Inspection·June 5, 2023

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** Based on observation, interview, and record review the facility failed to utilize safe transfer techniques to prevent accidents for 4 of 5 residents (R1, R28, R30, R53) reviewed for accidents/supervision in the sample of 36. Findings include: 1. R1's Care Plan, dated 7/26/21, documents I am a total lift for transfers with two staff assist. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is totally dependent of 2 staff members for transfers. On 5/30/23 at 9:15 AM V11, Restorative Nurse, and V9, Restorative Aide, transferred R1 from her wheelchair to the bed using a full body mechanical lift. V11 operating the controls and V9 stood behind the wheelchair. V9 then moved the machine back and R1 started to sway in the sling. With V9 operating the controls V9 transported R1 from the wheelchair to the bed swinging without staff contact. 2. R28's Care Plan, dated February 3, 2017, documents Since having my stroke, I have left sided hemiplegia. I am not safe to get up on my own. I am a two person assist using the total lift with a TL2 purple edge sling. R28's MDS, dated [DATE], documents that R28 is totally dependent on 2 staff for transfers. On 5/31/23 at 130pm V12, Certified Nurse Aide/CNA, and V15, Nursing assistant (NA), assisted R28 to her bed from her wheelchair using a full body mechanical lift. V12 applied R28's sling straps to the lift. With V12 operating the controls V15 stood behind the wheelchair. V12 then moved the machine back transported R30 from the wheelchair at the far end of the room to the bed allowing R28 to swing freely in the sling without staff contact. 3. R30's Care Plan, Dated November 10, 2016, documents I am a two assist with total lift to transfer. R30's MDS, dated [DATE], documents that R30 is totally dependent on 2 staff for transfers. 05/30/23 at 2:18 PM V6, CNA, and V13, CNA, assisted R30 into the bed using a full body mechanical lift. V6 and V13 applied R30's sling straps to the lift. With V13 operating the controls V6 stood behind the wheelchair. V13 then moved the machine back and R30 started to swing in the lift. With V13 operating the controls transported R30 from the wheelchair at the far end of the room to the bed swinging without staff contact. 4. R53's Care Plan, dated August 28, 2022, documents I am a fall risk, and have a history of falls at home. I am a one person transfer with gait belt using a walker when I walk. R53's MDS, dated [DATE], documents that R53 requires extensive assist of 1 person for transfers. On 5/31/2023 at 11:31 AM R53's chair alarm was sounding. R53 transferred self to the toilet. V12 assisted R53 with toileting. V12 then grabbed R53 under her right arm and assisted R53 into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 2 of 16 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 06/05/2023 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 standing position. R53 noted to sway when standing and holding onto the bar. V12 then assisted R53 into the wheelchair. V12 did not apply a gait belt to R53 for the transfer. V12's gait belt was around her waist. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the staff to apply a gait belt when assisting with a manual transfer. V2 stated that V12 should have applied the gait belt when transferring R53 from the toilet. V2 stated that when the staff are transferring a resident in a total mechanical lift both staff are to participate in the transfer. V2 stated that a staff standing behind a wheelchair or on the other side of the bed is not participating in the transfer. V2 stated that the resident should not be left unattended and left to swing in the lift. The facility's Transfer Belt/Gait Belts policy, dated 4/14, documents the policy is to promote safety in transferring residents, a gait belt is utilized when deemed appropriate. It also documents, A gait belt is used if indicated on care plan. The (Full Body Lift) Total Lift policy documents that the (Full Body Lift) total lift is to be used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 3 of 16 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 06/05/2023 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** Based on observation, interview, and record review, the facility failed to provide complete incontinent and perineal care for 6 of 6 residents (R1, R9, R18, R30, R35 and R53) reviewed for incontinent and perineal care in the sample of 36. Findings include: 1. 