Health inspection·March 14, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent significant medications errors by ensure medications are available for 2 of 5 residents (R2, R5) reviewed for significant medication error in the sample of 12. Residents Affected - Few Findings Include: 1. R2's Face Sheet documents an admission date of 10/402021 and diagnoses include Hypertension, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes. R2's order sheet dated 10/25/2024 documents Metoprolol Tartrate Tablet 25 milligrams (mg), Give 1 tablet by mouth two times a day related to Essential Primary Hypertension. R2's Medication Administration Record (MAR) dated 3/1/2025-3/31/2025 documents Metoprolol Tartrate 25mg not administered on 3/1, 3/2 AM and PM, 3/3 AM, 3/7 AM and PM with no reason documented as to why not given. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses wheelchair for mobility. R2's Care Plan updated 3/13/2025 R2 has Congestive Heart Failure and Hypertension. Intervention: Give cardiac medications as ordered. On 3/12/2025 at 12:00 PM R2 stated I did not get my heart meds for a few days. On 3/12/2025 at 3:00PM V4, Licensed Practical Nurse, LPN, stated It looks like (R2) ran out of Metoprolol at the end of February. It was ordered on 3/3 and came in 3/5. (V2, Director of Nursing, DON), just started recently and is trying to get everything all caught up. 2. R5's Face sheet documents an admission date of 11/10/2023 with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes. R5's order sheet dated 1/27/2025 documents Warfarin tablet 1mg. Give 1 tablet by mouth at bedtime related to Essential Primary Hypertension. Take with 2.5 mg= 3.5mg. R5's order sheet dated 10/25/2024 documents Warfarin tablet 2.5mg. Give 1 tablet by mouth one time a day for Prophylaxis Take along with 1 mg= 3.5mg. Page 1 of 6 145981 145981 03/14/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0760 Level of Harm - Minimal harm or potential for actual harm R5's MAR dated 3/1/2025-3/31/2025 documents R5 missed doses of Warfarin on 3/5, 3/6, 3/7 both AM and PM doses. No progress notes written regarding missed Warfarin. On 3/13/2025 at 12:30PM R5 stated I was out of my Warfarin a couple weeks ago for a couple days. They just said I was out. Residents Affected - Few On 3/13/2025 at 1:10PM V2, Director of Nursing, DON, stated I have been here for 3 weeks. I was not told about missing medications. The only thing I can think of is we did not have lab services for a few days. Maybe that is why (R5) did not get Warfarin, but that is not a good thing. I do not know about (R2) missing meds either. On 3/14/2025 at 10:40AM V14, Pharmacist, stated Missing Warfarin, an anticoagulant, is a big deal. That would definitely be a significant medications error. Undated facility policy states Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner or as consistent with state law. No medication will be used for any resident other than the resident for whom it was prescribed. Medications must be given to the resident by the Licensed Nurse to prepare the medication, to as consistent with state law. 145981 Page 2 of 6 145981 03/14/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide information, obtain consents, and offer influenza (flu) vaccination for 4 of 4 residents (R1, R2, R3, R5) reviewed for Influenza immunization in the sample of 12. Residents Affected - Some Findings include: 1. R1's Face Sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal Blindness, Hypertension, Bipolar. R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is independent with transfers and requires supervision with ambulation. R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R1's paper chart documents vaccine on the following date: Influenza 10/19/2020. There was no documentation in R1's medical record that the facility provided R1 with information on influenza vaccination and obtained consent for vaccination. 2. R2's Face Sheet documents an admission date of 10/4/2021 with diagnosees to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Hypertension, Chronic Kidney Disease. R2's MDS dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses wheelchair for mobility. R2's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R2's paper chart documents vaccine on the following date: Influenza 10/26/2021. On 3/12/2025 at 12:00 PM R2 stated We did not get vaccines this winter. No flu, pneumonia, COVID or RSV. R2 stated she did want these vaccinations. There was no documentation in R2's medical record that the facility provided R2 with information on the flu vaccination or obtained consent for this vaccination. 3. R3's Face sheet documents an admission date of 2/7/2024. Diagnosis include Chronic Obstructive Pulmonary Disease, Dementia, Cirrhosis of the Liver, Epilepsy. R3's medical record documented R3 had a Power of Attorney (POA). R3's MDS dated [DATE] documents R3 is severely cognitively impaired. R3's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. 