Inspection·April 28, 2025

F 0550 R18's Minimum Data Set (MDS), dated [DATE], documents R18 has severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder. Level of Harm - Actual harm Residents Affected - Few On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), provided incontinence care on R18. The window blinds were left open with R18 lying in the bed by the door with the curtain between the beds not pulled to obstruct the view from the window. There is a patio where residents can sit outside, as well as cars seen parked in a parking lot outside her window. On 4/23/2025 at 9:57 AM R18 stated that she doesn't really pay attention to the CNAs if they pull the curtain or not. R18 stated that she would not feel comfortable if she was exposed to other people. R18 stated that with the staff she must be ok, but with other people she would be embarrassed and would not like it. On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am providing care to a resident in their room, I make sure the blinds are closed, the curtains are pulled, and the door is shut. 2. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Overactive Bladder, Chronic Kidney Disease-stage 4, Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs related to impaired mobility. Diagnosis Cerebrovascular Accident (CVA)/hemiplegia. R63 has shortness of breath (SOB) with exertion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, provide setup assist and encouragement for those task that resident can perform independently, observe for signs/symptoms or complaint of shortness of breath, elevate head of bed as needed/requested, administer oxygen as ordered per MD (Medical Doctor). It continues (1/13/25) R63 is at risk for skin issues related to impaired mobility. Interventions: Staff to provide incontinent care after each incontinent episode, weekly skin assessment, staff to assist with turning and repositioning as tolerated, pressure redistribution mattress to bed. R63's MDS, dated [DATE], documents R63 is cognitively intact and is dependent on staff for toileting. On 4/22/25 at 9:25 AM, V12, CNA, was seen providing incontinence care for R63. The window blinds were left open with R63 lying in the bed by the window. There is a patio where residents can sit outside, as well as cars seen parked in the parking lot outside the window. On 4/22/2025 at 1:20 PM, R63 stated that she did not pay attention to the CNA and if she closed the blinds or not. R63 stated that she would expect them to close the blinds, and she assumed that they do. R63 stated that her window is facing the patio and there are people out there at times. R63 stated at night with the light on, and during the day with the sun, you can see directly in her room. R63 stated that she would not want her privates to be exposed to the outside. R63 stated that this would be a problem for her. R63 stated that it would be embarrassing. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect staff to provide privacy for the resident at all times, including closing the blinds and curtains during care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 2 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0550 The Facility's Incontinent Care Policy, dated 1/2015, documents in part Procedure: 6. Provide Privacy. 9. Avoid unnecessary exposure of the resident during the procedure. Level of Harm - Actual harm Residents Affected - Few 4.R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia. R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder. On 4/23/25 at 10:45 AM, V26, CNA, and V24, CNA, left the blinds to R56's room and curtain open while having his peri-region exposed during peri care. V26 stated he forgot to close the blinds. V24 then went over to the blinds and closed them. The Residents' Rights for People in Long-term Care Facilities brochure, undated, documented that residents have the right to privacy, including medical and personal care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 3 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed maintain a clean, homelike environment for 2 of 3 (R13, R27) residents reviewed for housekeeping in the sample of 79. 1. R13's MDS, dated [DATE], documents that R13 is cognitively intact. On 4/23/2025 at 1:29 PM R13 stated that the facility is filthy. R13 stated that the odor in the building is overwhelming. R13 stated that it's so many people that live here and not enough staff to take care of the building. R13 stated that the staff won't help each other and housekeeping only mop the floor. R13 stated they don't scrub it they only light run the mop that's it. 2. R27's MDS, dated [DATE], documents that R27 is cognitively intact. 04/23/25 at 02:28 PM R27 stated that the facility smells of urine and poop all the time. R27's BIMS is 15. R27 stated that there was a leak last time it rained heavy. 04/28/25 at 10:30 AM V14, CNA stated that she would let housekeeping know if a resident's room needs cleaned or if there are any foul odors so they can clean it and take care of it. V14, CNA stated that if 2 residents are fighting, she would try and to diffuse the situation and report it to V1, Administrator. 04/28/25 at 10:35 AM, V25, CNA, stated that she lets housekeeping know if there is anything that needs cleaned up or if there are strong odors. 04/28/25 at 10:40 AM, V12, CNA stated that she carries her own air freshener if there are any odors and would let housekeeping know if a resident's room needs cleaned. On 4/21/25 at 8:15 AM, upon entrance to the facility and while walking through the dining room to get to the conference room, the dining room floor appeared dirty with food particles on the floor and was very sticky to walk on. A strong smell of urine was noticed while walking through the facility. On 4/22/25 at 7:45 AM, while walking through the facility, a strong smell of urine was noticed, residents were seen sitting in the dining room for breakfast with the floor appearing dirty and sticky to walk on. On 4/23/25 at 12:00 PM, the 100-hall had a strong smell of urine upon walking down the hall, even with the housekeeper mopping resident rooms. While walking back to the conference room, the dining room floor was dirty and sticky to walk on. 04/28/25 at 10:25AM V44, Housekeeping Supervisor, stated that residents' rooms are cleaned every day and that they use air freshener when there are odors. The facility's Job Card, not dated, documents Resident Room Cleaning (occupied) Daily Tasks: Prepare supplies & wash/sanitize hands/don gloves & applicable PPE. Check for additional signs and follow precautions as indicated. Knock/enter room /close door/ greet patient/ ask if any concerns. Survey room/remove used items /trash/ dispose of needles/ sharps. Remove infectious waste/soiled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 4 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete linen/personal items/loose equipment. Use EPA Registered disinfectant on room surfaces & BLUE microfiber cloth. Disinfect high touch surfaces main room using BLUE microfiber cloth -Bed rails/ controls / tray table I call box / phone/bedside table handle. Chairs/room sink/room light switch / room inner doer knob/tv remote Clean window glass. Spot clean walls/ damp wipe vertical surfaces/ counters/ledges/ sills. Disinfect high touch surfaces restroom using RED microfiber cloth - Bathroom inner doorknob & plate /bathroom light switch/handrails. Restroom sink / toilet seat I toilet flush handle I toilet bed pan cleaner / Disinfect tub and shower (10 min. dwell time) Dust mop and damp mop floor (using BLUE microfiber flat mop Damp mop restroom floor using BLUE microfiber flat mop.) Event ID: Facility ID: 145847 If continuation sheet Page 5 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) residents reviewed for abuse in the sample of 79. This failure resulted in R36 suffering psychosocial harm and feeling scared, unsafe, unable to protect himself and less of a man. This failure also resulted in R90 suffering harm and being hit in the face, stomach and leg by another resident and R88 having a scratch to upper lip. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], moderately cognitively impaired. On 4/21/2025 at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room. On 4/21/2025 at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation. On 4/22/2025 at 11:30 AM R36's medical record reviewed. No documentation of the resident to resident altercation. The facility's Midnight Census report dated 4/24/2025 at 9:54 AM documents that R38 and R36 remain roommates. On 4/23/2025 at 1:30 PM the facility provided documentation of resident to resident abuse reported to IDPH. On 4/22/2025 at 1:10 PM R36 stated that his roommate is still in the room. R36 stated that his roommate is mean. R36 stated that R38 has been mean and hitting him since moving to the room. R36 stated that he is scared and does not feel safe in the room. R36 stated that he feels that he can't protect himself. R36 stated that he feels less of a man because he can't really defend himself. R36 stated that he has notified V31, Social Services Director (SSD), about he and his roommate not getting along and feeling scared. On 4/22/2025 at 1:14 PM V4, Registered Nurse (RN), stated that she was not aware of a resident to resident altercation that occurred between R36 and R38. V4 stated that R38 does have aggressive and combative behaviors. V4 stated that R38 is usually the aggressor. V4 stated that R36 is quiet and doesn't bother anyone. V4 stated that R36 has not had any behaviors of aggression towards staff and or resident. On 4/23/2025 at 11:45 AM V4, RN, stated that she notified V2, DON, of the resident to resident altercation that was reported to her yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 6 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Actual harm Residents Affected - Few On 4/23/2025 at approximately at 12:30 PM V1, Administrator, stated that she was not aware of a resident to resident altercation that occurred between R36 and R38 until today. V1 stated that when the state surveyor reported it; V1 that is the time it was reported to the state. V1 stated that she was not notified by the staff that were present. V1 stated that V29 is not a CNA. V1 stated that V29 is a safety aide and here to help monitor the residents to keep them safe. V1 stated that V29 did not report the abuse. On 4/28/2025 at 11:00 AM V4 stated that R36 is alert and oriented and able to voice needs. V4 stated that he can answer questions appropriately. R38's Care Plan, dated 12/30/2024, documents that R38 BEHAVIOR: (R38) has a hx (history) of physical aggression towards peers. i.e. (for example) on 12/1/24 (R38) grabbed another resident's arm causing him to bleed. 