05/31/23 10:35 AM R9 was on the bedpan. V9, Certified Nurse Assistant, CNA, removed the bed pan from underneath of R9. V9 rolled R9 back over on to her back. V9 then cleansed R9's abdominal fold, left inner groin and down the center of R9's labia. She did not cleanse R9's right groin. V9 then assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock, and peri rectal area. V9 did not cleanse R9's right hip or buttock. R9's Minimum Data Set (MDS), dated [DATE], documented that her cognition was severely impaired, she was totally dependent upon 2 staff members for toileting and that she was always incontinent of bowel and bladder. 2. R1's Care Plan, dated 7/26/21, documents I am incontinent of both bowel and bladder. I do wear incontinent protective undergarments. R1's MDS, dated [DATE], documents that R1 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R1's Bladder Continence Evaluation, dated 5/15/23, documents that R1 is incontinent of bladder and dependent on staff for toileting. On 05/30/23 at 2:00 PM V13, CNA, and V6, CNA, assisted R1 with incontinent care. R1 was incontinent and heavily soiled of urine. R1's lift pad and pants were soiled with urine. V6 and V13 assisted R1 into the bed using the mechanical lift. V6 and V13 removed R1's pants, opened the incontinent brief and rolled it between R1's legs. V6 using a premoistened washcloth wiped down the middle of R1's peri area. V6 and V13 assisted R1 onto her right side. V6 then using a premoistened wipe and wiped R1's rectal area. V6 and V13 then applied R1's incontinent brief. V6 and V13 did not clean R1'sinner labia, vaginal, peri, groin area, inner thighs, and buttocks. 3. R30's Care Plan, dated 11/10/2016, documents I am incontinent of urine/bowel and need assistance with peri-care after each incontinent episode. I do wear protective undergarments. I am also at risk for urinary tract infections due to my incontinence so monitor me for signs and symptoms of infection. R30's MDS, dated [DATE], documents that R30 is always incontinent of bowel and bladder and totally dependent on 2 staff for toileting. R30's Bladder Continence Evaluation, dated 5/15/2023, documents that R30 is moderately impaired cognitively. It documents that R30 is incontinent and dependent on staff for care. On 05/30/23 at 2:18 PM V13 and V6 assisted R30 with incontinent care. R30 was incontinent of urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 4 of 16 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 06/05/2023 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 V6 and V13 assisted R30 into the bed using the mechanical lift. V6 and V13 removed R30's pants, opened the incontinent brief and rolled it between R30's legs. V6 using a premoistened washcloth wiped down the middle of R30's peri area. V6 and V13 assisted R30 onto her right side. V6 then using a premoistened wipe wiped R30's rectal area. V6 then using a premoistened wipe wiped R30's rectal area again. V6 and V13 then applied R30's incontinent brief. V6 and V13 did not clean R30's inner labia vaginal, peri, groin area, inner thighs, and buttocks. 4. R53's Care Plan, dated August 28, 2022, documents I am occasionally incontinent of bowel and bladder. R53's MDS, dated [DATE], documents that R53 is frequently incontinent of urine, occasionally incontinent of bowel and requires extensive assist of 1 person for toileting. On 5/31/2023 at 11:31 AM, V12, CNA assisted R53 with toileting. R53 transferred self to toilet. R53 was incontinent of urine. V12 removed R53's heavily soiled incontinent brief and applied a new one. R53 then voided on toilet. R53 with 2 squares of toilet paper wiped her vaginal area. V12 then took toilet paper and wiped R53's anal area. 5. On 06/01/23 at 1:25 PM, V17, CNA, and V15, CNA, entered R18's room to provide incontinent care. V15 and V17 washed hands with soap and water and donned gloves. R18 was wet as verified by V17 and V15. V17 cleansed R18 front peri area during cleansing of labia visible stool on the cleansing wipe. V17 did not obtain any additional wipes to cleanse R18. R18 then turned to left side facing wall. R18 was incontinent of loose stool which had leaked out of adult brief and leaked on the bed. V17 rolled soiled linens under R18 and cleansed R18. V17 did cleanse R18's thighs and buttock and when cleaning rectal area. R18 had visible stool on cleansing wipe. V17 did not cleanse rectal area after cleaning wipe visible with feces. R18 was never dried during incontinent care. R18's MDS, dated [DATE], documents R18 is totally dependent and requires two plus physical assistance for toileting. R18's MDS documents that R18 is always incontinent. 