145981 Page 3 of 6 145981 03/14/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0883 R3's paper chart documents vaccine on the following date: No influenza vaccine documented. Level of Harm - Minimal harm or potential for actual harm There was no documentation in R3's medical record that R3's POA was provided any information on the flu vaccination or given the opportunity to consent to the vaccination. Residents Affected - Some 4. R5's Face sheet documents an admission date of 11/10/2023. Diagnosis include Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes. R5's MDS dated [DATE] documents R5 has no cognitive deficits. R5's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R5's paper chart documents vaccine on the following date: Influenza 11/6/2023. R5's medical record had no documentation that the facility provides information to R5 on the flu vaccination or received consent from R5 to have the vaccination. On 3/13/2025 at 11:20AM V2, Director of Nursing, DON, stated I just started 3 weeks ago. I saw where consents for Influenza, COVID and Pneumonia were taken, but I did not see where the vaccines were given. On 3/14/2025 at 9:45AM V13, Regional Nurse Consultant, stated We just bought this building in December of 2024. We were going to have a company come in and do the immunizations, but we weren't sure of everyone's vaccine status. We are still working on it. Undated facility policy states On admission, each resident or the resident's representative will be provided with education regarding the benefits and potential side effects of the immunization. Once a consent is signed indicating that they wish to receive the influenza vaccine, this consent is valid for the duration of the resident's stay and the influenza vaccine will automatically be given annually. Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time. 145981 Page 4 of 6 145981 03/14/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide information, obtain consents, and offer COVID-19 vaccinations to 4 of 4 residents (R1, R2, R3, R5) reviewed for COVID-19 immunization in the sample of 12. Findings include: 1. R1's Face sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal Blindness, Hypertension, Bipolar. R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is independent with transfers and requires supervision with ambulation. R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R1's paper chart documents vaccine on the following date: COVID 19 11/6/2023. There was no documentation in R1's medical record that the facility attempted to provide R1 with information on the COVID-19 vaccination or obtain consent for this vaccination. 2. R2's Face sheet documents an admission date of 10/4/2021 with diagnoses to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Hypertension, Chronic Kidney Disease. R2's MDS dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses wheelchair for mobility. R2's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R2's paper chart documents vaccine on the following date: No COVID 19 vaccine documented. On 3/12/2025 at 12:00 PM R2 stated We did not get vaccines this winter. No flu, pneumonia, COVID or RSV. R2 stated he/she wanted the vaccination. There was no documentation in R2's medical record that the facility provided R2 with information regarding the COVID-19 vaccination or the facility obtained consent for this vaccination. 3. R3's Face sheet documents an admission date of 2/7/2024 with diagnoses to include Chronic Obstructive Pulmonary Disease, Dementia, Cirrhosis of the Liver, Epilepsy. The Face sheet documents R3 has a Power of Attorney (POA). R3's MDS dated [DATE] documents R3 is severely cognitively impaired. R3's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. 145981 Page 5 of 6 145981 03/14/2025 Evercare of Swansea 1405 North Second Street Swansea, IL 62226

F 0887 R3's paper chart documents vaccine on the following date: COVID 19 11/6/2023. Level of Harm - Minimal harm or potential for actual harm There was no documentation in R3's medical record the facility provided R3's POA with information on the COVID-19 vaccination or obtained consent for R3 to be vaccinated. Residents Affected - Some 4. R5's Face sheet documents an admission date of 11/10/2023. Diagnosis include Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes. R5's MDS dated [DATE] documents R5 has no cognitive deficits. R5's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R5's paper chart documents vaccine on the following date: COVID 19 11/6/2023. There was no documentation in R5's medical record the facility provided R5 with information on the COVID-19 vaccination or obtained consent from R5 to be vaccinated. On 3/13/2025 at 11:20AM V2, Director of Nursing, DON, stated I just started 3 weeks ago. I saw where consents for Influenza, COVID and Pneumonia were taken, but I did not see where the vaccines were given. On 3/14/2025 at 9:45AM V13, Regional Nurse Consultant, stated We just bought this building in December of 2024. We were going to have a company come in and do the immunizations, but we weren't sure of everyone's vaccine status. We are still working on it. Undated facility Immunization policy states To minimize the risk of residents acquiring, transmitting, or experiencing complications from (COVID-19). The facility shall provide pertinent information about the significant risks and benefits of the vaccine to residents (or resident's legal representative) and employees; for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. On admission, each resident or the resident's representative will be provided with education regarding the benefits and potential side effects of the immunization. 145981 Page 6 of 6