2. R88's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, osteoarthritis, degenerative disease of nervous system, and psychosis not due to a substance or known physiological condition. R88's MDS, dated [DATE], documented he is severely cognitively impaired. R88's Care Plan does not include him to be at risk for abuse. R90's face sheeting documented he was admitted on [DATE] with diagnosis of, in part, osteoarthritis, dementia with moderate agitation, and psychosis. R90's MDS, dated [DATE], documented he is severely cognitively impaired. R90's Care Plan dated 12/12/24 documented he is at risk for abuse and/or neglect related to impaired cognitive skills, diagnosis of Alzheimer's and Dementia. The facility's Initial Event Reporting dated 2/7/25, documented, Please find this as the initial reporting related to an allegation of a resident to resident physical altercation. R90 and R88, two cognitively impaired male residents of the facility locked dementia care unit, were reported to have had an altercation resulting in a small scratch to R88's upper lip. Staff intervened to ensure safety with assessments and notifications completed. R90 was transferred for evaluation related to his behaviors and remains at the ER (emergency room) at this time. The facility's final report regarding the allegation of resident-resident physical altercation occurring on 2/7/25 documented, On 2/7/25 at approx. (approximately) 1830 (6:30 PM), memory unit staff heard a commotion from the room of R88. Staff responded to the room urgently. As they were approaching R88 was exiting his room reporting R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 had entered his room and became agitated when he was asked to leave. R88 states that R90 hit him three time(sic). R88 reports that R90 hit his face, stomach, and leg. Staff separated resident's immediately. The facility's interview statement with V42, CNA, dated 2/8/25 documented, R88 was wandering said looking for his wife last I saw by shower room. We heard some yelling, rushed to them. R90 said he hit him. We got R88 away and watched him until he went out. He thought they were sleeping with his wife or something. V42 documented that R90 was last seen wandering. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 7 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Actual harm The facility's interview statement with V43, LPN, dated 2/8/25, documented, R90 was wandering looking for his wife. When we heard the commotion and got to the room they were just yelling. R88 said R90 hit him. We got them away, did assessments and notified and sent R90 out. R88 was okay. He said he thinks he was looking for his wife and he didn't have her. V43 documented R88 was last seen wondering. Residents Affected - Few The facility's interview statement with R90 dated 2/8/25, documented he had no recollection of the event. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 8 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report allegations of abuse for 4 of 4 (R36, R38, R49, R358) residents reviewed for Abuse in the sample of 79. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], documents moderately cognitively impaired. On [DATE] at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room. On [DATE] at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation. On [DATE] at 11:30 AM R36's medical record reviewed. No documentation of the resident to resident altercation. The facility's Midnight Census report dated [DATE] at 9:54 AM documents that R38 and R36 remain roommates. On [DATE] at 1:30 PM the facility provided No documentation of resident to resident altercation reported to IDPH. On [DATE] at 1:14 PM V4, Registered Nurse (RN), stated that she was not aware of a resident to resident altercation that occurred between R36 and R38. V4 stated that R38 does have aggressive and combative behaviors. V4 stated that R38 is usually the aggressor. V4 stated that R36 is quiet and doesn't bother anyone. V4 stated that R36 has not had any behaviors of aggression towards staff and or resident. On [DATE] at 11:45 AM V4, RN, stated that she notified V2, DON, of the resident to resident altercation that was reported to her yesterday. On [DATE] at approximately at 12:30 PM V1, Administrator, stated that she was not aware of a resident to resident altercation that occurred between R36 and R38 until today. V1 stated that when the state surveyor reported it, at that time it was reported to the state. V1 stated that she was not notified by the staff that was present. V1 stated that V29 is not a CNA. V1 stated that V29 is a safety aide and here to help monitor the residents to keep them safe. V1 stated that V29 did not report the abuse. On [DATE] at 12:05 PM V29, Safety Aide, stated that (R36) and (R38) were not hitting each other but they were cussing at each other and that he let a CNA know. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 9 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R38's Care Plan, dated [DATE], documents that R38's BEHAVIOR: (R38) has a hx (history) of physical aggression towards peers. i.e. (for example) on [DATE] (R38) grabbed another resident's arm causing him to bleed. [DATE] [NAME] had aggressive behaviors including attempting to pull his roommate from his bed. R38's MDS, dated [DATE], documents that R38's daily decision making skills are moderately impaired, has verbal and physical behaviors affecting others. R38's Progress Note, dated [DATE] at 4:45 PM, documents Resident has been agitated this shift. Has been yelling and cursing at other Residents and staff. He pushed on the back of another Resident's w/c. He was re-directed and explained his behavior is not appropriate. Re-directed him back to his room to lay down in bed. R38's Progress Note, [DATE] at 5:05 PM, documents that Resident has been angry and agitated this shift. He has been yelling and cursing at other Residents and staff. Re-directed him and explained that his behavior is not appropriate. Resident finally calmed down and allowed staff to help him with his ADL's. Will continue to monitor. On [DATE] at 1:15 PM V4, RN, stated that there was an incident that happened last week when R38 was cursing at other residents. V4 stated that she notified the Director of Nursing. On [DATE] at 12:25 PM V2, Director of Nursing, stated that incidents on [DATE] and [DATE] were reported to IDPH on [DATE]. V2 stated that they were made aware of the incidents at that time. V2 stated that the incidents had not been previously reported or investigated. V2 stated that the nurse documented the progress notes as late entry on [DATE]. V2 stated that she would expect the staff to report abuse immediately. 3. R49's admission Record, dated [DATE], documents R49 was originally admitted to the facility on [DATE] with diagnosis of Huntington's Disease, Major Depressive Disorder, and Anxiety Disorder. R49's Care Plan, dated [DATE], documents R49 has potential for psychosocial well-being problem related to history of physical and sexual abuse. Interventions: Consult with: Social services, Psych services, increase communication between (R49)/family/caregivers about care and living environment: Explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options, provide opportunities for the resident and family to participate in care. It continues R49 has an alteration in neurological status related to diagnosis of Huntington's Disease. Interventions: Assess for effects of psychotropic meds; dystonia, akathisia, akinesia, rigidity, tremors, etc., cueing, reorientation as needed, educate R49 to use scanning (move eyes across affected side) to prevent neglect/injury to affected side, give medications as ordered, monitor/document for side effects and effectiveness. R49's Minimum Data Set (MDS), dated [DATE], documents R49 has a moderate cognitive impairment and requires supervision/touching assistance for eating, setup/cleanup for toileting, partial/moderate assistance for bathing, and is independent on transfers. R49's Nurse Practitioner (NP) Note, dated [DATE], documents in part White female nursing home resident since [DATE]. Pt (patient) up in wheelchair, reports doing ok, random jerking and tremors present from neurological issue Huntington's disease psychosis. Staff observed roommate (R358) standing by her bed with pillow, pt woke up and began yelling, no physical contact made, peer has memory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 10 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few issues. Care conference with staff, behavioral tracking active, staff reports no concerns. Continue to use nonpharmacological interventions for behavioral management. 