6. On 05/30/23 1:25PM, R35 was being pushed down hall towards her room by V6, CNA. V6 transferred R35 to toilet from wheelchair with gait belt. While R35 stand holding bar, V6 removed R35's pants. R35's adult diaper was urine soaked. While R35 was sitting on the toilet, V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing has been. then placed clean pants on and up to R35's thighs. After toileting R35, V6 assisted R35 to stand while R35 was holding bar. V6 took cleansing wipe and stood behind R35 and swiped from the front to the back and then pulled up R35's adult diaper and pants. R35's MDS dated [DATE] documents R35 requires extensive assistance of one person for toileting. R35's Care Plan, dated 3/12/ 2018, documents R35 has a history of urinary tract infection and urinary retention. On 6/1/2023 at 1:40 PM V2, Director of Nursing, stated that she expects the CNAs to clean all areas of incontinence. V2 stated that she would expect the CNA to perform incontinent care. The facility policy Incontinent Care dated reviewed 1/15 documents #10 wash the resident's entire perineal area, and all areas affected by incontinent with wash cloth, soap, warm water, peri-wash, or wipes. #11 When washing perineal area, wash the entire area moving from the front to back. #12 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 5 of 16 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 06/05/2023 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 Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back. The Policy documents #14 Dry the perineal area front to back of all skin surface washed. #16 remove gloves and discard. Wash hands. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 6 of 16 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 06/05/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure nutrition was provided as ordered and per standards of practice for 1 of 2 residents (R10) reviewed for tube feeding management in the sample of 36. Findings include: R10's Physician's Order (PO), dated 12/02/19, documents Jevity 1.5 @ (at) 55 ml (milliliters)/hr. (hour) x 24 hours via g tube (gastrostomy tube). R10's Care Plan, dated December 3, 2019, documents I am NPO (Nothing by mouth). I have a diagnosis of Dysphagia. I have a PEG (Percutaneous Endoscopic Gastrostomy)- tube and receive Jevity per MD (medical doctor) orders. I receive Jevity 1.5 at 55ml/hr./24 hours. I have water flushes per tube per MD order. I am to receive medication per tube, all those compatible can be given at once with a 30 ml bolus of water at appropriate times. It also documents that it can be disconnected for no more than one hour a day during ADLs (Activities of Daily Living), therapy, or activities. On 5/30/23 at 9:30 AM R10 was up in wheelchair, out of room. The tube feeding container was not attached to the gastric tubing. On 5/30/23 at 12:40 PM V14, Licensed Practical Nurse, crushed R10's Baclofen 10mg tablet and placed in a cup. V14 then poured and unmeasured amount of water into the cup and entered R10's room. R10 was lying in bed. R10's gastric tubing not connected to feeding container. V14 grabbed a hold of the gastric tubing, opened the spout, and poured the mixture in the cup into the gastric tubing. The liquid stopped flowing. V14 then milked the tubing freeing sections of feeding caught in the tubing. V14 then allowed the liquid to free flow into tubing. V14 then connected the gastric tubing to the bottle of feeding and turned it on. The Jevity feeding bottle was not labeled with the resident's name, formula ordered and date. On 6/1/2023 at 12:45 PM V2, Director of Nursing, stated that she expects the feeding bottles to be filled in prior to administration of feeding. V2 stated that she would expect the staff to flush the g tube before and after administration of medication. V2 stated that the facility only checks placement every eight hours but that she would expect the nurses to follow the policy. V2 stated that R10 has an order to be off the feeding for an hour and that is what she expects. The facility's Tube Feeding policy, dated 7/2018 documents Procedure: 5c. Flush prior to administering medication, in between and after all medication with approximately 15cc of water. 7. Label the feeding bag with the resident's name, formula ordered and date. The facility's Enteral Tube Medication Administration Procedures, dated 2/18/2023, documents Procedure 2. Prepare medications for administration. 4. Wash hands and apply gloves. 