Health inspection·May 19, 2022

F 0550 R27's MDS, dated [DATE], documented that his cognition was intact. Level of Harm - Minimal harm or potential for actual harm 4. On 05/16/2022 from 11:17 AM to 12:30 PM, R37 was sitting up to the high back wheelchair up at nurse's station. He was not participating in an activity. Residents Affected - Some On 05/17/2022 at 09:35 AM, V32, Activity Aide was going around with a coffee cart and did not stop in R37's room and provide him with coffee. At 9:41 AM, V32 left the hallway without offering coffee or activity to R37. On 05/18/2022 at 2:15 PM, R37 was in bed during the activity of hallway bingo. R37's Care Plan, dated 3/23/2022, documents, Activities/Psychosocial/Spirituality. Ask me if I would like to participate in activities at this time. It continues, Please remind me when activities are so I can choose to participate. Please encourage me to participate in activities. 5. On 05/17/2022 at 09:35 AM, V32 was going around with coffee cart did not stop by R61's room. At 9:41 AM, V32 left hallway without offering coffee or an activity to R61. On 05/18/2022 at 2:15 PM R61 was lying in bed, hallway bingo was being played. R61 stated that she would have liked to played bingo. R61's Care Plan, undated, documented Activities/Psychosocial/Spirituality. I enjoy card games, BINGO, watching TV mostly the Hallmark channel. Based on observation, interview and record review, the facility failed to promote residents' dignity by allowing them access to communal dining and group activities for 10 of 10 residents (R9, R11, R13, R18, R27, R37, R39, R50, R56 and R61) reviewed for dignity in a sample of 33. Findings include: 1. R50's Minimum Data Set (MDS), dated [DATE], documents that R50 is cognitively intact. On 5/16/2022 at 1:15 PM R50 stated that he is the president of Resident Council. R50 stated that all of the residents are in their rooms. R50 stated that he assumes it's because of the person testing positive for COVID but unsure. R50 stated that he overheard the nurses talking about it but have not been told directly what the reason is. R50 stated that he would like to be out of his room. On 5/19/2022 at 8:58 AM V28, [NAME] County Health Department COVID representative, stated that she was notified by the facility of their recent COVID outbreak. V28 stated that she gave the facility written guidance and told them specific pages to look at. V28 stated that she informed the facility that the residents that were fully vaccinated were still able to go about the facility to meals. V28 stated that she did not tell the facility to stop out of room activities for vaccinated residents. V28 stated that she informed the facility to continue visitation. V28 again stated that she did not tell the facility to stop out of room activities. On 5/19/2022 at 11:40 AM V2, Assistant Director of Nurses, ADON, stated that when she spoke with V28 she was instructed by her with the staff and felt it was not clear to her as to isolation for the residents. V2 stated that she was informed that she could always do more. V2 stated that she thought that keeping the resident in their rooms was the directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 2 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8. On 5/18/22 at 10:25 AM, R9 stated I liked to go eat in the dining room. I really wasn't too much into the activities, but I did go because I enjoyed talking to others in the dining room. I would like to go again. R9's Care Plan dated 3/2/22, documents (R9) is alert and oriented with confusion at times. (R9) does not have a diagnosis of dementia. (R9) is able to use his call light. (R9) is able to initiate conversations and express his needs well. (R9) is understood and understands others. (R9's) hearing and speech are adequate. It continues Please give (R9) a What's Up sheet every day, and a monthly calendar so he knows when things are. Please remind (R9) when activities are so he can decide to participate or not. Please encourage (R9) to participate in activities. 9. On 5/18/22 at 10:20 AM, R13 stated Oh yes, I liked getting out of my room. I liked to do a little of everything. I really miss eating in the dining room. I used to go in and talk to people. That was my social hour. I did like to play bingo too. R13's Care Plan dated 2/23/22, documents (R13) is alert and oriented and can make needs known. It continues Please give me a What's Up every day and a monthly calendar so he knows when things are. Please remind him when activities are so he can decide to participate or not. R13's MDS dated [DATE], documents R13 is cognitively intact. 10. On 5/18/22 at 9:30 AM, R39 stated I wasn't much for Bingo, but I did like to go to some of the other activities and to the dining room to eat. R39's MDS dated [DATE], documents that R39 is cognitively intact. On 5/18/22 at 9:55 AM, V19, Certified Nursing Assistant (CNA), stated Since COVID-19, we have not been able to take residents out of their rooms for dining or activities. I think it is because the area's percentage is high, and we won't be able to take them out of their rooms until it drops. The facility policy, Exhibit D Resident [NAME] of Rights, undated, documents, 19. To participate in other activities, including social, religious and community activities that do not interfere with the rights of other residents in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 3 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to individualize and address the current needs of residents on the Care Plan for 5 of 16 residents (R7, R31, R37, R41, R61) reviewed for Care Plans in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Medication Record, dated May 2022, documents, Bactrim DS 1 tab (tablet) po (by mouth) bid (two times a day) x 10 days. Start date of 5/9/22. R7's Treatment Record, dated May 2022, documents, Cleanse wound to left lateral foot with WC (wound cleanser), apply Melgisorb AG and cover dressing daily and prn (as needed) until resolved. R7's Initial Weekly Wound document, dated 5/18/22, documents that R7 has an unstageable pressure ulcer on her left lateral foot measuring 1.0 x 0.7 x 0.2 cm (centimeters). This wound document also documents, Notes: 3/30 resident was noted to have blood filled blister with purple discoloration to surrounding tissue MD (Medical Doctor) and RR (Resident Representative) notified. Treatment order received 5/9 Blood blister opened and was reclassified as unstageable. MD and RR notified, Tx (treatment) orders. Treatment provided 5/17 and 5/18 FNP (facility Nurse Practitioner) notified and requesting orders. Resident did state pain when area is touched or bumped, refused pain medication from this nurse this AM and states that she has no pain when area is not touched. Currently on antibiotic will continue to observe. R7's Care Plan, goal date 5/16/22, fails to document R7's left lateral foot pressure ulcer. 2. On 5/1/6/22 at 11:01 AM, R31's indwelling urinary catheter drainage bag was observed with clear amber urine. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's Treatment Record, dated May 2022, documents 20 FR (French)/ 10 ml (milliliters) indwelling (urinary) catheter. change month et (and) PRN (as needed) (placed 3/24/22 per Urology). R31's Care Plan, dated 12/29/20, fails to document that R31 has an indwelling urinary catheter. 3. On 05/18/22 at 10:00 AM, R37 way lying in bed. R37 had bed rails up at the head of his bed. R37's Side Rail Evaluation, dated 6/23/2021, documents the need of assist rails for turning and repositioning in bed. R37's Care Plan, with a goal date for his Care Plan was 06/22/2022, does not document the need for bedrails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 4 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 4. On 05/18/22 at 10:08 AM R61 was lying in bed and had bilateral 1/4 bedrails up. Level of Harm - Minimal harm or potential for actual harm R61's Bed rail evaluation dated 5/14/2021 documents the use of assist rails for both sides. R61's Care Plan dated 5/2/2022 does not address the use of bedrails. Residents Affected - Some R61's Care Plan dated 5/2/2022 does not address the use of bedrails. 