4. R358's admission Record, dated [DATE], documents R358 was admitted to the facility on [DATE] and was discharged /deceased on [DATE]. R358's diagnosis include: Depression, Anxiety Disorder, Disorientation, Cerebral Aneurysm-non-ruptured. R358's Baseline Care Plan, dated [DATE], documents Cognition: Confused, Communication: Verbal, Vision: Adequate, Bowel and Bladder: Incontinence care, Safety: History of Falls, Smoking. R358's MDS, dated [DATE], documents R358 had a severe cognitive impairment and was independent for all transfers and ambulation. R358's Nurses Note, dated [DATE] at 1:38 AM, documents Resident remains on Hospice Care. She is resting comfortably in bed with no signs of acute distress or pain. Lorazepam given as ordered and Fentanyl patch confirmed to be in place to left side of chest. CNA remains at bedside for monitoring. Plan of care ongoing including monitoring for changes in condition, needs, and safety. Care coordination with the Hospice team is ongoing. R358's NP Note, dated [DATE], documents in part White female nursing home resident since [DATE]. Pt. (patient) is being followed by Hospice, pt up in wheelchair, on one-to-one staff supervision, was standing by roommate's (R49) bed last night holding a pillow, no ill intent or physical contact between patients, peer was yelling out for staff scared, today patient does not remember event reporting she went home last night. Care conference with staff, behavior tracking active, electronic record from last month reviewed, continue to use nonpharmacological interventions for behavior management. V1, Administrator's Investigation includes the following: The Facility's Supervisor Investigation Summary Form, dated [DATE], documents How and when was event discovered: CNA (Certified Nursing Assistant) passing room reported to nurse a concern of (R358) attempts to do something with (R49) pillow and was concerned. Briefly describe event: Notified, DNS (Director of Nursing Supervisor) spoke to CNAs on phone. CNA states (R358) was standing by (R49) bed holding the pillow. (R358) did not touch her. Follow-Up Actions: Psych NP (Nurse Practitioner) evaluates to ensure safety without concerns. Contacted VP (Vice President) to review at time reported. Based on statement of concern no evidence of concern. (R358) was assisting (R49) with pillow positioning per (R49) reports/statements. Conclusion: No alleged issue - CNA observation concerned her. No Reportable per interviews immediate on eve of [DATE]. V2, Director of Nursing (DON), Interview/Investigation Record, dated [DATE], documents V27, CNA, stated per phone call I saw her (R358) standing by (R49) bed with her pillow in her hands. That's all. She didn't touch her. V2, DON, Interview/Investigation Record, dated [DATE], documents When asked did anything happen last night? (R358) stated I wasn't here. I just got here this morning with my husband. V2, DON, Interview/Investigation Record, dated [DATE], documents Asked did something happen with your roommate last night? (R49) stated No No Did your roommate try to hurt you? (R49) stated No No Help Help Happy Happy she good. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 11 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0609 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 2:05 PM, V1, Administrator, stated In our eyes it did not happen, therefore it was not reportable. There was no separation of residents pending investigation, and nothing reported to Illinois Department of Public Health (IDPH). Residents Affected - Few The Facility's Abuse Prevention - Illinois Only, dated 1/2025, documents in part a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. e) Mental Abuse: The use of verbal or non-verbal conduct which cause or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation including staff taking or using photograph or records in any manner that wound demean or humiliate a resident. Reporting: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24-hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, APS, and local law enforcement as required). Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 12 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to investigate allegations of abuse for 1 of 4 (R38) residents reviewed for allegations of abuse in the sample of 79. Residents Affected - Few Findings include: 1. R38's Progress Note, dated 4/18/2025 at 5:05 PM, documents that Resident has been angry and agitated this shift. He has been yelling and cursing at other Residents and staff. Re-directed him and explained that his behavior is not appropriate. Resident finally calmed down and allowed staff to help him with his ADL's. Will continue to monitor. On 4/22/2025 at 10:00 AM request abuse investigations. As of 4/28/2025 at 2:00 PM the facility had not provided an investigation for verbal altercations occurring on 4/15/2025 and 4/18/2025. On 4/22/2025 at 1:15 PM V4, RN, stated that there was an incident that happened last week when R38 was cursing at other residents. V4 stated that she notified the Director of Nursing. On 4/28/2025 at 12:25 PM V2, Director of Nursing, stated that incidents on 4/15/2025 and 4/18/2025 were reported to IDPH on 4/22/2025. V2 stated that they were made aware of the incidents at that time. V2 stated that the incidents have not been investigated. V2 stated that the nurse documented the progress notes as late entry on 4/22/2025. V2 stated that she would expect the staff to report abuse immediately. The facility's Abuse Prevention policy dated 1/2025 documented, the facility is committed to protecting the residents form abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. It also documents Invesyigation: The facility will initiate at the time of any finding of abuse or neglect and injuries of unknown origin an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 13 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to refer a resident to the appropriate state-designated mental health or intellectual disability authority for review after being diagnosed with a serious mental disorder, intellectual disability or related condition for 1 out of 1 resident, (R53); reviewed for Coordination of PASARR (pre-admission screening and resident review) in a sample of 79. Findings include: R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, heart valve replacement, atrial fibrillation and congestive heart failure. R53's face sheet documented he was diagnosed with severe dementia with agitation on 11/8/24, dementia with psychotic disturbance on 11/6/24 and schizoaffective disorder, depressive type on 12/29/23. R53's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired, had non-Alzheimer's dementia, schizophrenia and had not received psychological therapy in the last 7 days. R53's Care Plan dated 12/5/24 documented he is at risk for abuse and/or neglect related to impaired cognitive skills, diagnosis of schizoaffective disorder depressive type and dementia; R53 experienced an episode of resident-resident physical aggression on 4/27/24. R53's care plan dated 1/13/25 documented he is an elopement risk due to the following behaviors: exit seeking, confusion, wandering aimlessly; R53 resides on a secured unit. R53's PASRR Level I Review dated September 21, 2022, documented, Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. On 4/23/25 at 9:50 AM V31 (Social Worker) stated she missed having R53 re-evaluated with a PASARR after his new diagnoses and is getting together all the documentation to have it completed today. The facility's PASRR Screening for Mental Disorder or Intellectual Disability dated 7/2024 documented, Facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD (mental disorder) or ID (intellectual disability), or related condition experiences a significant change (residents that exhibit behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder, where dementia is not the primary diagnosis or previously identified and evaluated through PASRR) unless exemption criteria is met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 14 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 residents (R18) reviewed for wound care in the sample of 79. This resulted in R18 experiencing severe excoriation, including skin breakdown and pain. Residents Affected - Few The Findings Include: R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment. R18's Minimum Data Set (MDS), dated [DATE], documents R18 has a severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder. R18's Physician Order, dated 2/10/25, documents Skin assessment weekly every Tuesday day shift. Every day shift every Tuesday for weekly skin check. Please complete skin checks in (computer system). R18's Physician Order, dated 4/22/25, documents Cleanse bilateral buttocks with NS (normal saline) or WC (wound cleaner), apply barrier cream daily and PRN (as needed). Every Day shift for incontinence dermatitis. R18's Physician Order, dated 7/19/24, documents Cleanse peri area with mild soap and water or facility wipes, pat dry, apply Calazinc cream to buttocks, peri area, and inner thighs PRN. R18's Weekly Skin Assessment, dated 4/15/25, documents Incontinence Dermatitis to left