5. Verify tube feeding placement per tube feeding policy. 6. Stop enteral feeding and flush tube with at approximately 15 ml of water prior to administration of water each dose unless fluid restriction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 7 of 16 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 06/05/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 provide pain relief for 1 of 16 residents (R51) reviewed for pain in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Residents Affected - Few Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set, dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams) PO Q 6 hours PRN, No weight bearing and to make an appointment with (V18 Orthopedic Doctor) on 5/30/23 for follow up noted. R51's Nursing Note, dated 5/30/23 at 6:27 PM, documents, Resident very restless this am Tylenol given for discomfort with no relief noted. Called pharmacy and asked them when the e-run (emergency run) for the Norco (Hydrocodone) would get here spoke with (V19, Pharmacy Technician) and he said he did not know it needed to be sent out but he would take care of it this was at 830am and 1130 resident still having lots of pain called pharmacy and spoke with (V20, Pharmacy Technician) and he said he had just gotten a hard copy from (V21, Nurse Practitioner) told him that was for addition meds (medications) the initial order was for 15 pills and 1 -2 pills every 6 hours he researched and found the order and said it has not been sent earlier but was on its way now. Contacted (V21) and receive order for 1 time stat dose of tramadol 50 mg po 2 tabs. Medication given with some relief. At 4pm received Norco from pharmacy and meds given to resident. R51's Nursing Note, dated 5/31/23 at 1:11 AM, documents, Resident noted to be in extreme pain at times. PRN given this shift and was effective. R51's Hospital Emergency Department Disposition, arrival date of 5/29/23, documents, Instructions: No weight bearing. Prescription Medications: Hydrocodone / APAP 5 mg / 325 mg: take 1 to 2 orally every 6 hours as needed for acute pain. Dispense fifteen (15). No refills. R51's Pelvis X-ray, dated 5/29/23 at 11:20 PM, documents, Impression: Left pubic fracture. R51's Medication Administration Record, dated 5/30/23, documents that R51 got her first dose of Hydrocodone /APAP at 4:00 PM and a dose of Tramadol 100 mg at 2:00 PM. On 5/30/23 at 10:48 AM, R51 was sitting up at the nurses station in a recliner geriatric chair. R51 was observed to be fidgeting in the seat throwing her left leg across the arm of the chair, holding her left buttock, moaning and having facial grimaces. On 05/30/23 from 1200 PM to 12:50 PM, R51 stated several times the she was in pain and was uncomfortable. Throughout meal service, R51 was sitting up in a high back reclining geriatric chair with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 8 of 16 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 06/05/2023 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 0697 left leg hanging off of the chair, when staff attempted to reposition R51, she groaned out in pain, expressed facial grimacing and did not want the pillow underneath her which is what they were trying to do for comfort. Level of Harm - Actual harm Residents Affected - Few On 05/30/23 at 1:20 PM, V23, Certified Nurse Aide (CNA), and V8, CNA, transferred R51 from her geriatric reclining chair to her bed using a full mechanical lift. During the transfer R51 hollered out in pain. Once in bed, V23 and V8 attempted to roll R51 to the side to remove the full mechanical lift sling and provide incontinent care. R51 hollered out in pain and refused to move. R51 continually attempted to hold her left buttock. V23 and V8 both questioned what they should do. V8 left the room to get help. V8 came back with V3, Registered Nurse (RN) / Staff Development Coordinator. V23 and V8 attempted to roll R51 again. R51 hollered out in pain and continually attempted to hold her left buttock. V3 left the room and went and got V5, ( Fill in Administrator/RN). Another attempt to roll R51 was made. R51 hollered out in pain, attempted to hold her left buttocks and grimace in pain. V5 stated to V23 and V8 to just leave R51 the way she is and she was going to go talk to (V7 RN) about R51. On 05/30/23 at 3:10 PM, R51 was lying in bed with her eyes closed, left leg bent and an ice pack on her left buttock. On 5/30/23 at 9:20 AM, V7, Registered Nurse (RN), stated, (R51) fell last night and fractured her pelvis. The hospital sent her back with an order of Vicodin for