5. On 5/16/22 at 9:50 AM, R41 was sitting in his wheelchair with Oxygen being administered at one and a half liters per nasal cannula. On 5/17/22 at 8:45 AM, R41 was sitting in his wheelchair with Oxygen on at one and a half liters per nasal cannula. R41's Physician Order dated 4/20/22, documents Oxygen two liters nasal cannula as needed to keep sats above ninety two percent. R41's Physician Order dated 4/20/22, documents BIPAP (bilevel positive airway pressure) nightly and as needed per instructions. R41's Physician Order dated 4/20/22, documents Iprat-Albut 0.5-3 (2.5) mg/3ml solution for Nebulizer, take 3ml by inhalation every six hours as needed for shortness of breath or wheezing. R41's Care Plan dated 4/14/22, documents (R41) has a diagnosis of Paroxysmal Atrial Fibrillation, COPD, Pulmonary Hypertension, Chronic Respiratory Failure with hypoxia or hypercapnia, Hypertension and Edema. Give all medications as ordered and monitor for any adverse effects of the medication. Routinely assess my vital signs, listen to heart, lung and abdominal sounds and report to nurse/physician if problems. R41's Care Plan does not document R41's use of Oxygen or Respiratory Care such as BIPAP. On 5/18/22 at 3:40 PM, V31, Corporate Nurse, stated the Care Plan tags are the hardest to clear because they always needed updated. The facility's policy, Comprehensive person-centered care plans, dated 03/2018, documents, Comprehensive Person-Centered Care Plan (CCP)-contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 5 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 05/17/22 at 11:49 AM V29, R11's daughter, stated, I don't think they should be locked down again. She can't see so those papers they hand out for them to do she can't. They tell me she walks the halls. I tell them it's because she is bored and there is nothing for them to do. She is vaccinated and boosted. Residents Affected - Some On 5/17/22 at 2:15 PM, V32 stated, We are doing room activities. I went around today and did resident education. They can read the education and do the games on the back. I don't know how much (R11) got out of it though with her dementia. With the coffee club I hand had out a paper with quotes and quizzes on it. We also have the ability to stream movies into the resident's rooms. We do one in the morning and one in the evening. Unfortunately, the system broke last week so that is not working. Tomorrow we will do coffee club in the morning and at 2:00 PM we will do bingo. They come to the doorway and play. I call all the numbers over the telephone system. We will have 6 games of bingo 5 regular games and one cover all. The residents that are more confused the aides will help. The more confused residents we do one's to one's on. I will go in and talk to them or watch tv with them. The residents were enjoying being back out in the building. It took some residents awhile before they got back into the activities, so I hope this doesn't last long. V32 stated that coffee club is the snack cart that she goes around with in the morning. On 05/18/22 at 2:26 PM, R11 is asleep in her bed during the hall bingo game. R11's Face Sheet, print date of 5/19/22, documents R11 was admitted on [DATE] and has a diagnosis of Dementia. R11's MDS, print date of 5/19/22, documents that R11 is severely cognitively impaired. R11's Care Plan, dated 12/7/20, documents, Activities/Psychosocial/Spirituality, Please give me a 'What's Up' every day and a monthly calendar so know when things are. Please remind me when activities are so I can decide to participate or note. It continues, I am seen for small group. I receive a daily work packet.Based on observation, interview and record review, the facility failed to provide activities to promote psychosocial well-being for 8 of 8 residents (R9, R11, R13, R18, R27, R37, R39, and R61) reviewed for activities, in a sample of 33. Findings include: 1. On 05/16/2022 from 9:51 AM until 12:00 PM, R18 was sitting up at nurse's station, playing with a paper facemask that was not on her face. R18 was not involved with any activities. On 05/17/2022 at 9:00 AM, R18 was sitting up across from the nurse's station and was not involved with an activity. At 12:30 PM, R18 remained sitting up across from the nurse's station in her wheelchair not engaged in any activities. On 05/18/22 at 10:30 AM, R18 was sitting up in her wheelchair, in the doorway of her room drinking a cup of coffee. On 05/18/2022 at 2:15 PM, R18 was lying in bed while an activity of hallway bingo was occurring. R18's Care Plan, dated 3/26/2022, documents Please remind me when activities are so I can decide to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 6 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0679 participate or not. Level of Harm - Minimal harm or potential for actual harm 2. On 05/18/2022 at 9:51 AM, R27 stated that he wants to be able to get out of his room and talk to people. He also stated that he wants to go to activities and that he misses it. Residents Affected - Some R27's Minimum data set (MDS), dated [DATE], documented that his cognition was intact. 3. On 05/16/2022 from 11:17 AM to 12:30 pm, R37 was sitting up to the high back wheelchair up at nurse's station, he was not participating in an activity. On 05/17/2022 at 09:35 AM, V32, Activity Aide was going around with coffee cart and did not stop at his room. At 09:41 AM, V32 left the hallway without offering coffee or activity to R37. On 05/18/2022 at 02:15 PM, R37 was in bed during the activity of hallway bingo. R37's Care Plan, dated 3/23/2022, documents, Activities/Psychosocial/Spirituality. Ask me if I would like to participate in activities at this time. It continues, Please remind me when activities are so I can choose to participate. Please encourage me to participate in activities. 4. On 05/17/2022 at 09:35 AM, V32 was going around with coffee cart did not stop R61's room. At 9:41 AM, V32 left hallway without offering coffee or an activity to R61. On 05/18/2022 at 2:15 PM R61 was lying in bed, hallway bingo was being played. R61 stated that she would have liked to played bingo. R61's Care Plan, undated, documented Activities/Psychosocial/Spirituality. I enjoy card games, BINGO, watching TV mostly the Hallmark channel. 6. On 5/18/22 at 10:25 AM, R9 stated I liked to go eat in the dining room. I really wasn't too much into the activities, but I did go because I enjoyed talking to others in the dining room. R9's Care Plan dated 3/2/22, documents (R9) is alert and oriented with confusion at times. (R9) does not have a diagnosis of dementia. (R9) is able to use his call light. (R9) is able to initiate conversations and express his needs well. (R9) is understood and understands others. (R9's) hearing and speech are adequate. It continues Please give (R9) a What's Up sheet every day and a monthly calendar so he knows when things are. Please remind (R9) when activities are so he can decide to participate or not. Please encourage (R9) to participate in activities. On 5/18/22 at 9:55 AM, V19, Certified Nurse's Aide, CNA, stated Since COVID-19, we have not been able to take residents out of their rooms for dining or activities. I think it is because the area's percentage is high, and we won't be able to take them out of their rooms until it drops. 