buttock, right thigh, and left thigh. R18's Weekly Wound Assessment, dated 3/11/25, documents R18 had a Pressure Ulcer to left buttock that was healed. There is no further wound notes completed. R18's (Wound Management Specialist) Note, dated 3/18/25, documents in part Visit Date: 3/18/25, DC (discontinue) (Wound Management Specialist) services, Nursing to continue to monitor and notify me of changes. On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), in to do peri-care on R18, and during incontinent care, R18 was rolled to her right side, and her buttocks appeared very reddened with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 15 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 open sores that appear like skin tears with slight bleeding from areas. V12 continued to wipe R18, causing even more bleeding. A clean brief was applied with no moisture barrier cream applied to R18 and no drying seen done. On 4/22/25 at 10:18 AM, V12, CNA, stated (R18) did not have these sores on her bottom the last time I was working here. It looks like it is from sitting in wetness, especially when sitting her in her wheelchair. On 4/23/25 at 9:10 AM, V19, Wound Nurse, stated (R18) did have sores on her buttock before and the (Wound Management Specialist) was working with her, but that was all healed. The CNAs are supposed to be putting moisture barrier on her with each incontinence care. When told that R18's buttocks were excoriated and bleeding, V19 stated No one has told me about that, I was not aware of it. I will check her out this morning and probably have (Wound Management Specialist) look at her again. On 4/23/25 at 9:48 AM, V15, CNA, stated If I'm doing incontinent care and the resident has redness or open sores, I would use a barrier cream and will tell the nurse about it. On 4/23/25 10:50 AM, V19 gathered supplies to assess R18's wounds with V22, CNA, assisting. V19 opened R18's legs to expose her inner thighs and perineum area which were very bright red and excoriated. V22 turned R18 to her right side exposing her buttocks which showed three open wounds to her back side with the entire buttocks, anal area, gluteal creases all red and excoriated. V19 stated I was not aware of any of these wounds. R18 has been red for quite a while, and we were supposed to be using moisture barrier cream for it because she is a heavy wetter and is always saturated. I will have to call the physician now and get some orders for wound treatment. This looks very painful, and she should be in pain the way it looks. V19 measured R18's wounds which was the right buttock 2 CM (centimeters) X 5 CM X 1.0 CM, the left inner thigh 1.0 CM X 4.3 CM, and the right gluteal fold 0.4 CM X 3.7 CM. On 4/23/25 at 10:55 AM, V22 stated I just did peri-care on (R18), and she was yelling that it hurt every time I would wipe her. She was definitely in pain. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the CNAs to report any resident's change in skin condition to the nurse and I would expect the nurses to perform skin and wound assessments and provide appropriate treatments as ordered by the physician. On 4/23/25 at 11:30 AM, V19 stated I just spoke with the physician and (R18) will be followed up with (Wound Management Specialist) again and he gave me orders to take care of her wounds. On 4/23/25 at 11:35 AM, V19 gathered her supplies for wound care. V19 sprayed 4X4 gauze with wound cleaner and right buttock wound wiped, then Collagen and Calcium Alginate and foam dressing applied. R19 started to have a loose bowel movement so the wound care paused for peri-care. On 4/23/25 at 11:53 AM, V19 continued wound care on R18. Previous dressing was replaced due to feces on it. Wound cleanser sprayed on 4X4, wound wiped, then patted dry. Cavalon wiped on left inner thigh and right gluteal fold wounds, allowed to dry, then V19 wiped barrier cream all over R18's buttock/anal area. The previous dressing on R18's right buttock was falling off, V19 removed the old dressing, recleaned site, applied Collagen and Calcium Alginate and foam dressing again. While R18 was turned to her right, a small thin open slit was noticed on R18's gluteal cleft, V19 made aware and wiped barrier cream on it. R18 rolled back to her back side and covered up. There was no cleaning, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 16 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 wound care provided to R18's front inner thighs or peri-area. Level of Harm - Actual harm R18's New Physician Order, dated 4/23/25, documents Cleanse bilateral buttocks with NS or WC, apply barrier cream Q shift and PRN. Every shift for incontinence dermatitis/excoriation/ MASD (moisture associated skin dermatitis). Residents Affected - Few R18's New Physician Order, dated 4/23/25, documents Cleanse wound to right buttock NS or WC, apply Collagen, Calcium Alginate, and cover with a foam dressing daily and PRN. Every Day shift for open area to right buttock. R18's New Physician Order, dated 4/23/25, documents Cleanse anterior inner things with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to BIL (bilateral) inner thighs. R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs with NS or WC and apply barrier cream Q shift and PRN. Every shift for excoriation/MASD to inner thighs. R18's New Physician Order, dated 4/23/25, documents Cleanse BIL posterior inner thighs/gluteal folds with NS or WC, pat dry, and apply Cavilon once weekly and PRN. Every day shift every Wed (Wednesday) for excoriation/MASD to BIL thighs. The Facility's Guide for Wound Evaluation, undated, documents in part Procedure: 1. Upon identification of a pressure ulcer/injury (arterial, venous, or neuropathic), regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation Form or in the electronic format. 2. Non-Ulcers are to be documented weekly on a Skin Condition Form or in electronic format. 3. Contact physician, interdisciplinary team, family members, and significant others as indicated. 4. Initiate appropriate treatment per treatment protocol and physician order. 5. Evaluate further interventions that may be indicated to promote healing and prevent infection. 6. Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form / Skin Condition Form as appropriate. 7. The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. 10. The Director of Nursing Services and/or designated Licensed Nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The Facility's Wound Care Treatment Protocol, dated 11/2012, documents in part Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document / Report findings. Provide treatment as per physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 17 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17's admission Record, dated 4/24/25, documents R17 was admitted to the facility on [DATE], with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Anxiety Disorder, HTN, Encephalopathy, Spinal Stenosis, Thoracolumbar and Lumbar Region, Low Back Pain, Radiculopathy Lumbar Region. R17's Care Plan, dated 1/13/25, documents R17 has potential for acute risk for falls related to Confusion, Deconditioning, Psychoactive drug use. Interventions: Anticipate and meet R17's needs, educate R17/family/caregivers about safety reminders and what to do if a fall occurs, encourage R17 to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure that R17is wearing appropriate footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating or mobilizing in wheelchair, follow facility fall protocol, PT (physical therapy) evaluate and treat as ordered or PRN (as needed), review information on past falls and attempt to determine cause of falls, record possible root causes, alter/remove any potential causes if possible, educate R17/family/caregivers/IDT (interdisciplinary team) as to causes. R17's MDS, 3/19/25, documents R17 has a moderate cognitive impairment and requires supervision/touching assistance for toileting, and supervision/touching assistance for sit-to-stand and toilet transfers. R17's Fall Risk Assessment, dated 3/20/25, documents R17 is a High Fall Risk. R17's EZ Move Assessment, dated 3/21/25, documents in part Device Required: Gait Belt. On 4/21/25 at 9:02 AM, R17 put her call light on with V12, CNA, entering to assist. R17 stated she needed to use the restroom and V12 assisted R17 to side of her bed, R17 stood and pivoted into her wheelchair with V12 holding onto R17 by under her arm and down into the wheelchair, then pushed R17 into restroom. R17 stood and pivoted to the toilet again with V12 holding onto under R17's arm. V12 had a gait belt around her waist, and it dropped to the floor with V12 picking it back up and putting it around her waist again, but never used it on assisting R17 in her transfers. 