/23 at 2:45 PM, V8 (Regional Administrator) stated that she would expect therapy to have evaluated R135 for a proper wheelchair. V8 stated that the CNA's (Certified Nurse Assistants) and licensed nursing staff use the equipment that therapy leaves in the room after the initial evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 3 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete under the impression that is what is safest and most appropriate for the resident. V8 stated that occupational therapy is typically the therapy that evaluates/fits residents in wheelchairs. A facility policy titled Quality of Life-Accommodation of Needs with a revision date of February 2012 documents: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The procedure of the policy includes: 1. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and on an ongoing basis. 3. In order to accommodate individual needs and preferences, adaptions may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples may include: providing a variety of types (for example, chairs with and without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position . Event ID: Facility ID: 145628 If continuation sheet Page 4 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 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 staffing levels were sufficient to meet resident needs in a timely manner. This failure has the potential to affect all 35 residents residing in the facility. Findings Include: On 08/29/23 at 01:55 PM, R17, R7, R31, R30, R12, and R8 stated that their needs are not tended to in a timely manner by staff. All agree that the staff do the best they can with the amount of people they have working, but there just doesn't seem to be enough to tend to everyone when needed. R17 and R7 stated that staffing levels and response times seem to be worse on weekends. R12 stated that previously she has had to wait for 30 minutes for her call light to be answered, as evidence by watching the clock. R12 stated she finds that amount of time to be unsatisfactory because, when ya gotta go, ya gotta go, referring to using the restroom. R8 stated that he has had to wait 2 hours for his call light to be answered, which he too finds acceptable. R17, R7, R31, R30, R12, and R8 were all observed as being alert and oriented to person, place, and time during these interviews. No statements indicating a concern with dignity were made. On 8/29/23 at 10:00 AM, R31 who was alert to person, place and time stated that they do not have enough CNA's (Certified Nurse Assistant) especially after lunch and at night. R3 stated that she is dependent on staff to get her to the restroom and there have been times that she had an accident in the night waiting for them to get to her call light. R31 was unable to state the last time this had occurred and said that she is occasionally incontinent even with timely staff response. R31 stated that sometimes there is only one CNA that works the whole building, and that is not enough. On 8/29/23 at 11:20 AM, R26 who is alert to person place and time stated that they could use more CNA's. R26 stated that they ones who work do a good job, but they just don't have enough to get to everyone timely. On 8/29/23 at 10:20 AM, R22 who is alert to person place and time stated that they do not have enough CNAs after lunch through the rest of the day. R22 stated that they take too long to answer call lights. On 8/29/23 at 9:30 AM, R135 stated that they never answer his call light timely, and he waits forever for them to answer his call lights. On 8/30/23 at 10:03 AM, V6 (CNA) stated that while staff do their best to attempt to serve residents in a timely manner, they do not have enough staff to always do so. V6 stated she works 6 AM - 2 PM. V6 stated usually there is one aide assigned per hallway and then staff float from hall to hall to assist each other as needed, with residents who require assistance of more than one person, etc. V6 stated that she has had residents complain regarding the amount of time it takes staff to answer call lights. V6 stated one resident in particular that comes to mind that has complained regarding call light answer times is R31. V6 stated there are residents who have had incontinence episodes, waiting on their call lights to be answered. V6 stated she has expressed to V2 (Assistant Director of Nursing, ADON) that more staff are needed to care for residents in a timely manner. V6 stated it is her goal to have call lights answered within 5-10 min. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 5 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 On 8/30/23 at 10:15 AM, V7 (CNA) stated that she works as a facility employee from 6 AM - 2 PM. V7 stated she has had residents complain to her regarding the amount of time it takes staff to respond to their call lights. V7 stated there also have been residents who were waiting to use the restroom experience incontinence episodes while waiting for staff to tend to them. V7 stated it has been expressed to V1 (Administrator), this past Monday during a staff meeting that more staff are needed. V7 stated that V1 stated the facility is within their required amount for staffing. V7 stated that she isn't sure of the patient ratios that the facility is using, but the facility has to many residents now that require