7. On 5/18/22 at 10:20 AM, R13 stated Oh yes, I liked getting out of my room. I liked to do a little of everything. I really miss eating in the dining room. I used to go in and talk to people. That was my social hour. I did like to play bingo too. R13's Care Plan dated 2/23/22, documents Please give me a What's Up every day and a monthly calendar so he knows when things are. Please remind him when activities are so he can decide to participate or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 7 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0679 R13's MDS dated [DATE], documents R13 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm 8. On 5/18/22 at 9:30 AM, R39 stated I wasn't much for Bingo, but I did like to go to some of the other activities and to the dining room to eat. Residents Affected - Some R39's Care Plan dated 4/4/22, documents Please give (R39) a What's Up every day and a monthly calendar so he knows when things are. Please remind (R39) when activities are so he can decide to go or not. Please encourage (R39) to attend out of the room activities. R39's MDS dated [DATE], documents that R39 is cognitively intact. On 5/19/2022 at 8:58 AM V28, [NAME] County Health Department COVID representative, stated that she was notified by the facility of their recent COVID-19 outbreak. V28 stated that she gave the facility written guidance and told them specific pages to look at. V28 stated that she informed the facility that the residents that were fully vaccinated were still able to go about the facility to meals. V28 stated that she did not tell the facility to stop out of room activities for vaccinated residents. V28 stated that she informed the facility to continue visitation. V28 again stated that she did not tell the facility to stop out of room activities. On 5/19/2022 at 11:40 AM V2, Assistant Director of Nurses, ADON, stated that when she spoke with V28 she was instructed by her with the staff and felt it was not clear to her as to isolation for the residents. V2 stated that she was informed that she could always do more. V2 stated that she thought that keeping the resident in their rooms was the directive. The facility's policy, Coronavirus (COVID19), 02/2022, documented, 3. Resident who are fully vaccinated may dine and participate in activities without face coverings or social distancing if all participating residents are fully vaccinated. If unvaccinated residents are present during communal dining or activities, then all residents should use face coverings when not eating and unvaccinated resident should physically distance from others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 8 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to monitor and assess a new pressure ulcer and provide the Physician Ordered treatment for existing pressure ulcers for 3 of 7 residents (R6, R31, R37) reviewed for pressures ulcers in the sample of 33. Residents Affected - Few Findings include: 1. R6's Face Sheet, print date of 5/19/22, documents R6 was admitted [DATE] and he has diagnoses of pressure ulcer to heel and type 2 diabetes mellitus. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact and requires extensive assistance from 1 staff member for bed mobility and transfers. R6's Physician Orders, dated 4/13/22, documents, Cleanse right heel ulcer with w/c (wound cleanser) ns (normal saline) apply Santyl and cover dressing daily and prn (as needed). R6's Weekly Wound document, dated 5/13/22, documents that R6 has a right heel pressure ulcer measuring 0.5 x 0.5 cm (centimeters). This Wound documents, Support and Specialty Devices: Heel Boots, Repositioning, Heels Elevated off the bed. On 5/16/22 at 3:14 PM, V13, Licensed Practical Nurse (LPN), entered R6's room to change his right heel pressure ulcer dressing. R6 was lying in bed on his back. R6 was not wearing his bilateral pressure offloading boots. V13 washed her hands, went to the treatment cart, and obtained the needed supplies, V13 placed supplies on the bedside table and then donned gloves. V13 raised R6's right leg exposing the heel pressure ulcer. The ulcer did not have a dressing on it. V13 cleansed the wound with wound cleaner and placed R6's foot back onto his bedding. V13 went to the restroom to wash her hands. V13 returned and stated, I guess I should not have put his foot back down on his dirty bedding. V13 proceeded to don gloves, raise R6's foot, place Santyl on the wound bed and place a bordered foam dressing. V13 removed her gloves, gathered supplies, left the room, put supplies on the dressing cart, walked down the hall to throw trash away in utility closet, returned to cart and then performed hand hygiene. On 5/16/22 at 3:14 PM, R6 stated, The girl didn't put my boots on. It depends who helps you if they get put on. R6 was unsure when his heel dressing came off. On 5/16/22 at 3:16 PM, V13 stated that R6 has 2 sets of heel boots ones for sitting up and ones for lying down. On 5/16/22 at 3:14 PM 2 sets of heel boots were observed on R6's floor next to the head of the bed. On 5/19/22 at 1:41 PM, V3, Assistant Director of Nurses (ADON), stated that R6's wound should have been cleansed again and that V13 knew better than to just dress the wound trapping in possible debris. 2. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 9 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. On 05/16/22 at 10:30 AM, V23 Nurse Practitioner and V13 entered R31 to apply a new dressing to R31's pressure ulcers. V23 donned gloves without hand hygiene, applied wound cleaner to a gauze pad, cleansed the pressure ulcer on the upper coccyx, flipped the gauze pad and cleansed the left buttock wound. With the same gloves, V23 applied Santyl with a q-tip then placed a heart shaped dressing to the upper coccyx. On 5/19/22 3:40 PM, V31 Regional Nurse stated that a Nurse Practitioner should know better, and she expects if an area is dirty to clean it again. 4. R37's Physician's Order, dated 05/02/2022, documents, (1) Cleanse right heel with wound cleanser apply skin prep daily and prn until resolved (2) Vitamin C 500mg 1 po bid. The facility's Weekly Pressure Wounds dated 12/01/2022 through 05/17/2022, documents that R37's Suspected Deep Tissue Injury occurred on 05/02/2022. There was no assessment of the size of R37's pressure ulcer until 5/13/22. R37's Weekly Wound sheet, with an assessment date of 05/13/2022 documents, Wound location: 13-Right heel. Wound type: Suspected (Deep tissue injury). Wound measurement (length by width) 1.5 (by) 2.0 (centimeters) Depth: 0.5 (centimeters) It continues, Treatment(s) Skin Prep. It continues, Notes: Suspected DTI is now at healing stage 2. No (signs or symptoms) of infection or pain noted. Heal boot as tolerated. On 05/18/2022 at 10:00 AM, V35, LPN cleansed R37's open area to his right heel with dermal wound cleanser, applied hydrogel and the pressure ulcer was covered with a border dressing. There was no physician's order (PO) for this treatment. The facility's policy, Pressure ulcer/injury and skin conditions guide for wound evaluation documentation, dated 11/2017, documents, 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 electronic format. It continues, 4. Initiate appropriate treatment per treatment protocol and physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 10 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's MDS, dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. On 5/17/22 at 1:52 PM, V13, Licensed Practical Nurse, LPN, V15 CNA and V12 CNA/staff development, all entered R7's room to transfer her to bed. V13 and V12 hooked the mechanical lift sling to the machine. V12 raised R7 up out of her wheelchair using the remote. Once R7 was raised in the full mechanical lift sling. V13 moved to the left side of the bed. V12 pushed R7 over to her bed while in the sling. No staff members held the sling while being pushed to the bedside. 3. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. On 5/16/22 at 10:40 AM, V13 and V16 CNA entered R31's room to transfer her from the bed to her recliner using a full mechanical lift. V13 placed the right upper strap of the sling on the last loop on the strap, V16 placed the left upper strap of the sling on the second last loop on the strap. The bottom strap loops were placed correctly. V16 raised R31 up using the remote control, R31 was tilted to the right, V16 pushed the sling over to the recliner chair. During this time V13 was standing behind V16 holding the indwelling urinary drainage bag. V16 went behind the recliner and pulled the sling while V13 was operating the remote to lower R31 into her recliner chair. Based on observation, interview, and record review, the facility failed to implement fall interventions and provide safe transfers for 5 of 6 residents (R3, R7, R31, R37 and R48) reviewed for accidents/surpervision in the sample of 33. Findings include: 1. On 05/18/2022 at 09:47 AM R37 was in bed asleep and there was no bed alarm in place. On 05/18/2022 at 10:40 AM, V20, Certified Nurse's Aide, CNA, stated that R37 should have a bed alarm while he is in bed. R37's Incident report, dated 05/7/2022, documents, (R37's) visitors put him in bed and left the room leaving the bed in an up position, resident then rolled out of bed and received a new skin tear to his right elbow. He denied hurting anywhere. R37's Care Plan dated 5/7/2022, documents, I had a fall on this day, please educate my family of low bed protocol and proper bed positioning for safety. It continues, I have alarms to my bed and wheelchair for safety awareness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 11 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R37's Incident report dated 5/12/2022 at 3:31 AM, documented Staff heard resident yelling for help, when staff went into resident's room resident was (Found on floor) next to bed and nightstand. Resident could not explain occurred. Skin assessment performed. Cut to left eye, skin tear to left elbow and left knee were found. Resident helped into bed. proper footwear was not on. Poor lighting in room (due to) it being bedtime. bed lowered. (Range of Motion) performed and (within normal limits) Wounds were bandaged and steri strips applied. Neuros in place. (As needed) Tylenol given for any pain. Will continue to observe. Cut to left eye, skin tear to left elbow, abrasion on left knee. R37's Minimum Data Set (MDS) dated [DATE], documents that R37 requires extensive assist of 2 staff members to transfer in and out of bed and to be turned and repositioned in bed. On 05/19/2022 at 01:50 PM V3, Assistant Director of Nurses (ADON), stated that R37's bed was in the high position the night of 5/12/2022, when he fell out of bed and that it should have been in the low position. V3 also stated that she would expect the staff to make sure his bed was as low as it can go and that the staff should make sure all bed and chair alarms are in place. 4. On 5/17/22 at 9:42 AM, V11, CNA, and V7, CNA assisted R3 to bed using a full body mechanical lift. V11 and V7 did not check to see if the full body mechanical lift sling straps were attached to the lift arm prior to R3 being lifted off her wheelchair. While R3 was transferred to her bed, V11 and V7 did not hold onto her as she was freely swinging in the air while V11 moved the wheelchair. V11 then pulled R3 towards the bed while V7 lowered R3 to bed and disconnected from the device. On 5/19/22 at 1:20 PM, V19, CNA, stated When I am transferring someone using a (full body mechanical lift), I usually use the blue strap at the top and the purple strap at the bottom. We always have two people doing this. Once the resident is hooked up, I will pull the resident back with the lift while the second person will hold the resident like a spotter towards the bed, then we will lower them. R3's Care Plan dated 5/9/22, documents (R3) has left sided hemiplegia and is not safe to get up on her own. (R3) is a two person assist using the total lift with a purple edged sling. It continues (R3) has a diagnosis of Arthritis, Hemaplegia left sided and Stroke Syndrome . (R3) is unable to walk or transfer herself. (R3) is a two person assist using the total lift with a purple edged sling. R3's MDS dated [DATE], documents R3 has a moderate cognitive impairment and is totally dependent of two staff members for transfers. 5. On 5/16/22 at 1:15 PM, V7, CNA, and V8, CNA, transferred R48 from her geriatric chair to her bed using a full body mechanical lift. V7 and V8 attached the full body mechanical lift sling straps to the lift arm and R48 was lifted off her wheelchair without V7 and V8 checking if the straps were securely connected. R48 was moved approximately 3 feet to her bed with no one holding her during the move as she was freely swinging in the air. R48 was then lowered to her bed. R48's Care Plan dated 4/18/22, documents (R48) is a fall risk due to history of falls and diagnoses of Convulsions, status post CVA (Cerebral Vascular Accident) and Osteoporosis. The Care Plan documents (R48) is an assist of two with total lift for transfers. R48's MDS dated [DATE], documents that R48 has a severe cognitive impairment and requires extensive assistance from two staff members for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 12 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 5/19/22 at 1:45 PM, V3, ADON, stated Yes, I would expect the staff to maintain contact at all times with the resident while transferring using a full body mechanical lift. The Facility's (Total Body Mechanical Lift Policy, dated 8/2016, documents 6. Attach the sling using color coded straps, position sling under resident with base of divided leg sling at base of spine, top of sling at top of head. Cross straps prior to hooking to hanger bar. 7. Place the straps of the sling over hooks of the swivel bar. 8. Match the corresponding colors on each side of the sling for an even lift of the resident. 10. Before and after transfer, observe all sling loops are securely connected. 11. Stand next to the resident, pump the lift handle or press the UP button on the hand control to slowly raise the lift to the height necessary to clear the surface to make sure the sling is properly connected to the hooks of the swivel bar. Maintain contact with the resident in order to guide or steady the resident during lift, as necessary. Event ID: Facility ID: 145910 If continuation sheet Page 13 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's MDS, dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. This MDS documents that R7 has an indwelling urinary catheter which R7 does not at this time. On 5/17/22 at 1:35 PM, V13, LPN, stated, (R7) usually sits up all day. The girls will lay her down after meals and change her and then put her back in her chair. She will tell you she likes to sit up. She naps during the day in her chair. On 05/17/22 at 01:39 PM, V16, CNA, stated, (R7) has been up since this morning. Usually, we lay her down after lunch. She has not been changed since she got up this morning. On 5/17/22 at 1:52 PM, V13, LPN, V15, CNA, and V12, CNA/ staff development, all entered R7's room to transfer her to bed. V13 and V12 hooked the mechanical lift sling to the machine. V12 raised R7 up out of her wheelchair using the remote. Once R7 was raised in the full mechanical lift sling, R7's pants and the seat of her wheelchair was visibly saturated with urine. Upon lying down, V13 stated, (R7) I am so sorry the girls know better than this. R7 placed on the bed, the sheet immediately became wet, R7 was rolled to her left side, V15 began to take the sheet off and R7's pants. V13 and V12 both left the room. V26, CNA, entered the room. V26 donned gloves without hand hygiene. R7's pants and incontinent brief were removed. R7's pants were saturated with urine from the seat of the pants to the mid-thigh area. The incontinent brief was saturated with urine. V26 placed the saturated mechanical lift sling and pants in a bag. V26 placed the incontinent brief in a trash bag. With the same gloves, V26 wiped R7's rectal area, gluteal folds and buttocks with premoistened cloths. V26 failed to cleanse R7's hips, inner