4. R11's admission Record, dated 4/23/25, documents R11 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, Dementia, Major Depressive Disorder, Psychosis, Generalized Osteoarthritis, and Vertigo. R11's Care Plan, dated 1/20/25, documents R11 is at moderate risk for falls related to gait/balance problems, incontinence, psychoactive drug use, behaviors. Interventions: Follow facility fall protocol. R11's MDS, dated [DATE], documents R11 has a severe cognitive impairment and requires partial/moderate assistance for sit-to-stand and bed to chair transfers. R11's EZ Move Assessment, dated 1/24/25, documents in part Lifting/Mobility Required: one-person, Device Required: Gait Belt. R11's Fall Risk Assessment, dated 1/24/25, documents R11 is a High Fall Risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 18 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 The Facility's Fall Log, documents R11 had a fall on 3/21/25, and 3/26/25. Level of Harm - Actual harm On 4/23/25 at 8:55 AM, R11 was seen in bed with V20, CNA, assisting to get her out of bed. V20 had R11 sit up on side of bed, held R11 under her right arm, while R11 stood up and pivoted to her wheelchair. V20 had a gait belt wrapped around herself and did not use on R11. Residents Affected - Few On 4/24/25 at 9:40 AM, V14, CNA, stated Any time I am assisting a resident with a transfer, I always carry a gait belt around my waist and will use it while assisting the resident. On 4/28/25 10:35 AM, V25, CNA, stated that she uses a gait belt on residents during transfers. On 4/28/25 10:40 AM, V12, CNA, stated that she uses her gait belt when transferring residents. On 4/28/25 at 11:00 AM, V2, DON, stated I would expect all staff to maintain resident safety and perform safe resident transfers by using the gait belt for high fall risk residents. The Facility's Transfer Belts/Gait Belts Policy, dated 4/2014, documents in part To promote safety in transferring residents, a gait belt is utilized when deemed appropriate. The Facility's Fall Prevention Strategies and Interventions undated in part Transfer Assistive Devices: Ensure staff uses gait belt, transfer resident with gait belt. The Facility's Elopement Guidelines, dated 8/2017, documents in part The Elopement Risk Evaluation is to be done upon admission and quarterly and as needed with exit seeking behaviors. At the beginning and end of each shift the charge nurse is to make visual rounds on each high risk resident to ensure that they can be located in the facility. When exit seeking activity occurs consider 1:1 supervision or 15-minute checks. Based on interview, observation, and record review the facility failed to ensure safety as indicated per plan of care for 4 of 4 (R11, R17, R53, R72) residents reviewed for accidents and hazards in the sample of 79. This failure resulted in R72 suffering multiple falls and receiving a skin tear to her right knee. Findings include: 1. R72's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, neoplasm of brain, dementia, and neoplasm of lung. R72's MDS dated [DATE] documented she is moderately cognitively impaired and required supervision or touching assistance for all transfers, walking, and going from a sitting to a standing position. R72's Care Plan dated 1/7/25 documented she has high risk for falls related to confusion, gait/balance problems, psychoactive drug use, mood adjustment disorder and anxiety. Fall risk interventions put in place included: for 2/25 0900: provide sign on walker to remind resident to use walker when ambulating added on 3/4/25, for 2/25 1200: place in-room signage to remind resident to request help from staff when feeling tired/weak added on 3/4/25, anticipate and meet R72's needs added on 1/7/25, ensure that she is wearing appropriate footwear i.e. shoes/non-skid socks) when ambulating with wheeled walker added on 11/19/24, evaluate the effectiveness and side effects of psychoactive drugs for possible decrease in dosage/elimination of drug on 11/19/24, follow facility fall protocol added on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 19 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Actual harm Residents Affected - Few 11/19/24, hospice to provide Bolstered mattress for increased safety and to avoid rolling out of bed when resting added on 4/15/25, increase safety observations: staff to check room during routine rounding and PRN for environment safety, ensure no clothing are left on the floor added on 3/4/25, observe for removal of shoes when sitting in chair, re-direct resident to ensure shoes remain in place when OOB (out of bed) added on 4/15/25, Pt (physical therapy) evaluate and treat as ordered or PRN (as needed) added on 11/19/24, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible, educate resident/family/caregivers/IDT (interdisciplinary team) as to causes added on 11/19/24, and R72 needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach added on 1/7/25. R72's fall care plan had interventions added on the following dates: 11/19/24, 1/7/25, 2/25/25, 3/4/25, and 4/15/25. R72's Morse Fall Risk assessment dated [DATE] documented she is a high fall risk and to implement high fall risk interventions. The Facility's Incidents by Type Report from 1/21/25 to 4/21/25 documented R72 had 8 total falls on 2/25/25 (twice), 3/9/25, 4/13/25, 2/23/25, 2/27/25, 3/31/25, and 4/4/25. R72's Progress Notes documented her having a total of 12 falls on the following dates: 1/10/25, 1/16/25, 2/23/25, 2/25/25 (twice), 3/10/25, 3/12/25, 3/17/25, 4/4/25, 4/13/25, 4/19/25, and 4/23/25. R72's Progress Note dated 4/19/25 at 2:59 PM, documented R72 obtained a skin tear to her right knee after being found laying on the floor next to her bed on the left side of her face. R72's Progress Note dated 4/19/25 at 6:27 PM, documented she returned from the hospital with diagnosis of pneumonia and a urinary tract infection. On 4/21/25 at 8:59 AM, on 4/22/25 at 9:23 AM, 11:39 AM and at 2:55 PM R72 was observed not wearing non-slip socks or shoes. On 4/21/25 at 8:59 AM, R72 had a bruised left eye with bloody sclera. R72 does not remember what from; she did not have non-slip sock on and was sitting in her wheelchair. On 4/22/25 at 9:04 AM R72's door was closed, this surveyor knocked, and walked in. R72 was lying in bed awake, call light on floor, fall mat on left side, no mat on right side, bed in low position, and no footwear on and her bed did not have a bolster mattress in place. On 4/22/25 at 9:23 AM, R72 was in wheelchair at dining area in front of nurse's station with a snack after her morning medications; R72 was not wearing non-slip socks or shoes. On 4/22/25 at 2:55 PM, V23, R72's daughter, stated her mother came here with lung cancer and it has since metastasized to her brain. Since the metastasis, V23 stated she thinks R72 has had increased falls. V23 stated her mother doesn't have non-slip socks on and she is supposed to. V23 stated she requested the facility try to utilize an alarm system for R72 but was told they couldn't. V23 stated she does not feel like R72 has enough supervision to prevent falls and would like to know if the bolster mattress will be put in place soon. V23 stated she does like the fall mats in place. On 4/23/25 at 10:26 AM, V24, CNA, stated fall interventions for R72 include floor mats, frequent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 20 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 checks, and assistance to the bathroom, as well as offering the restroom often. Level of Harm - Actual harm On 4/23/25 at 10:28 AM V25, CNA, stated fall interventions for R72 include floor mats by bed, providing assistance. Residents Affected - Few On 4/23/25 at 10:29 AM V5, LPN, stated fall interventions for R72 include having the bed in low position, use of fall mats, observation, keep closer to nurse's station, non-slip socks, and fall interventions for R10 include bed in low position, reminders for safety, offering help fast. V5 stated she is new to the facility and since working here for about 2 weeks she has not seen any concerns between R88 and R90. V5 stated interventions for wandering include offering lots of activities, keeping the residents busy, toileting them and providing naps with frequent assistance of needs. On 4/23/25 at 2:24 PM, V2 DON (director of nursing) stated there was no fall for R72 on 4/19/25 after a fall investigation was requested for that date and would have to check back after this surveyor mentioned there was one documented in the progress notes. On 4/23/2025 at approximately 2:40 PM V2, Director of Nursing, stated that initially she did not remember what fall that occurred on 4/19/2025 until she read the note in the computer. V2 stated that R72 was sent to the hospital for a change in condition. V2 stated that she remembered at that time R72 was on the floor. V2 stated that they thought R72 had a stroke. V2 stated that the hospital determined that R72 did not have a stroke and was diagnosed with pneumonia. 2.R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of dementia with severe agitation and psychotic disturbance, and schizoaffective disorder. R53's MDS dated [DATE] documented he was severely cognitively impaired and exhibits wandering behavior daily. R53's Care Plan dated 1/13/2025, documented he is an elopement risk due to the following behaviors: exit seeking, confusion, wandering aimlessly and he resides on a secured unit. Interventions for this care plan included encourage R53 to verbalize through one-to-one interaction added on 1/8/2025, place R53 in area where observation is possible added on 1/8/2025, and provide diversional activities for resident when anxious, offer resident a snack added on 12/4/2024. On 4/21/25 at 9:30 AM, R69 stated R53 wanders into his room and takes things so they keep his door closed, he needs to be watched. On 4/22/25 at 9:00 AM, R53 was observed walking up and down the hallway. At 9:07 AM, R53 walked into R90's room then came back out and walked into R80 and R33's room, closed the door and came back out within a couple minutes. This surveyor observed no staff intervene while R53 walked into other resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 21 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R41's Care Plan, dated 1/27/2025, documents that (R41) has an ADL (activity of daily living) self-care performance deficit r/t (related to) Hemiplegia, Impaired balance, Musculoskeletal impairment, CVA affecting right side. It also documents TOILET USE: (R41) is not toileted due CVA (Stroke) affecting right dominate side, (R41) is inc (incontinent) of B & B (bowel and bladder), Peri care is provided q 2 hours and as needed. R41's Minimum Data Set (MDS), dated [DATE], documents that R41 is cognitively intact, always incontinent of bowel and bladder and dependent on staff for toileting. On 4/22/2024 at 9:25 AM observed V14, Certified Nurse's Assistant (CNA) perform incontinent care. R41 was incontinent of urine and stool. Using a wet wipe V14 cleansed R41's peri and groin area. V14 assisted R41 onto her right side. Using wet wipes V14 then cleansed R41's entire left buttock and partial right buttock. V14 then applied R41's incontinent brief. V14 did not cleanse R41's entire buttock. 