pain. I am waiting for the pharmacy to deliver it. She has been given some Tylenol for pain. She is Non-weight bearing and she has a follow up appointment with the orthopedic doctor (V18) in a week. There is nothing they can do for a pelvic fracture so it is just pain control and non weight bearing until she sees (V18). On 5/30/23 at 10:50 AM, V22, Certified Occupational Therapy Assistance (COTA), stated, (R51) was transferred to the geriatric reclining chair using the full mechanical lift. V22 was questioned how V22 handled the transfer, V22 stated, 'It was very painful for her. She is having a lot of pain. On 5/30/23 at 2:02 PM, V7 stated, Pharmacy has still not delivered the Vicodin for (R51). I have been trying to get it for her. They tell me it is on the way. I just spoke to (V21) and she sent a prescription for Tramadol to the pharmacy. Our emergency pharmacy kit does not have Vicodin in it. That is why the order for Tramadol. Once pharmacy gets that I can access the emergency pharmacy kit and get the Tramadol out of it to give to her. On 6/1/23 at 12:50 PM, V2, Director of Nurses, stated, When a resident comes from the hospital with a prescription for narcotics, the hard copy of the prescription has to go to the pharmacy. When she came back it was in the middle of the night and we did not have staff to drive it to [NAME] to get it filled. The pharmacy came in the morning and picked up the prescription and took it to the pharmacy in St. Louis Missouri which even took longer. I don't know why (V7) didn't try to get her Tramadol earlier and why she waited. I agree the order to get her Tramadol should have been done earlier so she could have some pain relief while waiting on the Vicodin. (V21) sent the script for Tramadol over to the pharmacy electronically. That is how the pharmacy is getting that prescription so it can be processed. I know in the future if the emergency room is going to send a resident back with a narcotic the hospital doctor needs to electronically send the prescription directly to the pharmacy and not send a hard copy for narcotics that way there will not be a long delay in getting narcotics. On 6/1/23 at 1:54 PM, V5 stated, I was mortified when I saw her. I can't believe the hospital sent her back and did not admit her. I even called the hospital on Wednesday to make sure she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 9 of 16 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 06/05/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supposed to be out of bed and they said they wanted her up and not bed rest. If they sent her back they should have pre-medicating her for pain. V5 was questioned as to what her opinion of the delay of Vicodin was, V5 stated, Well she was getting Tylenol and she got a Tramadol while we were waiting on the Vicodin. The policy Pain Evaluation / Management, dated 1/15, documents, 4. If no relief or if the resident finds pain above acceptable levels notify the physician. 5. Notify the physician if resident's response to their medication or treatment is not satisfactory to develop further interventions for relief of pain. Event ID: Facility ID: 145910 If continuation sheet Page 10 of 16 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 06/05/2023 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to obtain pain medication in a timely manner and have a system in place to obtain pain medication for a resident in a timely manner for 1 of 16 residents (R51) reviewed for pharmacy services in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set (MDS), dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams) PO Q 6 hours PRN, No weight bearing and to make an appointment with (V18, Orthopedic Doctor) on 5/30/23 for follow up noted. R51's Nursing Note, dated 5/30/23 at 6:27 PM, documents, Resident very restless this am Tylenol given for discomfort with no relief noted. Called pharmacy and asked them when the e-run (emergency run) for the Norco (Hydrocodone) would get here spoke with (V19, Pharmacy Technician) and he said he did not know it needed to be sent out but he would take care of it this was at 830am and 1130 resident still having lots of pain called pharmacy and spoke with (V20, Pharmacy Technician) and he said he had just gotten a hard copy from (V21, Nurse Practitioner) told him that was for addition meds (medications) the initial order was for 15 pills and 1 -2 pills every 6 hours he researched and found the order and said it has not been sent earlier but was on its way now. Contacted (V21) and receive