thighs or the back of R7's thighs. R7 was rolled over and V15 wiped the left and right groin and wiped the labia. V15 failed to cleanse the inner thighs or the pubic area. 4. R54's Face Sheet, dated May 2022, documents R54 was admitted on [DATE] with diagnoses of Hypertensive chronic kidney disease w (with) stg (stage) 1-4 unsp (unspecified). R54's MDS, dated [DATE], documents that R54 is severely cognitively impaired, totally dependent on 2 staff members for transfer, totally dependent on one staff member for toileting and personal hygiene and is always incontinent of bowel and bladder. R54's Care Plan, dated 5/3/22, documents, I am incontinent of both my bowels and bladder and need assistance of staff for pericare after each incontinent episode. Please apply barrier cream each shift and PRN (as needed). On 5/17/22 at 9:32 AM, V16, CNA, and V15 transferred R54 to bed. R54's pants and incontinent brief were removed. R54's incontinent brief was wet with urine. V16 washed hands and donned gloves, V16 cleansed the left groin, the right groin, retracted R54's foreskin and cleaned the meatus and surrounding area, V16 replaced the foreskin, V16 cleansed the scrotum and the buttocks. R54's scrotum was very red and irritated. V16 failed to cleanse the penis. V16 failed to apply barrier cream. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 14 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 On 5/18/22 3:40 PM, V31, Corporate Nurse, stated that all areas soiled should be cleansed. Level of Harm - Minimal harm or potential for actual harm The Facility's Incontinent Care Policy dated 1/2015, documents To provide routine, preventive skin, perineal care to residents after an incontinent episode. It continues, Procedure: 7. Put on gloves before removing wet and/or soiled items. 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. 14. Dry the perineal area front to back and all skin surfaces washed. 16. Remove gloves and discard. Wash hands. 17. Place a dry brief on the resident. 22. Wash hands. Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 4 of 7 residents (R7, R48, R51, R54) reviewed for incontinent care in the sample of 33. Findings include: 1. On 5/16/22 at 1:15 PM, V7, Certified Nursing Assistant (CNA) and V8, CNA, transferred R48 from her geriatric chair to her bed via full body mechanical lift. R48's pants were removed and R48 was turned to her side. V7 pulled some wipes out of the package and put them on her bed. V7 reached between R48's legs from behind and wiped from the vaginal area to anal area. Using the same gloves used to clean R48, V7 put some moisture barrier cream on the clean incontinence brief and spread it all over the clean incontinence brief with his hands. V7 then used same gloves to put on a new incontinence brief. R48 rolled over to her back and her vagina and both groins were wiped. R48 was not dried prior to putting on a new brief. V7 stated I got the new depends wet with the wipes, so now we need to put a new one on. R48's buttock was cleansed again due to moisture barrier cream from the previous incontinence brief all over her buttocks. V7 then applied the moisture barrier cream to R48's buttocks and then applied another incontinence brief. R48's Minimum Data Set (MDS) dated [DATE], documents that R48 has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers and toilet use. R48 requires extensive assistance from one staff member for dressing, eating, bathing and personal hygiene. R48 is always incontinent of both bowel and bladder. 2. On 5/18/22 at 10:30 AM, R51 stated, I sh** my pants. I will have to tell them. On 5/18/22 at 10:45 AM, V13, Licensed Practical Nurse (LPN), rolled R51 to the right side to view his pressure ulcer. Incontinence brief was untaped and opened to see R51's buttocks. R51's coccyx area had a dry scabbed wound, appeared to be healing well, open to air. While the incontinence brief was opened, there was stool noted on R51's buttocks and anal area and on the incontinent brief. V13 closed the incontinence brief and retaped it, rolled R51 back over and covered him up with a blanket without cleaning R51 and then left the room. On 5/18/22 at 1:50 PM, V19, CNA, stated, (V13) came to us and said that (R51) needs cleaned up because he had messed his pants. She said the surveyor saw this too. I'm not sure why she didn't clean him up when she saw it, especially with you there. On 5/18/22 at 1:55 PM, V18, CNA, stated, If anyone sees that a resident is incontinent, they should clean them up right then and not wait until later. I always check on my residents and clean them if needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 15 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 FORM CMS-2567 (02/99) Previous Versions Obsolete R51's Care Plan dated 4/11/22, documents (R51) is incontinent of both bladder and bowel. (R51) needs staff to do perineal care and apply barrier cream after each incontinent episode. (R51) does wear incontinent products. It continues (R51) needs assistance to turn and reposition in bed and reposition in his chair every two hours and PRN. R51's MDS dated [DATE], documents R51 has a moderate cognitive impairment and is totally dependent on two staff members for transfers. R51 requires extensive assistance from two staff members for bed mobility and toilet use. R51 requires extensive assistance from one staff member for dressing, eating, personal hygiene and bathing. R51 is always incontinent of both bowel and bladder. Event ID: Facility ID: 145910 If continuation sheet Page 16 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 4. On 05/16/2022 at 10:20 AM, R23 was lying in bed, had an undated oxygen tubing and the oxygen concentrator did not have a humidified water bottle. Residents Affected - Some R23's Face sheet, dated 05/19/2022, documents a diagnosis of Chronic obstructive pulmonary disease. R23's Care Plan, undated, documented, I am also on oxygen per nasal cannula. The Facility's Continuous Aerosol on Oxygen Policy dated 1/2015, documents To use continuous aerosol on oxygen to assist with secretion management while delivering oxygen. It continues Equipment needed: 1. Oxygen source. 2. Aerosol bottle (prefilled or refillable). 3. Disposable aerosol tubing. 4. Trach/Aerosol mask. 5. Drain bag. 6. Sterile water. &. Oxygen adapter. It continues Procedure: 3. Fill non-prefilled nebulizer with sterile water or assemble prefilled unit. It continues 8. Date individual components. Based on interview, observation and record review, the facility failed to provide respiratory care, including the changing of the humidified bottle and the dating and timing of both the humidified bottle and nasal cannula for 4 of 4 residents (R8, R23, R41, R46) reviewed for respiratory care in the sample of 33. Findings include: 1. On 5/16/22 at 11:05 AM, R8 had Oxygen being administered at 2 liters per nasal cannula. The humidified water bottle was empty and was dated 5/1/22. The nasal cannula was not dated. R8's Physician Order dated 3/10/21, documents O2 (Oxygen) at 2 Liters per Nasal Cannula continuous. R8's Care Plan dated 5/16/22, documents (R8) has a diagnosis of Diabetes Mellitus, Alzheimer's, Dementia, COPD (chronic obstructive pulmonary disease), Heart Failure, Depression and Anxiety that (R8) takes medications for. (R8) has accuchecks twice daily with routine insulin per physician order. (R8) also wears Oxygen per nasal cannula continuously. 2. On 5/16/22 at 9:50 AM, R41 was sitting in his wheelchair with Oxygen being administered at one and a half liters per nasal cannula. R41 stated he's out of water in his oxygen. Humidified water bottle for the oxygen is empty, dry and not dated. R41's Oxygen cannula was also not dated. On 5/17/22 at 8:45 AM, R41 was sitting in his wheelchair with Oxygen on at one and a half liters per nasal cannula. A new Humidified water bottle is now labeled with a date of 5/16/22. R41's Oxygen nasal cannula was still not labeled or dated. R41's Care Plan dated 4/14/22, documents (R41) has a diagnosis of Paroxysmal Atrial Fibrillation, COPD, Pulmonary Hypertension, Chronic Respiratory Failure with hypoxia or hypercapnia, Hypertension and Edema. Give all medications as ordered and monitor for any adverse effects of the medication. Routinely assess my vital signs, listen to heart, lung and abdominal sounds and report to nurse/physician if problems. 