4. R42's Care Plan, dated 1/28/25, documents that (R42) has an ADL self-care performance deficit r/t Hemiplegia, Impaired balance. It also documents TOILET USE: (R42) is incontinent of bowel and bladder and is dependent on staff for toileting. Staff to provide peri care q 2 hours and as needed. R42's MDS, dated [DATE], documents that R41 is cognitively intact, always incontinent of bowel and bladder and dependent on staff for toileting. On 4/22/2025 at 9:27 AM Observed V17, CNA, perform incontinent care. R42 was incontinent of urine and bowel. V17 pulled back covers and revealing an incontinent brief dated 4/22 4:53. V17 opened R42's incontinent brief and using wet wipes cleansed R42 peri and groin area. V17 then assisted R42 onto her right side and cleansed R42's entire left buttock and partial right buttock. R42 V17 then applied R42's clean incontinent brief with stool remaining on R42's buttock. V17 did not cleanse R42's entire right buttock and inner thighs. The facility's Incontinent Care policy, dated 1/15, documents that the POLICY: To provide routine, preventive skin, perineal care to residents after an incontinent episode. PROCEDURE: 10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire area moving from front to back. Based on Interview, Observation, and Record Review the Facility failed to provide timely and complete incontinent care for 4 of 5 residents (R18, R41, R42, R63) reviewed for incontinent care in the sample of 79. The Findings Include: 1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 22 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as needed), observe skin daily with care, notify MD (medical doctor)/NP (nurse practitioner) of any abnormal findings, pressure redistribution mattress to bed, provide diet as ordered, RD (registered dietitian) to follow related to wound care and nutrition, refer to Specialized Wound Management, staff to assist with turning and repositioning as tolerated, staff to provide incontinent care after each incontinent episode, weekly skin assessment. R18's Minimum Data Set (MDS), dated [DATE], documents has severe cognitive impairment and is dependent on staff for toileting and bathing. R18 is always incontinent of both bowel and bladder. R18's Physician Order, dated 7/19/24, documents Cleanse abdominal fold with soap and water. Pat dry Apply Antifungal powder PRN (as needed). R18's Physician Order, dated 7/19/24, documents Cleanse peri area with mild soap and water or facility wipes, pat dry, apply Calazinc cream to buttocks, peri area, and inner thighs PRN. On 4/21/25 at 9:25 AM, R18 stated they have not gotten her up yet today, has not been cleaned up yet, and is currently wet from the night. On 4/22/25 at 8:13 AM, R18 stated she was unsure when the last time she was cleaned up. R63, R18's roommate, stated that both of them (R18 and R63) were last cleaned up between 4:00 AM -5:00 AM this morning. R63 stated they will come in and clean them both up again after breakfast. R18 complained of her butt hurting. On 4/22/25 at 10:00 AM, V12, Certified Nursing Assistant (CNA), entered to do incontinence care on R18. Feces was seen in R18's incontinent brief from the front side and it also appeared saturated. R18's incontinent brief was unfastened and tucked between her legs. V12 wiped R18's right groin three times, left groin twice, down both thighs, and then wiped twice down the middle of R18's vagina with feces showing on the cloth on the last wipe. There was no further wiping of R18's vagina or abdominal fold and no drying of R18. R18 was rolled to her right side, and her buttocks appeared very reddened with open sores that appeared like skin tears with slight bleeding from areas. V12 continued to wipe off some white cream on R18, causing more bleeding. A clean brief was applied with no moisture barrier cream applied to R18 and no drying seen done. On 4/22/25 at 10:15 AM, V12, CNA, stated I checked (R18) at 6:00 AM when I got here, and she was dry at that time. We don't get (R18) up until after breakfast. 2. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen, Overactive Bladder, Chronic Kidney Disease-stage 4, Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily living) related to impaired mobility. Diagnosis CVA/hemiplegia. Interventions: Assist with all ADLs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 23 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0690 Level of Harm - Minimal harm or potential for actual harm as needed, provide setup assist and encouragement for those task that resident can perform independently. It continues (1/13/25) R63 is at risk for skin issues related to impaired mobility. Interventions: Staff to provide incontinent care after each incontinent episode, weekly skin assessment, staff to assist with turning and repositioning as tolerated, pressure redistribution mattress to bed. Residents Affected - Some R63's MDS, dated [DATE], documents R63 is cognitively intact and is dependent on staff for toileting. On 4/21/25 at 9:30 AM, R63 stated I have not been out of my bed or cleaned up yet today. I am currently wet from the night. I am usually in bed until around lunch time. There was a urine smell coming from R63. On 4/22/25 at 8:13 AM, R63 stated I was last checked and cleaned up between 4:00 and 5:00 AM this morning. I am wet now and they will come in and clean me up again after breakfast. On 4/22/25 at 9:00 AM, V11, Licensed Practical Nurse (LPN), answered R63's call light with R63 stating that she was wet and needed changed. V11 told R63 that she will let a CNA know. On 4/22/25 at 9:25 AM, V12, CNA, brought in supplies, which included a pack of wet wipes and two trash bags. The window blinds were left open with R63 lying in the bed by the window. There were cars seen parked in a parking lot outside her window. R63 was laid flat in bed for care with her oxygen cannula removed to wash her face and was never put back on. V12 unfastened R63's incontinence brief and tucked it between R63's legs with a strong urine smell filling the room. V12 wiped once to left groin, once to right groin, and once down the middle of R63's vagina. There was no further cleaning of R63's peri-area or vaginal area and there was no drying of R63. On 4/24/25 at 9:40 AM, V14, CNA, stated The CNAs should be checking on every resident at least every two hours and should provide peri-care at that time if needed. When I do peri-care, I gather all my supplies, which are two basins of water, one with soap and one for rinse or sometimes will use wipes depending on the situation. I will then clean the resident's groins, then the right side, left side, and down the middle of a female's vagina, then roll them over and completely wipe the back side. I will then dry them. Any time I am providing care to a resident in their room, I make sure the blinds are closed, the curtains are pulled, and the door is shut. Any time I am assisting a resident with a transfer, I always carry a gait belt around my waist and will use it while assisting the resident. On 4/28/25 10:35 AM, V25, CNA, stated that during incontinent care, all areas are washed and dried. V25 stated that during resident care, doors, blinds, and curtains are pulled for privacy. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect staff to perform timely and complete incontinent care and to provide privacy for the resident at all times, including closing the blinds and curtains during care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 24 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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** 4. R13's Care Plan, not dated, does not address R13's oxygen use. Residents Affected - Some R13's MDS, dated [DATE], documents that R13 is cognitively intact. On 4/21/2025 at approximately 9:15 AM observed oxygen concentrator in room with oxygen tubing on the floor. The concentrator did not have humidified water bottle in place. The oxygen tubing was not dated. On 4/24/2025 at 1:25 PM observed oxygen concentrator in room with oxygen tubing on the floor. The concentrator did not have humidified water bottle in place. The oxygen tubing was not dated. On 4/24/2025 at 1:29 PM R13 stated that she uses the oxygen when she is short of breath. R13 stated that it's not all the time but when she needs it it's there. R13 stated that they do not change the oxygen tubing. R13 stated that she doesn't remember ever having a water bottle on the concentrator. On 4/28/2025 at 10:48 AM V2, Director of Nursing stated that R13 had a change in condition and went out to the hospital. V2 stated that when R13 returned she had an order for oxygen. On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the nurses to attach humidified water bottles and to date the nasal cannulas for those residents on oxygen. I would expect the staff to use the portable oxygen stands for all portable oxygen tanks and not to leave them free standing. The facility's Oxygen Therapy policy, dated 8/14, document that the OXYGEN THERAPY POLICY: Oxygen (02) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. EQUIPMENT: Cannula - used for oxygen flow of 1-4 liters per minute (LPM). Humidification is not necessary for flow rates of 1-2 LPM or less and should only be used as clinically required. PROCEDURE: I. Oxygen therapy is to be provide under the direction of a written physician's order. A Physician's Order for 02 therapy is to contain liter flow per minute via mask or cannula/timeframe. On an emergency basis, 02 may be used at 2L/minute until the physician is notified. 