order for 1 time stat (now) dose of tramadol 50 mg po 2 tabs. Medication given with some relief. At 4pm received Norco from pharmacy and meds given to resident. R51's Hospital Emergency Department Disposition, arrival date of 5/29/23, documents, Instructions: No weight bearing. Prescription Medications: Hydrocodone / APAP 5 mg / 325 mg: take 1 to 2 orally every 6 hours as needed for acute pain. Dispense fifteen (15). No refills. R51's Medication Administration Record, dated 5/30/23, documents that R51 got her first dose of Hydrocodone /APAP at 4:00 PM and a dose of Tramadol 100 mg at 2:00 PM. The policy Ordering and Receiving Medications form Pharmacy, dated 8/16, documents, Medications are ordered and received from the pharmacy in a timely manner. The policy Controlled Medications Administration, dated 8/16/23, documents, 3. Schedule !! controlled medications are delivered to the facility only if original written or faxed (if allowed by state law) prescription has been received by the pharmacy. Schedule III, IV and V controlled medications are delivered to the facility only if a written or verbal prescription with all legal requirements has been received by the pharmacy. Only the prescriber or their agent can provide the pharmacy with a legal prescription for controlled substances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 11 of 16 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 06/05/2023 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 0755 Level of Harm - Actual harm Residents Affected - Few On 5/30/23 at 10:48 AM, R51 was sitting up at the nurses station in a recliner geriatric chair. R51 was observed to be fidgeting in the seat throwing her left leg across the arm of the chair, holding her left buttock, moaning and having facial grimaces. On 05/30/23 from 1200 PM to 12:50 PM, R51 stated several times the she was in pain and was uncomfortable. Throughout meal service, R51 was sitting up in a high back reclining geriatric chair with her left leg hanging off of the chair, when staff attempted to reposition R51, she groaned out in pain, expressed facial grimacing and did not want the pillow underneath her which is what they were trying to do for comfort. On 05/30/23 at 1:20 PM, V23 Certified Nurse Aide (CNA), and V8, CNA, transferred R51 from her geriatric reclining chair to her bed using a full mechanical lift. During the transfer, R51 hollered out in pain. Once in bed V23 and V8 attempted to roll R51 to the side to remove the full mechanical lift sling and provide incontinent care. R51 holler out in pain and refused to move. R51 continually attempted to hold her left buttock. V23 and V8 both questioned what they should do. V8 left the room to get help. V8 came back with V3, Registered Nurse (RN) / Staff Development Coordinator. V23 and V8 attempted to roll R51 again. R51 hollered out in pain and continually attempted to hold her left buttock. V3 left the room and went and got V5, Fill in Administrator / RN to come and assess. Another attempt to roll R51 was made. R51 hollered out in pain, attempted to hold her left buttocks and grimace in pain. V5 stated to V23 and V8 to just leave R51 the way she is and that she was going to go talk to (V7, RN) about R51. On 05/30/23 at 3:10 PM, R51 was lying in bed with her eyes closed, left leg bent and an ice pack on her left buttock. On 5/30/23 at 9:20 AM, V7, Registered Nurse (RN), stated, (R51) fell last night and fractured her pelvis. The hospital sent her back with an order of Vicodin for pain. I am waiting for the pharmacy to deliver it. She has been given some Tylenol for pain. She is non-weight bearing and she has a follow up appointment with the orthopedic doctor (V18) in a week. There is nothing they can do for a pelvic fracture so it is just pain control and non weight bearing until she sees (V18). On 5/30/23 at 10:50 AM, V22, Certified Occupational Therapy Assistance (COTA), stated, (R51) was transferred to the geriatric reclining chair using the full mechanical lift. V22 was questioned how V22 handled the transfer, V22 stated, 'It was very painful for her. She is having a lot of pain. On 5/30/23 at 2:02 PM, V7 stated, Pharmacy has still not delivered the Vicodin for (R51). I have been trying to get it for her. They tell me it is on the way. I just spoke to (V21) and she sent a prescription for Tramadol to the pharmacy. Our emergency pharmacy kit does not have Vicodin in it. That is why the order for Tramadol. Once pharmacy gets that I can access the emergency pharmacy kit and get the Tramadol out of