3. On 5/16/22 at 10:40 AM, R46 was sitting in her recliner with Oxygen being administered at three Liters per nasal cannula. The humidified water bottle was dry and not labeled or dated and R46's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 17 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 nasal cannula was also not dated. Level of Harm - Minimal harm or potential for actual harm R46's Physician's Order dated 7/5/22, documents Oxygen continuous at one and a half liters per nasal cannula, may increase Oxygen with activity to maintain saturation greater than ninety percent. Residents Affected - Some R46's Care Plan dated 4/11/22, documents (R46) has a diagnosis of Hypertension, Hypercholesterolemia, Depression and COPD that (R46) takes daily medications for. (R46) requires continuous Oxygen per nasal cannula per physician order and does get short of breath with exertion. On 5/17/22 at 2:10 PM, V13, Licensed Practical Nurse (LPN), stated There are tasks for each shift to get done on our daily sheets. For example oxygen tubing and water changes are done on Sunday Nights only. On 5/19/22 at 1:40 PM, V3, Assistant Director of Nursing (ADON), stated We don't really have a policy for changing the oxygen tubing and water, however, we do use the form that we use for each day for staff to check off. The nights are supposed to change the oxygen tubing and water on Sundays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 18 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to evaluate and assess the use of side rails in a timely manner and explain the risk versus benefits of the use of side rails for 5 of 6 residents (R7, R31, R37, R54, R61) reviewed for side rails in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. R7's Side Rail Evaluation, dated 5/18/22, documents that R7 had a side rail evaluation done 8/13/21 and then 5/18/22 both of these documents list the only risk of having a side rail physical contact. On 5/18/22 at 1:48 PM, R7 was observed in bed with bilateral half rails raised in up position. 2. R31's Face Sheet, dated 4/14/22, documents R31 was admitted on [DATE] with diagnoses of Type two diabetes mellitus and polyneuropathy. R31's MDS, dated [DATE], documents R31 is cognitively intact, requires extensive assistance from 2 staff members for bed mobility and is totally dependent on 2 staff members for transfers. R31's Side Rail Evaluation, dated 5/18/22, documents that R31 had a side rail evaluation done 8/13/21 and then 5/18/22 both of these documents list the only risk of having a side rail physical contact. On 5/16/22 at 10:30 AM, R31 was lying in bed with bilateral half side rails raised in the up position. 3. On 05/16/22 at 1:50 PM, R54 was sitting at the nurses station. R54 had a black purple bruising to his left eye, cheek and neck. On 5/16/22 at 1:51 PM, V2, Director of Nurses (DON), stated, (R54) rolled out of his bed. R54's Face Sheet, dated May 2022, documents R54 was admitted on [DATE] with diagnoses of Hypertensive chronic kidney disease w (with) stg (stage) 1-4 unsp (unspecified). R54's MDS, dated [DATE], documents that R54 is severely cognitively impaired, totally dependent on 2 staff members for transfer and requires extensive assistance of 2 staff members for bed mobility. R54's Care Plan, dated 5/3/22, documents, Safety Notes: I am not safe to get up on my own. It continues, Keep items that I frequently use within my reach on my right side while keeping the area free (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 19 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0700 of clutter and safety hazards. It continues, 5/3/22 I have a low bed and landing strips dt (due to) my fall this day /bed side mat. R54's Care Plan fails to document the use of bed rails. Level of Harm - Minimal harm or potential for actual harm On 5/18/22 at 1:42 PM, R54's Medical Record failed to document a bed rail assessment for R54. Residents Affected - Some On 5/18/22 at 1:48 PM, R54 was lying in bed on his left side with bilateral half bed rails raised. On 5/19/22, the facility provided a Side Rail Evaluation, dated 5/18/22, this form fails to document the risks of using the side rails. On 5/19/22 at 1:50 PM, V3, Assistant Director of Nurses, stated that she did not realize that she was the one that was supposed to be doing the assessments so when she realized it she did them. V3 further stated that she did not realize the risks versus benefits need to be clearly written and that all risks of having a side rail must be listed. 4. On 05/18/22 at 10:00 AM, R37 was lying in bed, rails were up at the head of his bed. R37's side rail evaluation, dated 6/23/2021, documents the need of assist rails for turning and repositioning in bed. R37 last reduction of physical restraints was dated 6/23/2021. R37's Care Plan, with a goal date for his Care Plan was 06/22/2022, does not documents the need for bedrails. 5. On 05/18/22 at 10:08 AM, R61 was lying in bed, bilateral 1/4 bedrails were up. R61's Bed rail evaluation dated 5/14/2021 documents the use of assist rails for both sides. R61's most recent restraint (physical) reduction attempt was 5/14/2021. R61's Care Plan dated 5/2/2022 does not address the use of bedrails. The facility's policy, Restraint Evaluation and Restraint Reduction, dated 08/2013, documented, 2. All resident using a restraint are to be evaluated and re-evaluated approximately every quarter. It continues, 3. All residents who have evaluations which justify the use of restraints are to be using the least restrictive method possible as identified by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 20 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 62 residents in the facility. Residents Affected - Many Findings include: There was no consecutive 8-hour RN coverage in 24 hours on 1/2/22, 1/11/22, 1/15/22, 1/20/22, 1/30/22, 2/7/22, 2/8/22, 3/6/22, 4/20/22, 4/22/22, 4/23/22, 4/29/22, 5/3/22, 5/7/22, 5/8/22, 5/12/22, 5/17/22. On 5/18/2022 at 11:30 AM, the Nursing Working staffing schedule from 1/1/2022 through 5/18/2022 was reviewed with V3, Assistant Director of Nurses. V3 stated that the facility has had some staffing concerns. V3 stated that they are actively recruiting and currently using agency staff to fill shifts. V3 stated that she does not handle the RN schedules and that RN coverage would need to be discussed with V2, Director of Nurses. V3 stated that V2 is out on medical leave at this time and is not available. On 5/19/2022 at 10:27 AM, V2, Administrator, stated that the facility does not have a staffing policy. V2 stated that they follow state and federal guidelines for staffing. