Health inspection·January 16, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, Observation, and Record Review, the facility failed to provide sufficient staffing to care for resident needs, including assisting a resident to get out of bed, and answering call lights, for 3 of 4 residents (R2, R3, R4) reviewed for sufficient staffing in the sample of 4. The Findings Include: 1. R3's Face Sheet, dated 1/14/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure (CHF), Major Depressive disorder, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (DM) with Polyneuropathy, Hypertension (HTN), and Intestinal obstruction. R3's Care Plan, dated 12/18/24, documents R3 uses anti-anxiety medications related to (r/t) anxiety disorder. R3 uses multiple antidepressant medication r/t major depressive disorder. R3 may display symptoms of crying or sadness r/t depression. R3 Resident utilizes a wheelchair for mobility. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and is dependent on staff for all Activities of Daily Living (ADLs) and transfers. On 1/15/25 at 8:40 AM, R3 was seen lying in bed. R3 stated she normally gets out of her bed around 7:00 AM, however today, the facility is short staffed, and the Certified Nursing Assistants (CNAs) get the people out of bed who eat in the dining room first, and since she eats breakfast in her room, she has to wait for someone to help her. R3 stated she uses the call light when she needs help and it is usually answered timely unless they are short staffed, then can take a while. On 1/15/25 at 1:15 PM, R3 stated the staff finally got her out of bed this morning around 9:20 AM. R3 stated she does not like waiting because she has high anxiety and even while waiting this morning, she felt like she was going to have an anxiety attack. 2. R2's Face Sheet, dated 1/14/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Alzheimer's, Dementia, Type 2 DM, HTN, Malnutrition, COPD, Polyosteoarthritis, Malignant neoplasm of prostate, Hypothyroidism, Morbid Obesity, Atherosclerosis of bilateral legs. R2's Care Plan, dated 12/27/24, documents R2 has impaired cognitive function d/t dementia. R2's review shows Moderate risk for falls. R2 needs prompt response to all requests for assistance. R2's MDS, dated [DATE], documents R2 is cognitively intact (BIMS 14) and requires Page 1 of 4 145981 145981 01/16/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0725 substantial/maximal assistance from staff for ADLs and transfers. Level of Harm - Minimal harm or potential for actual harm On 1/15/25 at 8:55 AM, R2 stated he uses his call light and sometimes has to wait for help if they don't have staff working. Residents Affected - Few On 1/15/25 at 10:13 AM, V7, R2's Daughter, stated that on 1/11/25 she was visiting R2 and she put R2's call light on for assistance and no one answered the light. V7 stated it was at least a half hour because she recorded the time frame on her phone while she walked around the facility trying to find an employee. V7 stated she did not find anyone on R2's floor (100-hall) and had to go across the building to the other floor (200-hall) to find a staff member. V7 stated her concern is the facility does not have the staff available to answer resident call lights or help the residents when they need it. V7 feels like she needs to visit R2 at the facility almost every day because of the facility's lack of staff and her need to check on R2. 3. R4's Face Sheet, dated 1/15/25, documents R4 was admitted to the facility on [DATE] with diagnosis of Seizures, Depression, Generalized Anxiety Disorder, Schizophrenia, Hypothyroidism, and Nicotine dependence. R4's Care Plan, dated 12/18/24, documents R4 is usually able to perform ADLs independently with minimal assist with toileting and hygiene. Transfer/Mobility: R4 is independent in transferring and mobility. Remind of safety issues as they arise. It continues R4 is a Moderate risk for falls. R4's MDS, dated [DATE], documents R4 has a Moderate Cognitive Impairment and is independent on ADLs, including transfers. On 1/15/25 at 9:00 AM, R4 stated she uses her call light for assistance, and it gets answered timely unless they are short staffed. R4 stated she feels the facility is very short staffed, both CNAs and Nurses, and at times only has one CNA on her hall (200-hall) which makes it hard to get all residents taken care of and to answer call lights. 