it to give to her. On 6/1/23 at 12:50 PM, V2, Director of Nurses, stated, When a resident comes from the hospital with a prescription for narcotics, the hard copy of the prescription has to go to the pharmacy. When she came back, it was in the middle of the night and we did not have staff to drive it to [NAME] to get it filled. The pharmacy came in the morning and picked up the prescription and took it to the pharmacy in St. Louis Missouri which even took longer. I don't know why (V7) didn't try to get her Tramadol earlier and why she waited. I agree the order to get her Tramadol should have been done earlier so she could have some pain relief while waiting on the Vicodin. (V21) sent the script for Tramadol over to the pharmacy electronically. That is how the pharmacy is getting that prescription so it can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 12 of 16 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 06/05/2023 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 0755 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete be processed. I know in the future if the emergency room is going to send a resident back with a narcotic the hospital doctor needs to electronically send the prescription directly to the pharmacy and not send a hard copy for narcotics that way there will not be a long delay in getting narcotics. On 6/1/23 at 1:54 PM, V5 stated, I was mortified when I saw her. I can't believe the hospital sent her back and did not admit her. I even called the hospital on Wednesday to make sure she was supposed to be out of bed and they said they wanted her up and not bed rest. If they sent her back, they should have pre-medicating her for pain. V5 was questioned as to what her opinion of the delay of Vicodin was, V5 stated, Well, she was getting Tylenol and she got a Tramadol while we were waiting on the Vicodin. Event ID: Facility ID: 145910 If continuation sheet Page 13 of 16 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 06/05/2023 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, and label Tubersol. This has the potential to affect all 57 residents living in the facility. Findings include: On 5/30/23 at 9:00 AM, The facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 3 open multidose vial of Tubersol (TB) without an open date. The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. 2. R33's bottle of liquid Lorazepam Concentrate. 3. R6's bottle of liquid Lorazepam Concentrate. 4. R31's bottle of liquid Lorazepam Concentrate. On 5/30/2023 at 9:05 AM V8, RN, stated that the multidose vial of Tubersol was open and in use. V8 stated that the Tubersol should have an open date on it. V8 stated that the refrigerator should be locked. V8 stated that she unlocked the refrigerator and did not lock it back. On 5/23/2023 at 2:30PM, V2, Director of Nursing, stated that multi dose vials of Tubersol have a different expiration date from what's on the bottle once open and should be thrown away after this date. V2 stated that she believes it is 28 or 30 days. V2 stated that the TB vials are to be labeled with an open date when put in use. V2 stated that labeling the medication with a date open date lets the nurses know when the expiration date is. V2 state the Tubersol can be used on everyone as long as they have no allergies. The Resident Census and Condition of Residents form (CMS 672), dated 5/30/2023, documents that the facility has 57residents living in the facility. The facility's Medication Storage Policy, dated 11/10, documents Policy: All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 14 of 16 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 06/05/2023 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 Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately during care, and cleaning soiled bed mattress and wheelchair seat pad for 6 of 6 residents(R9, R18, R33, R35, R48, R50) reviewed for infection control in the sample of 36. Residents Affected - Some Findings include: 1. 05/31/23 10:35 AM, R9 was on the bedpan, V8, Certified Nurse Assistant (CNA) and V9, CNA, came into the room, both performed hand hygiene, both donned gloves. V8, with gloved hands, touched her hair, tucking her hair behind her right ear and the placed hand in shirt pocket, proceeded to the right side of R9's bed to assist with taking her off of the bed pan. V9 proceeded to uncover R9, open the disposable cleansing wipes with same gloved hands, removed the bedpan from underneath R9 and started to cleanse R9's abdominal fold, left inner groin and down the center of R9's labia with the same pair of gloves. V9, with the same soiled gloves, assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock and peri rectal area. 2. On 05/31/2023 at 10:20 AM, V8 took R48 into her room. V8 placed a gait belt on R48 and transferred her into her bed without the benefit of hand hygiene nor did she don gloves. 