the assistance of two staff, or are very demanding, taking up much of staff's time. V7 stated while resident care tasks do get completed, V7 stated they are not always in a timely manner. On 08/29/23 at 9:15 AM, V1 stated the facility utilizes agency staff as well as having their own staff at the facility. V1 stated employees always want more staff, but based on their census, the facility is within the desired staffing levels to meet resident needs. On 08/30/23 at 2:23 PM, V1 stated there was a day over this past weekend on the 10 PM - 6 AM shift when there was 1 CNA working the building with 1 nurse. V1 stated there were 2 aides scheduled, but one was an agency staff and didn't show up. V1 stated there were no complaints made to her or ill outcomes from the 1 nurse and 1 CNA working the building that night. V1 stated usually there are 2 CNA's and a nurse scheduled during night shift. V1 stated that the nurse already working that night was their staff member on call. 08/31/23 8:25 AM V1 stated that the facility schedules the following number of staff for each shift: Day- 3 CNA & 2 nurses; Afternoon- 2 CNA & 1 nurse, although attempting to start scheduling 3 CNA recently due to a rise in census; Night- 2 CNA & 1 nurse. V1 stated this past Monday, 8/28/23, she did have a meeting with the staff. V1 stated the only concern expressed by staff were staffing levels. V1 stated staff expressed their need for more staff and that they were having trouble getting tasks completed. V1 stated staff expressed to her they wish she could come walk in their shoes, in which she stated she previously has as she worked as an agency nurse prior to starting this job. On 8/31/23 at 10:10 AM, V2 stated that there was a day recently in which she was working night shift as the nurse and only one aide was working with her. V2 stated that there were no complaints regarding staffing that night and herself and the aide were able to complete all duties needed. V2 stated that another CNA, which was agency, was also scheduled to work that night, but didn't show up. V2 stated that she makes the schedules and night shift staff now at the facility are mainly agency staff. V2 stated that she will send out messages to staff to see if they can come fill the vacant positions, but they do not always come in. V2 stated the night the agency CNA didn't show up, a day shift aide was supposed to come in at 4 AM but didn't show up. V1 provided a list of the following residents which utilize a mechanical lift in the facility: R8, R7, R135, R15, R12, R29, R31, R1. Review of the Daily Staffing Information Form dated 8/25/23 documents 1 Licensed Practical Nurse and I CNA worked night shift on this date. Review of the Resident Census and Conditions of Residents dated 8/29/23 documents a facility census of 35 residents. The same document notates the number of residents which need Assist of One or Two Staff for the following Activities of Daily Living: Bathing- 28, Dressing- 32, Transferring- 22, Toilet Use- 34, Eating33. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 6 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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, record review, and interview, the facility failed to appropriately date and label refrigerated food items and store foods to maintain food quality in the freezer. This failure has the potential to affect all 35 residents. The Findings Include: On August 29th, 2023, from 9:00 AM-9:45 AM the initial tour of the kitchen was conducted, and the following items were found in the freezer: There were items that were opened for use and not labeled with date and time of opening and were not tied up to prevent freezer burn. Two bags of undetermined food products in clear plastic bags were loosely twisted at the top and not secured to prevent freezer burn. During this initial tour the reach in refrigerator was found to have a bowl of potato salad that was not labeled with food item/date/time, drinks that were poured in glasses ready for tray assembly that were not covered, a black container that had a lid on it was not labeled with food item/date or time, and a bag of lunch meat on the bottom was not labeled. V11 (Food Service Supervisor) stated that a resident's family member had brought that food in and that is why it was not labeled, and the bag of lunch meat was hers from yesterday that she brought for lunch. In the walk-in refrigerator several items were not dated/labeled, and these items included: ranch salad dressing, shredded cheese, sour cream, lunch meat, tortillas, and cheese slices. Luncheon meat was found to be dated 7/29 and was brown in color. V11 stated that she had not been here over the weekend and that must have been when all this occurred and that she would throw out the luncheon meat and discard the items that were not labeled with date and time of opening. A Food and Supply Storage policy with a revision date of January 2023 states: Food and supply storage shall be maintained in a clean, safe, and sanitary manner. The procedure lists: 4. prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date 6. All foods will be covered, labeled, and dated . The Resident Census and Conditions of Residents dated 8/29/23 documents 35 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 7 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 