8. Change tubing weekly. 9. Date tube when changed (weekly). Based on Interview, Observation, and Record Review, the Facility failed to provide a humidified bottle of water and to date the nasal cannula for 4 of 5 residents (R63, R65, R43, R13) reviewed for residents on Oxygen (O2) in the sample of 79. The Findings Include: 1. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen (O2), Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 25 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Some living) related to impaired mobility. Diagnosis CVA/hemiplegia. R63 has SOB (shortness of breath) with excretion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, observe for signs/symptoms or complaint of shortness of breath, elevate head of bed as needed/requested, administer oxygen as ordered per MD (Medical Doctor). R63's Minimum Data Set (MDS), dated [DATE], documents Section C: R63 is cognitively intact and is dependent on staff for toileting. Section I: Pulmonary - Asthma Yes, Respiratory Failure Yes, Other: Dependence on Supplemental Oxygen Yes. Section J: Other Health Conditions: A. Shortness of Breath or trouble breathing with exertion Yes, B. Shortness of breath or trouble breathing when sitting at rest Yes, C. Shortness of breath or trouble breathing when lying flat Yes. R63's Physician Order, dated 10/31/24, documents Oxygen: Tubing and Humidifier Change. Every night shift, every Sun (Sunday) for oxygen use, please label tubing with date changed. R63's Physician Order, dated 10/31/24, documents Oxygen: Obtain SPO2 (measure of the percentage of oxygen in the blood). Every shift for SOB (shortness of breath). R63's Physician Order, dated 10/31/24, documents Oxygen: Obtain SPO2. As needed for SOB. R63's Physician Order, dated 9/17/24, documents Check O2 Sats Q Shift and if SPO2% is <90% Notify MD Immediately. Every shift related to Dependence on supplemental oxygen. R63's Physician Order, dated 9/17/24, documents Oxygen 3 Liters Per Nasal Cannula Continuous. On 4/21/25 at 9:30 AM, R63 seen lying in bed on O2 at 3 Liters (L)/Nasal Cannula (NC) per O2 concentrator. There was no humidified water bottle attached to the concentrator and the NC was not dated. There was also a portable O2 tank free standing in front of the concentrator with no stand or container. On 4/22/25 at 8:13 AM, R63 lying in bed with 3 L/NC on per oxygen concentrator with no humidified water bottle and the NC not dated. The portable O2 tank remains free standing and now by the door. On 4/22/25 at 9:25 AM, while providing incontinent care to R63, V12, CNA, laid R63 flat with her NC removed from her nose and placed on the concentrator during care. R63 was transferred from her bed to her wheelchair via (full body mechanical lift device) without her oxygen. After care and the transfer of R63, V12 gave R63 her O2 NC with R63 putting it in her nose, then V12 told V13, CNA, to take R63 to the nurse to get her oxygen turned on. R63 appeared to be slightly short of breath without her oxygen on. On 4/23/2025 at 10:50 R63 stated that she has COPD and always wears her oxygen because she can't breathe without it. R63 stated that she has to have her head up. R63 stated that she can't lay flat. R63 stated that when lying flat she has trouble breathing. R63 stated that she struggles to breathe and feels like she is suffocating when lying flat. R63 stated that she wears the oxygen and can't breathe without it. 2. R65's admission Record, dated 4/24/25, documents R65 was admitted to the facility on [DATE] with diagnosis of Congested Heart Failure (CHF), Hypertension (HTN), Atherosclerotic Heart Disease (ASHD), Morbid Obesity, Major Depressive Disorder, and Anxiety Disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 26 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 R65's Care Plan, dated 1/17/25, documents R65 has altered cardiovascular status related to diagnosis of Systolic and Diastolic Heart Disease and Atherosclerotic Heart Disease. Intervention: Monitor/document/report PRN (as needed) any changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Residents Affected - Some R65's MDS, dated [DATE], documents R65 is cognitively intact and is independent for ADLs. R65 does not have a Physician Order for O2. On 4/21/25 at 10:05 AM, R65 was on an O2 concentrator with 2 L/NC. The NC was seen lying in the resident's bed, there was no water bottle attached to the concentrator and the NC was not dated. 3. R43's admission Record, dated 4/24/25, documents R43 was admitted to the facility on [DATE], with the diagnosis of Acute Respiratory Failure, CHF, Pneumonia, HTN, Generalized Anxiety Disorder, and Major Depressive Disorder. R43's Care Plan, dated 1/16/25, documents R43 has altered respiratory status/difficulty breathing related to diagnosis of acute respiratory failure. Interventions: Administer medication/puffers as ordered, monitor for effectiveness and side effects, encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn, maintain a clear airway by encouraging resident to clear own secretions with effective coughing, if secretions cannot be cleared, suction as ordered/required to clear secretions, monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, Oxygen Settings: O2 via NC at 2L continuous. R43's MDS, dated [DATE], documents R43 is cognitively intact and is independent on some ADLs. R43's Physician Order, dated 6/10/24, documents Continuous O2 2 L/NC Check SPO2 Q Shift if SPO2 is < 90 Then Notify MD. Every shift related to Acute respiratory failure, with hypoxia or hypercapnia. On 4/21/25 at 10:00 AM, R43 stated she is on O2 at 2 L/NC. There was no humidified water bottle attached to the concentrator and the NC was not dated. On 4/24/25 at 9:35 AM, V30, Licensed Practical Nurse (LPN), stated The Nurses are responsible for taking care of the resident's oxygen needs. The Nurses should add a water bottle to the concentrator and should be changing the nasal cannula once a week. The Nurses should date each one when they put a new bottle or cannula on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 27 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Many 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 properly store and discard expired medications for 30 of 32 residents (R11, R15, R18, R23, R27, R29, R30, R31, R32, R35, R39, R40, R41, R43, R44, R45, R46, R48, R58, R60, R63, R65, R81, R82, R86, R94, R96, R97, R101, R357) reviewed for medication storage in the sample of 79. Findings include: On 4/21/2025 at 9:55 AM the facility's 100 Hall North Back Medication Cart was inspected. The medication cart contained the following: R41's opened multi dose Lantus insulin Pen. The multi-dose vial was labeled with no open date. On 4/21/2025 at 9:59 AM V4, Registered Nurse (RN), verified that the multi dose vial was open, in use and did not have an open date. On 4/21/2025 at 10:07 AM the facility 100 hall medication room was inspected. The unlocked refrigerator located in the medication room contained the following: R29's plastic sealable bag with 1 sealed 1ml vial of Lorazepam and 1 open and partially used 1ml vial of Lorazepam. 1 unlabeled plastic sealable bag with R46's sealed 1ml vial of Lorazepam and 1 open and partially used 1ml vial of Lorazepam. The unlabeled plastic sealable bag also contained 2 sealed 1ml vials with no name. R23's plastic sealable bag with 1 opened and partially used 1ml vial of Lorazepam and 1 sealed 1ml vial of Lorazepam. Both vials manufacturer expiration date was documented on vial 1/2025. On 4/21/2025 at 10:15 AM the 100 Hall North front medication cart was inspected. Facing the 10-drawer medication cart there are 4 narrow drawers to the right side. The second drawer from the top is missing creating a large hole and gap between the first and third drawer. This hole in the cart exposes the narcotic lock box to anyone in the facility. On 4/21/2025 at 10:20 AM V8, LPN, stated that the vials of Lorazepam should be under a double lock and with the refrigerator not having a lock it's not. V8 stated that R23's Lorazepam is expired and should have been destroyed. V8 stated that she is agency and has been coming to the facility for some time and the medication cart has been this way. V8 stated that she asked about it and was told to keep it in the medication room. V8 stated that she must take the cart out of the medication room to pass medications. V8 stated that she can reach in the opening and access the narcotics. On 4/21/2025 at 12:02 AM observed V8 access the narcotic drawer through the opening above. V8 was able to unlock the box and obtain R48's Clonazepam medication. On 4/21/2025 at