3. 05/31/2023 at 11:00 AM, V10, Registered Nurse (RN)/ Wound Nurse, performed hand hygiene, donned gloves, took a medicine cup of dakin's solution, packages of 4x4 gauze, a package of Melgisorb AG, cotton tip applicators, mepilex foam dressing, gloves and a barrier for the bed. V10 set all the wound dressing supplies on R50's overbed table, pulled R50's privacy curtain and then closed R50's door with her gloved hands. V10 went to R50's bedside, touched R50's right arm with the same gloved hands, explained what she was about to do. V10 pulled the blankets down to expose R50's buttocks and hips placed barrier down on the bed, unfastened R50's incontinent brief, that was wet, and removed the saturated wound dressing from R50's sacral coccyx area. V10 then doffed gloves, performed hand hygiene and donned a clean pair of gloves. V10, with her clean gloves opened the 4x4 gauze packages, placed gauze in medicine cup of dakin's solution, took 1 piece of dakins solution soaked gauze, wrapped it around a cotton tip applicator and cleansed the 9 o'clock tunnel, then took a 2nd gauze soaked with dakin's solution and used it to clean the wound bed. She then took the 3rd dakins soaked gauze and cleansed around the outside of of the wound all with the same gloved hands. V10 then doffed her gloves, performed hand hygiene with Alcohol Based Hand Rub, donned gloves, opened the Melgisorb AG package and took out the dressing, wrapped it around the cotton tipped applicator and placed it in the wound tunnel spreading it down into the wound bed. V10 took the foam dressing placed a 4x4 gauze pad on top of it and placed it over the wound. She then removed the barrier and reattached the soiled adult incontinence brief. 4. On 5/30/23 at 12:05 PM, V10, RN, entered R33's room to do the treatment on R33's legs. R33 right lower leg has multiple scattered scratches and scabs. R33's left leg has 2 scabbed venous ulcer areas with the approximate size of dimes. The areas around the wounds were red. The areas were cleansed and Bacitracin was applied, abdominal pad (ABD) and then gauze. During the dressing changes, V10 changed her gloves 3 times without hand hygiene in between. 5. On 06/01/23 at 1:25 PM during incontinent care, V17, CNA, rolled soiled linens under R18 and cleansed R18. R18's mattress was visibly wet from loose stool. V15 took soiled linens that were removed out from under R18 and swiped across the wet area on mattress. Then both CNAs placed adult diaper on R18. While R18 on mattress, V15 used cleansing wipes and cleansed the area on mattress that R18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 15 of 16 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 06/05/2023 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 has already been placed in. Level of Harm - Minimal harm or potential for actual harm 6. On 05/30/23 01:25PM during incontinent care while R35 sitting on the stoo,l V6, CNA, removed wet pants and diaper which was soaked. V6 placed clean adult diaper around ankles and pulled up above thighs where wet clothing had been. V6 placed clean pants on and up to thighs. The pad in wheelchair wasvisible wet with urine. V6 did not clean pad in wheelchair prior to sitting R35 back in the chair. Residents Affected - Some On 06/01/2023 at 12:55 PM, V2, Director of Nurses, stated that she would expect to staff to perform hand hygiene and change gloves during incontinent care and wound care. The facility policy Standard Precautions dated history 9/19 documents standard precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. The policy documents standard precautions applies to blood; all body fluids, secretions, exertions except sweat, non-intact skin; mucous membranes. The policy documents #4 during delivery of healthcare, avoid unnecessary touching of surfaces in close contact proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands t surface. #2 Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patients intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. #6 environmental control- follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touches surfaces in patient care areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 16 of 16