4. On 1/15/25 at 8:05 AM, upon entrance to the facility, there were only three CNAs and one Nurse on duty. On 1/15/25 at 9:07 AM, V4, CNA, stated they usually work with four to five CNAs, but today they are working with only three CNAs for the entire building. V4 stated it is difficult to get things done when short staffed, because they have people to get up in the morning, take residents to dining room, make beds, and provide good resident care. V4 stated it is not always like this, but when it is, it makes it more difficult to get things done. On 1/15/25 at 9:10 AM, V5, Licensed Practical Nurse (LPN), stated she is an agency nurse, was called in for today to work the 100-hall. V5 stated the last time she worked at this facility, she had one CNA for each hall and one CNA as a float which made it difficult to keep up with the resident needs. On 1/15/25 at 9:14 AM, V6, CNA, stated they normally work with two CNAs on each hall and things go smooth. V6 stated it can be rough trying to get everything done on days like this when there are only two to three CNAs on duty. On 1/15/25 at 11:02 AM, V1, Administrator, stated the normal staffing pattern for CNAs is for Days: 145981 Page 2 of 4 145981 01/16/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4-CNAs. Evenings: 3-CNAs, and Nights: 3-CNAs. V1 stated that the CNA Day shift is from 6:00 AM to 2:00 PM, the Evening shift if from 2:00 PM to 10:00 PM, and the Night shift is from 10:00 PM to 6:00 AM. V1 stated the Nurses work 12-hour day shift from 6:00 AM to 6:00 PM and 12-hour night shift from 6:00 PM to 6:00 AM. V1 stated that is what they are budgeted for. On 1/15/25 at 2:40 PM, V8, Regional Nurse, stated she is not sure what the facility is supposed to do, they have ads placed and they are not getting people applying for the open positions. V8 stated that she would expect the facility to make every attempt to obtain more staff on days they may be short staffed so that resident care needs are taken care of. The Facility's CNA Schedules for the months of December 2024 and January 2025 were reviewed with the following dates not meeting V1's normal staffing pattern: 12/27/24, 1/3/25, 1/5/25, and 1/15/25. The Facility's Nurse Staffing Policy, undated, documents It is the policy of (this facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. 145981 Page 3 of 4 145981 01/16/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, Observation, and Record Review, the facility failed to provide a Registered Nurse (RN) for a minimal of eight hours per day seven days per week and failed to have a Director of Nursing (DON) on a full-time basis. These failures have the potential to affect all 39 residents residing in the facility. The Findings Include: V1, Administrator, stated they have been without a Director Of Nursing (DON) since 11/27/24. V1 stated they interviewed V2, DON, and offered her the position on 12/13/24, however, V2 did not accept the position until 12/20/24. V1 stated that V2, DON, did not start until 1/6/25. On 1/15/25 at 8:05 AM, upon entrance to the facility, there were only three Certified Nursing Assistants (CNAs) and one Licensed Practical Nurse (LPN) on duty. V1 arrived around 8:15 AM and began passing medications on the 100-Hall. V1 stated she had an agency nurse call off and the DON called off. On 1/15/25 at 11:02 AM, V1 stated the Nurses work 12-hour day shift from 6:00 AM to 6:00 PM and 12-hour night shift from 6:00 PM to 6:00 AM. V1 stated she staffs with two nurses during the day shift and one nurse for the night shift, and that is what they are budgeted for. On 1/15/25 at 11:20 AM, V1 stated that 1/6/25 was the only day that V8, Regional RN, worked the floor due to weather and no staff coming in. The other days V8 is on the schedule was considered an office day. V1 stated they only have one RN on staff right now and they are actively searching for more. On 1/15/25 at 1:10PM V3, LPN, stated she worked at the facility recently, unsure of exact date, and when she came on to work the night shift, there was only one Nurse working the day shift. V3 stated she has expressed her staffing concerns to the facility management but has not received any feedback or improvement. V3 stated when the facility recently had a COVID outbreak, about 75 percent of the building was positive for COVID and she was not comfortable working by herself at night but came in anyway and worked it. V3 stated she had no help, and it was difficult to get through that shift. V3 stated the facility really needs a nurse on each hall because you must go to the other side of the building to get to the other hall and can't really see anyone from one side to the other. The Facility's Schedule for the months of December 2024 and January 2025 were reviewed with the following dates the facility was without an RN on duty. 12/20/24, 12/23/24, 12/24/24, 12/26/24, 12/28/24, 12/29/24, 12/31/24, 1/1/25, 1/3/25, 1/7/25, 1/9/25, 1/12/25, 1/14/25 and 1/15/25. The Facility's Nurse Staffing Policy, undated, documents It is the policy of (this facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The Long-Term Care Facility Application for Medicare and Medicaid, dated 1/15/25, documents the total number of residents in the facility was 39. 145981 Page 4 of 4