ensure 5 of 5 (R3, R5, R7, R21, and R26) residents reviewed for immunizations in the sample of 32, received the education addressing the benefits and risks and/or had the opportunity to receive the 20-valent pneumococcal conjugate vaccine (PCV20 or Prevnar 20). Residents Affected - Some Findings Include: 1. Review of R3's Resident Face Sheet documents an admission date to the facility as 10/29/18 and documents a birthdate indicating R3 is [AGE] years of age. Diagnoses on this same document include, but are not limited to: Chronic Kidney Disease, stage 5; Diabetes Mellitus; Cerebral Infarction; Essential Hypertension. Review of R3's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 2. Review of R5's Resident Face Sheet documents a current admission date to the facility as 3/3/14 and birthdate indicating R5 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Schizoaffective Disorder; Gastro-esophageal reflux without esophagitis; Arthropathy. Review of R5's Clinical Record did not indicate that R5 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 3. Review of R7's Resident Face Sheet documents a current admission date to the facility as 3/11/16 and birthdate indicating R7 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Multiple sclerosis; Osteoporosis without current pathological fracture; Morbid (severe) obesity due to excess calories; Shortness of Breath. Review of R7's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 4. Review of R21's Resident Face Sheet documents a current admission date to the facility as 9/29/17 and birthdate indicating that R21 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Type 2 Diabetes Mellitus Without Complications; Essential Hypertension; Weakness; Dependence on Supplemental Oxygen. Review of R21's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 5. Review of R26's Resident Face Sheet documents a current admission date to the facility as 10/5/19 and birthdate indicating R26 is [AGE] years of age. Diagnoses on this same document include but are not limited to: Acute Respiratory Failure With Hypoxia; Encounter For Prophylactic Immunotherapy For Respiratory Syncytial Virus; Chronic Obstructive Pulmonary Disease; Acute On Chronic Diastolic (Congestive) Heart Failure; Emphysema; Shortness Of Breath; Essential Hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 8 of 9 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 145628 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of R26's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. On 8/31/23 at 10:15 AM, V2 (Assistant Director of Nursing, ADON) stated that she started at the facility in July 2023. V2 stated that 2 weeks ago, she started an immunization audit and mailed out consents for Flu and Pneumonia Vaccines to be given. V2 stated that they have not received any consents back from families yet, so she has started calling families to follow up and get verbal consent. V2 stated that the facility uses (company name) pharmacy and have been notified that they do not have any of the 20-valent pneumococcal conjugate vaccine available to send them currently. On 08/31/23 at 02:07 PM, V8 (Regional Administrator) stated that the facility acknowledges that R21, R7, R5, R3, and R26 were all eligible to currently receive the 20-valent pneumococcal conjugate vaccine. V8 stated these residents were not provided education regarding the 20-valent pneumococcal conjugate vaccine or given the opportunity to accept or decline the vaccine. V8 concedes that the facility is now in the process of providing the education for this vaccine, obtaining consents, and administering the vaccination once available. Although V8 stated the facility has not offered 20-valent pneumococcal conjugate vaccine to any residents yet at this time, it is also acknowledged that not everyone in the facility will be eligible to receive the 20-valent pneumococcal conjugate vaccine, and a screening process will be conducted. R26, R21, R7, R5, and R3's Clinical Records were reviewed with V8 and revealed past administration of previous versions of the pneumonia vaccine had been given per resident wishes or education with documented refusal were noted. Review of the facility policy titled, Pneumococcal Vaccine with a revision date of December 2016 stated, It is the policy of (company) that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per CDC (Centers for Disease Control and Prevention) guidelines. Review of information found at https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html documents, Pneumococcal disease is common in young children, but older adults are at greatest risk of serious illness and death. In the United States, there are 2 kinds of vaccines that help prevent pneumococcal disease Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20), Pneumococcal polysaccharide vaccine (PPSV23). Additional information found on the same site documents, For those who have never received any pneumococcal conjugate vaccine, CDC recommends PCV15 or PCV20 for Adults 65 years or older. Adults 19 through [AGE] years old with certain medical conditions or other risk factors. Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. These adults can talk with their doctor and decide, together, whether to get PCV20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 9 of 9