Inspection·April 9, 2025

F 0584 200-hall shower room and stated it was mold in the corners of the shower stall. Level of Harm - Minimal harm or potential for actual harm On 4/8/25 at 1:00 pm R3's shower head in R3's bathroom is noted to have a large amount of a fuzzy black substance on the surface of the shower head. Residents Affected - Some On 4/8/25 at 2:25 pm, 200-hall med room was observed. A very musty odor smelled. On the floor on the front of the sink is an area with a yellowed paper is stuck to the floor. On top of this is a moderate amount of a black substance that can be smudged with a gloved hand. There is also a hole in the wall with a splotchy black substance noted on the right edge of the hole. Black splotches are also noted in the peripheral walls of the stainless-steel sink. On 4/8/25 at 2:35 PM, V2, Director of Nurses, (DON) stated she has not actually seen mold. V2 stated that R5 had reported to her a few weeks ago that she noticed the smell of mold in her room. V2 went to R5's room and stated she did smell a faint mold odor, but she did not visualize any mold. On 4/8/25 at 2:35pm, R5's room did have a slight musty smell. R5's room is adjacent to the 100-hall shower room. On 4/8/2025 at 3:45 pm, V2 stated that there is currently no housekeeping supervisor. V2 stated she is acting as the supervisor as she has been overseeing the housekeepers. V2 accompanied the survey team to the med room on the 200-hall and when asked if that was mold on the floor, wall and sink she stated that it was. V2 also acknowledged the extreme musty odor. On 4/8/25 at 4:40 pm, V2 stated that any resident who takes a shower uses one of the two shower rooms in the facility and do not shower in their rooms. At this time, the facility provided a document V1 signed and dated it that has listed the residents who take bed baths (BB) and do not shower. The document shows there are 37 residents who use the resident shower rooms. Undated Facility policy titled Mold & Mildew Policy & Guidelines Policy Statement documented mold and mildew growth can occur in areas of humid or often damp areas like shower stalls, kitchens, and restrooms. Surface mildew and mold can be mitigated by ensuring these areas are routinely deep cleaned. If areas of mildew or mold are found, these areas must be immediately cleaned with proper mold and mildew cleaners, ensuring all areas are free of mildew or mold. Policy Implementation: In the event areas of surface mold or mildew are found, immediate notify Administrator of concerns and the areas must be immediately cleaned and sanitized with appropriate cleaners effective at removal of mold and mildew and growth before use of areas. Proper PPE required for safely handling the cleaning chemicals must be adhered to during use. Areas should be cleaned and then re-inspected regularly to ensure no other growth of areas of concerns. A Center for Disease Control, (CDC) document dated September 26, 2024, documented the possible health effects of mold. Exposure to damp and moldy environments may cause a variety of health effects, or none. For some people, mold can cause a stuffy nose, sore throat, coughing or wheezing, burning eyes, or skin rash. People with asthma or who are allergic to mold may have severe reactions. Immune-compromised people and people with chronic lung disease may get infections in their lungs from mold. For people who are sensitive to molds exposure to molds can lead to symptoms such as stuffy nose, wheezing, and red or itchy eyes, or skin. Severe reactions, such as fever or shortness of breath, may occur (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 2 of 3 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 145981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Swansea 1405 North Second Street Swansea, IL 62226 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete among workers exposed to large amounts of molds in occupational settings, such as farmers working around moldy hay. In 2004 the Institute of Medicine (IOM) found there was sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people; with asthma symptoms in people with asthma; and with hypersensitivity pneumonitis in individuals susceptible to that immune-mediated condition. Event ID: Facility ID: 145981 If continuation sheet Page 3 of 3