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 21 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on interview, and record review, the facility failed to ensure that Certified Nursing Aides (CNAs) received twelve hours of mandatory in-service training annually. This has the potential to affect all 62 residents living in the facility. Residents Affected - Many Findings include: 1. On 5/18/2022, the facility provided a list of Certified Nurse's Assistants (CNAs) with hire dates. A review of the facility's CNAs annual training was conducted. The review of four CNA training transcripts revealed 4 of the 4 CNAs selected for review did not meet the required 12 hours of required training. V20, CNA, had a hire date of 4/21/2017. According to V20's employee file, the facility has no documentation of the required hours of in-service education training V20 has completed in the last year. On 5/18/2022 at 10:12 AM V20, CNA, stated that she has not had dementia or Alzheimer's training. V20 stated that the facility has not provided dementia or Alzheimer's training to her. 2. V18, CNA, had a hire date of 1/03/01. According to V18's employee file, the facility has no documentation of the required hours of in-service education training V18 has completed in the last year. 3. V22, CNA, had a hire date of 5/01/90. According to V22's employee file, the facility has no documentation of the required hours of in-service education training V22 has completed in the last year. 4. V34, CNA, had a hire date of 5/01/90. According to V34's employee file, the facility has no documentation of the required hours of in-service education training V34 has completed in the last year. On 5/18/2022 at 10:30 AM, V19, CNA, stated that she has not had dementia or Alzheimer's training. V19 stated that the facility has not provided dementia or Alzheimer's training to her. On 5/19/2022 at 12:00 PM, V12, Staff Development Coordinator, stated that the staff have not had dementia training since 2020. On 5/19/2022 at 1:40 PM, V3, Assistant Director of Nursing stated that the facility does not have a policy for staff education, they follow the state and federal guidelines. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 22 of 28 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 145910 B. Wing (X3) DATE SURVEY COMPLETED A. Building 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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. Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and discard expired medications. This has the potential to affect all 62 residents living in the facility. Findings include: On 5/17/2022 at 9:15 AM, the North Apple Blossom Street Hall medication cart was inspected. The medication cart contained the following medications: 1. R10's Basaglar 100 unit/ml (milliliter) Kwikpen without open date. V9, Licensed Practical Nurse (LPN). Verified that the medication was open and in use. On 5/17/2022 at 9:17 AM, V9 stated that the Basaglar should have an open date. V9 stated that the the medication should not be used without the open date. V9 stated that there is a specific time that the medication can be used and this is why the open date is important so that the medication is not used past the ?? days. V9 stated that she would destroy the medication. On 5/18/2022 at 2:05PM, V3, Assistant Director of Nursing (ADON), stated that the insulin, tuberculin has a specific use time once open. V3 stated that the open date or the end date is important and one of them should be on the bottle to let the nurses know when it was open so that the medication won't be used passed its use by date. V3 stated that the expired medications are to be discarded. V3 stated that the nurse is to check the medication expiration date prior to administering medication. This is the triple check system. The Basaglar's Manufacturer instructions documents In-use Pen: Store the Pen you are currently using at room temperature [up to 86°F (30°C)] and away from heat and light. Throw away the Pen you are using after 28 days, even if it still has insulin left in it. On 5/17/2022 at 9:20 AM, the facility's medication storage room was inspected. The refrigerator, located in the medication storage room contained the following: 2. 1 box of Shingrid Zoster Vaccine Recomb adjunct with expiration of 5/7/22 3. Open unlabeled with date opened multi dose vial of Moderna COVID Vaccine. 4. Open unlabeled with date opened multi dose Tuberculin (TB) vial The medication room also had the following: 5. 4 bottles of Flonase 50 mcg (micrograms) with expiration date of 1/2022. On 5/17/2022 at 9:24 AM, V9 stated that the bottles of Flonase and the vial of TB is used for anyone that has an order and not allergic. V9 stated that if there was an order to give the medication she would have used this medication from the medication room and refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 23 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 The facility's Medication Storage, policy, dated 11/10, documents Policy: All drugs, treatments, and biological must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. It also documents, Procedure: 12. The following medications must removed from from stock and disposed of properly on a continuous basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. Residents Affected - Many The Resident Census and Conditions of Residents, CMS 672, dated 5/16/2022 documents that the facility has 62 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 24 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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** 7. On 5/17/22 at 8:45 AM, V24, agency CNA, was collecting breakfast trays out of residents' rooms without wearing eye protection. Residents Affected - Many On 5/17/22 at 8:48 AM, V24 stated that she was tested for COVID last week but not before her shift today, but she was screened at the front door. 8. On 5/17/22 at 8:50 AM, V11, CNA, was caring for residents on the north hall. V11 wore no eye protection and her K95 mask had one of the straps dangling in front of her neck not around her head. 9. On 5/17/22 at 11:37 AM, V25, unit aide, was in R163's lunch order with no eye protection on. 10. On 5/17/22 at 1:52 PM, V13, LPN, V15, CNA, and V12, CNA, staff development, all entered R7's room to transfer R7 to bed and perform incontinent care. V15 and V13 both donned gloves without hand hygiene. V26, CNA, entered the room and donned gloves without hand hygiene. R7's pants and incontinent brief were removed. R7's pants were saturated with urine from the seat of the pants to the mid-thigh area. The incontinent brief was saturated with urine. V26 placed the saturated mechanical lift sling and pants in a bag. V26 placed the incontinent brief in a trash bag. With the same gloves, V26 wiped R7's rectal area, gluteal folds and buttocks with premoistened cloths. On 5/19/22 at 1:40 PM, V3, ADON, stated that hand hygiene should be performed before donning and doffing gloves and that if gloves are soiled they should be changed. Based on interview, observation and record review, the facility failed to appropriately use PPE (personal protective equipment), secure airflow from a COVID positive room from coming into the hallway, clean multi-use equipment, and perform hand hygiene to prevent/control the spread of COVID-19 and other contaminants. This has the potential to affect all 62 residents living in the facility. Findings include: 1. The Facility's undated document lists R2 as positive for COVID-19. R2's POC (point of care rapid test) Test Result Reporting, dated 05/07/2022, documented R2 was positive for COVID-19. R2's Health and Wellness Care Plan, dated 5/7/22, documents, I have tested positive for COVID-19 I am on droplet precautions per CDC (Center for Disease Control) guidelines. On 05/16/2022 at 10:04 AM, R2 was on isolation for being COVID-19 positive on 5/7/22. There were 2 doors frames covered with heavy see-through plastic that leads into her room. The outside barrier had a 4 inch gap at the top and on the open side and there was a wheelchair alarm clipped to the plastic barrier. The second doorway that leads into R2's main room also had a frame covered with heavy see-through plastic that had a 5 inch gap and did not reach to the ceiling. On 05/18/2922 at 3:20 PM, V3, Assistant Director of Nurses (ADON), stated that R2 and R21 were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 25 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 roommates when R2 became positive and R21 showed signs and symptoms of COVID-19. Level of Harm - Minimal harm or potential for actual harm 2. The Facility's undated document lists R21 as exposed to COVID-19. Residents Affected - Many R21's Health and Wellness Care Plan documents, Droplet isolation per CDC and state guidelines 5/7/22 Please keep door open due to fall risk. On 05/16/2022 at 10:36 AM, R21 was on isolation for exposure for COVID-19. The door frame into R21's room was covered with heavy see-through plastic that did not reach to the ceiling and was gapped open on the side. The gaps measured 4 inches. After V15, Certified Nursing Assistant (CNA), and V17, CNA, used the full mechanical lift for R21 in her room, V15 brought the mechanical lift out of the isolation room and did not clean it. V16, CNA, took the mechanical lift to R54's room. On 05/16/2022 at 11:00 AM, V15 stated that they clean the full mechanical lift with a spray bottle with cleaner in it and could not remember the name of the cleaner, but said it started with a V. Asked if the spray bottle was in R21's room, V15 stated, No, it's usually on the laundry cart. V15 stated that she did not clean the full mechanical lift. 05/18/22 03:12 PM, V30, Regional Clinical Operations Manager, stated that the plastic see through barriers should not gap at the top or on the sides. 