approximately 1:40 PM V4 stated that she has worked at the facility for about 6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 28 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Many weeks. V4 stated that she has passed medication using the 100-hall front cart. V4 stated that the cart has had a missing drawer and opening since she has worked at the facility. On 4/21/2025 approximately 1:50 PM V2, Director of Nursing, verified that the Lorazepam was a controlled substance and should be under a double lock system. V2 stated that currently this is not the case but that they are working to correct this. V2 stated that they do not have a narcotic count sheet for R23's expired lorazepam located in the unlocked refrigerator. V2 stated that she was aware of the condition of the cart and the access to the narcotics and not being under a double lock system. V2 stated that she requested a new cart 2 weeks ago and that V1, Administrator was on it. On 4/21/2025 observed medication cart in the hallway, with the front of the cart facing outward with narcotic drawer accessible, unattended by staff. On 4/22/2024 the Medication Cart observed sitting in hallway from 9:57 AM to 11:00 AM unattended. The medication cart front facing to hallway with access to Narcotic drawer accessible to persons walking past. On 4/22/2025 at 10:00 AM observed R32 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R32's reach. On 4/22/2025 at 10:04 AM observed R65 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R65's reach. Observed R65 bump into cart and pushed off cart. On 4/22/2025 at 10:05 AM observed R39 propelling self in wheelchair next to unattended medication cart. The opening of medication cart was eye level and in R39's reach. Observed R39 propelling back and forth past the unattended medication cart. On 4/22/2025 at 10:14 AM observed R30 ambulating passed the unattended medication cart. The medication cart was within R30's reach. On 4/22/2025 at 2:35 PM V18, LPN, stated that the cart has been this way for at least 2 years. V18 stated that she has asked about it and was told it has been ordered but has it never shown up. This failure has the potential to affect independent, mobile residents (R11, R15, R18, R23, R27, R29, R31, R35, R40, R43, R44, R45, R46, R48, R58, R60, R63, R81, R82, R86, R94, R96, R97, R101, R357), which were identified by V2, Director of Nursing as residing in the facility. The facility's Medication Storage policy, dated 1/15, documents that POLICY: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Procedure: 12. The following medications must be removed from stock and disposed of properly on a continuing basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/ cracked containers. On 4/21/25 at 1:13 PM, the medication cart located on the 200-Hall was seen unlocked and unattended sitting by the nurse's desk, with R75 sitting in her wheelchair next to the desk and cart. R75's Minimum Date Set (MDS), dated [DATE], documents R75 has a severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 29 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 - Many On 4/28/25 at 11:00 AM, V2, Director of Nursing (DON), stated I would expect the nurses to keep the medication carts locked at all times when not administering medications. Stat-box Check-In (South E-kit Contents) inventory sheet, undated, documented the following medications and amounts as follows: Adrenaline x 2, Amlodipine x 10, Amoxicillin x 10, Amox/Clav x 10, Atorvastatin x 10, Azithromycin x 10, Carvedilol x 10, Cefdinir x 10, Ceftriaxone x 4, Cefuroxime x 10, Cephalexin x 10, Ciprofloxacin x 10, Clindamycin x 10, Clonidine x 5, Clopidogrel x 10, Digoxin x 10, Diphenhydramine x 1, Doxycycline x 10, Donepezil x 10, Furosemide 20 mg (milligrams) x 10, Furosemide 10mg x 2, Gabapentin x 20, Baqsimi (glucagon nasal spray) x 1, Haloperidol x 4, Heparin x 4, Levofloxacin x 10, Lisinopril x 10, Memantine x 10, Mephyton x 3, Methylprednisolone x 1, Metoprolol tartrate x 10, Metoprolol succinate x 10, Metronidazole x 10, Mirtazapine x 10, Naloxone x 1, Nitrofurantoin x 10, Nitroglycerin x 1, Ondansetron x 10, Pantoprazole x 10, Phenytoin x 10, Phytonadione x 2, Potassium ER x 10, Prednisone x 20, Prochlorperazine 5mg x 10, Prochlorperazine 10mg x 2, Spironolactone x 10, Sulfamethoxazole x 10, SPS (sodium polystyrene sulfonate) x 4, Trazodone x 10, Warfarin 1mg x 10, and Warfarin 2mg x 10. On 4/21/25 at 12:17 PM, the Medication Storage Room in Memory Care Unit contained the following: At 12:20 PM, located in a refrigerator, R10's Aspart (insulin) box dated 12/17/24 had 4 pens in it. One pen does not have a pharmacy label and has the name (name) written on it, expire date 2/28/27. V5 LPN stated we don't have any resident named (name) on this unit right now. R10 had pharmacy labels on the other 3 pens in her box unopened. At 12:30 PM, E-Kit (Emergency Kit) labelled Facility South, did not have a sealed tag/lock on it and had a slip for use of it dated 4/20/25 for R92 to be administered doxycycline, the box that is not sealed did not contain doxycycline. The box that contains Doxycycline was sealed/locked with a tag. Unsealed/unlocked box contained: epinephrine, diphenhydramine furosemide, heparin, nitroglycerin, vitamin k, prochlorperazine, and coumadin. V5 stated she does not know why it was not tagged or the process the procedure does when it is used, thinks there should be a booklet with it. The top compartment of the E-kit had medications freely accessible and included Narcan, lidocaine x 4, ceftriaxone, sodium polystyrene sulfonate x4, glucagon nasal spray, and methylprednisolone which. On 4/21/25 at 12:39 PM, V6 LPN/Unit manager stated the emergency kit with a box not tagged was never reported to her, she is unsure what was used or how much medication should be in it because there is no booklet here with the box. V6 stated the box should be retagged immediately after use to know the correct count. V5 tagged the open box without counting the medications in front of V6. V6 stated there should also be a book with the box. On 4/22/25 at 9:35 AM, V6, LPN Unit Manager, stated the E-kit not being tagged/sealed/locked appropriately is a concern as well as not having the book that is supposed to be filled out each time the kit is used unavailable. V6 stated she was unable to find the book for the E-kit and does not know why the box was not locked or why there was a box within the kit that was not tagged/locked either. V6 stated she thinks it was an agency nurse that used it over the weekend and was not familiar with the facility's protocols for using the E-kit. V6 stated she has no idea what medications were taken out. V6 stated she did not know where the inventory list was for the E-kit either when asked for a printout of it. This surveyor located it on the side of the box and V6 confirmed that was it. The insulin pen box for R10 should not have contained any other patient's medications and all should have a pharmacy label, not handwritten. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 30 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 On 4/24/25 at 8:24 AM, V28, LPN, stated the emergency kit has slips of paper we document what we need to use it for each time, and we record the amount we take out on there as well as what drug we needed, and the numbers of the lock tags used. V28 stated the E-kit is supposed to be locked/tabbed at all times as a security measure so no one can get into it. V28 stated the E-kit needs to have new lock tags placed right after use. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 31 of 32 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 145847 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at Stearns 3900 Stearns Avenue Granite City, IL 62040 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to perform hand hygiene and removal of dirty gloves for 1 out of 1 resident, (R56); reviewed for infection control in a sample of 79. Residents Affected - Few Findings include: R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia. R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder. On 4/23/25 at 10:45 AM, R56 had saturated his incontinence brief and his pants with urine and had a small amount of stool present. V26, CNA, did not perform hand hygiene after peri care on R56 and removing his gloves. V24, CNA, did not removed her gloves and perform hand hygiene after touching R56's soiled clothing and placing them in a trash bag. V24 then touched R56's wheelchair handles and R56's hands, body and gait belt while helping him up from the bed to his wheelchair. Both V26 and V24 touched R56's door handle without performing hand hygiene after leaving the room. On 4/28/25 at 10:30 AM, V14, Certified Nurse Assistant (CNA) stated that she washes her hands before putting gloves on and after she takes them off. V14 stated that she changes her gloves and wash her hands after handling soiled linen and before touching a resident's wheelchair or anything else. On 4/28/25 at 10:40 AM, V12, CNA stated that she washes her hands before putting gloves on and after she takes them off. V12 stated that she changes her gloves and wash her hands after handling soiled linen and before touching a resident's wheelchair or anything else. The facility's Proper Hand Washing and Glove Use policy dated 2016 documented under the procedure section, 6. Hands are washed before donning gloves and after removing gloves. 8.Staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145847 If continuation sheet Page 32 of 32