05/19/22 03:17 PM, V3, ADON, stated that she would expect the staff to clean the full mechanical lift with the appropriate cleaner after being used on a COVID-19 quarantined resident. 3. On 5/16/2022 at 12:00 PM, V15, CNA, wore a KN95 mask with only one strap securing it in place and the 2nd strap hanging down. 4. On 05/17/2022 at 09:28 AM, V15, CNA, wore a KN95 mask with only one strap securing it in place and the 2nd strap was hanging down and entered R23's room, performed resident care and exited R23's room. V15 then entered R54's room to assist with a transfer with the 2nd strap hanging down. 05/19/22 03:17 PM, V3, ADON, stated that she would expect the staff to wear their facemask and personal protective equipment appropriately. The facility's Coronavirus (COVID19) policy and procedure, dated 2/2022, documents, 4. The infected resident if in a private room can remain in his/her current room on precautions with the door closed. If in a semiprivate refer to the resident and staff isolation/Quarantine guideline for placement. the exposed roommate can be kept in their room with the door closed, if safe to do so. Every effort will be made to minimize movement of the infected resident and suspected resident within the facility. It continues, 6. Personal Protective Equipment (PPE) including gloves, gown, face mask or respirator, eye protection (goggles or face shield) are to be utilized for any healthcare worker entering the resident's room for suspected or confirmed cases. It further documents, Environmental Cleaning, 3. Physical and recreational therapy equipment- Standard facility procedures will be followed for routine cleaning and disinfection of recreational and therapy equipment used by residents with Coronavirus. 5. On 05/18/2022 at 10:20 AM, V35, Licensed Practical Nurse (LPN), donned gloves without benefit of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 26 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hand hygiene, removed R61's blankets and padded boot from right foot and removed R61's old dressing to right ankle. With clean gloves, V35 opened the applicator package, used the applicator, moved overbed table closer to her with her gloved hand and applied santyl ointment to the wound bed and covered wound with a border dressing without benefit of hand hygiene. 6. On 05/18/2022 at 10:00 AM, R37 was moving left leg upon right foot while V35, LPN, was trying to clean the open area to his right heel. V35, LPN, was trying to move R37's blanket out of the way and then moving R37's left foot with her gloved hands. V35 proceeded to perform wound care and dressing application without benefit of hand hygiene or changing her gloves after touching the dirty surfaces. The facility's policy, Standard Precautions, dated 09/2019, documented, 1. During delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface. 2. Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. It continues, 6. Environmental control-follow procedures for routine care, cleaning and disinfection of environmental surface, especially frequently touched surfaces in patient care areas. The CDC COVID-19 Data Tracker: County Transmission, dated 5/9/2022 for the week of 5/16/2022, documented that the community transmission rate was high for [NAME] county where the facility was located. The Updated Interim Guidance for the Nursing home and other licensed Long Term Care facilities, dated 03/22/2022, documented, Universal PPE for HCP - Updated o If a resident is suspected or confirmed to have COVID-19 or is not up to date with COVID-19 vaccinations, and the resident is identified to be a close contact, HCP (health care provider) must wear an N95 respirator, eye protection, gown, and gloves. o If a resident is identified to be a close contact and is up to date with COVID-19 vaccinations, HCP must wear PPE according to community transmission levels listed below. o For those residents not suspected to have COVID-19, HCP should use community transmission levels to determine the appropriate PPE to wear. When community transmission levels are substantial or high o At a minimum, HCP must wear a well-fitted mask at all times and eye protection while present in resident care areas. o Facilities might consider having HCP wear N95 respirators at all times while in the facility. o HCP are not required to wear eye protection for COVID-19 when working in non-resident care areas (e.g., offices, main kitchens, maintenance areas) when there are substantial or high community COVID-19 transmission levels. HCP should wear eye protection when entering the resident care areas. 11. On 5/17/22 at 9:42 AM, V11, CNA, and V7, CNA, assisted R3 to bed using a full body mechanical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 27 of 28 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many lift. V11 did not perform hand hygiene or don gloves prior to care done for R3. V7 did not perform hand hygiene prior to care done for R3. Neither CNA performed hand hygiene prior to leaving R3's room. 12. On 5/16/22 at 1:15 PM, V7, CNA and V8, CNA, performed perineal care for R48. V7 pulled wipes out of package and put on bed. V7 used the wipes to reach between R48's legs and wiped from her vaginal area to her anal area. Using the same soiled gloves, V7 applied barrier cream on the clean incontinent brief and spread it all over the brief with his hands. Using the same gloves, V7 put a new incontinence brief on R48. There was no hand hygiene done prior to donning of gloves to care for R48. During perineal care, there was no hand hygiene or glove changes done between the dirty and clean areas. On 5/19/22 at 1:30 PM, V19, CNA, stated When I go into a room to do perineal care, I wash my hands when I get into a room. I will make sure all supplies are set up in the room and once I touch a dirty field, I will change my gloves and use hand sanitizer. Once I do this three times, I will go and actually wash my hands. After cleaning the resident, they usually dry to air. I think our wipes dry quickly. The Facility's Hand Washing Policy dated 9/2019, documents Staff will use proper hand washing technique to prevent the spread of infection. The Facility's Proper Hand Washing and Glove Use Guideline, dated 2016, documents All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines. It continues Procedure: 4. Employees will wash hands before and after working with an individual resident. 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. 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. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. The Resident Census and Conditions of Residents, CMS 672, dated 5/16/22 documents that the facility has 62 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 28 of 28