Inspection·July 9, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hypertension, pneumonia, type 2 diabetes mellitus, and depression. R2's elopement evaluation, dated 5/21/25, documented a score value of 1 or higher indicates risk of elopement. R2's elopement evaluation score was 6. R2's community survival skills assessment, dated 6/8/25, documented R2 is not sufficiently alert, oriented, coherent nor knowledgeable to be considered for independent outside pass privileges. This form documented R2 does not know the facility address nor how to ask for/seek help in an emergent or problematic situation. This form also documented R2 does not have the ability to adhere to pass privilege policies, e.g., getting permission to leave, signing out, respecting time parameters and curfews, and informing staff upon return. This assessment conclusion documented the resident does not appear to be capable of unsupervised outside pass privileges at this time. R2's MDS (Minimum Data Set), dated 5/29/25, documented R2 is cognitively intact although on 6/18/25 at 11:51 AM V10 (Social Service Director) stated she completed R2's cognitive assessment and that R2 was able to answer the questions on the assessment but R2 was absolutely not safe to go outside on her own and that R2 would not have known to sign herself out of the building. R2's care plan, print date of 6/18/25, does not document or address R2's elopement risk. R2's hospital H&P (history and physical), dated 5/6/25, documented Pt (patient) with psychosis that appears to be new, but it appears has not been evaluated by a medical professional. She is also having an acute on chronic systolic heart failure exacerbation. Diagnosis for cause of psychosis is unclear but there is suspicion for a dementia related diagnosis given the age of onset. R2's regional hospital inpatient Discharge summary, dated [DATE], documented principal problem pneumonia of right lower lobe due to infectious organism. Active problems: delirium. Resolved problems: no resolved hospital problems. Details of hospital stay per H&P on 5/6/25 R2 is a [AGE] year old F (female) w/ (with) PMH (past medical history) of dilated cardiomyopathy, CAD (coronary artery disease), HTN (hypertension), DM (diabetes mellitus), insulinoma s/p (status post) Whipple (surgical procedure of pancreas), depression who was brought to the hospital by ambulance for paranoia, found to have exacerbation of known heart failure. Per chart review, patient was BIBEMS (brought in by emergency medical services) as she came to the airport and told people there, she had been kidnapped. On arrival to the ED (emergency department) patient was combative, attempting to leave the emergency department. She was treated with Ativan, Zyprexa, and eventually IM (intramuscular) Haldol multiple times during ED stay. It continues, patient was evaluated by psych team in ED who noted unspecified schizophrenia and other psychotic disorder but given elevated BNP (B-type natriuretic peptide) concerning for HF (heart failure) exacerbation, not appropriate for psych admission at this time. Patient arrived to the floor agitated, kicking at staff, but on room air and with stable vitals. Unable to obtain medical or social history from patient. It continues, hospital course: delirium and agitation: patient brought to the ED by EMS for bizarre behavior. Initially combative and aggressive requiring multiple doses of IM Haldol and patient was placed on elopement precautions. Intermittently requiring physical restraints during the initial presentation, patient became more appropriate, with better insight as her admission progressed. This was in the context of a psychiatric consult and the initiation of scheduled PO (by mouth) Haldol for symptom management. Given acute presentation, infectious workup was completed which was negative, at which point antibiotics were discontinued. Treatment of acute heart failure exacerbation as below. Improvement in heart failure exacerbation coincided with improvement in mental status, but this is in conjunction with scheduled antipsychotic medication. Initial attempts to wean off Haldol coincided with increased confusion and irritability, so psychiatry was reengaged and recommended a taper off of Haldol and onto Seroquel. This taper was initiated inpatient, and instructions for further tapering were provided to skilled nursing facility at time of discharge (see below). Per psych the underlying diagnosis for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 2 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few this is agitation in the setting of delirium and Seroquel is scheduled to stop after 2 weeks on just Seroquel, with encouragement to follow up outpatient with memory diagnostic center and geriatric clinic. It continues, Haldol to Seroquel taper (instructions below), f/u w/ memory diagnostic clinic for concerns for underlying neurocognitive disorder. On 6/26/25 at 10:26 AM V25 Transportation CNA stated she took care of R2 a few times during her stay and R2 was confused and wandered around the facility. V25 stated she started doing transports about a month ago and she did not take R2 to any appointments nor know anything about her order for a memory diagnostic center. Surveyor asked V25 how she is notified of resident appointments and V25 replied the nurses are supposed to write it down for her although they have not been doing this, so she is being trained on how to check the EMR (electronic medical record) for appointments.On 6/26/26 at 10:42 AM V25 stated she started doing resident transports on 6/2/25 and stated the facility has agency nurses and they usually do not know the process therefore she is often not notified of appointments that are needed for residents. On 6/26/26 at 10:47 PM surveyor called the Memory Diagnostic Center where R2 was referred to and V26 office employee stated there was never an appointment made for R2.On 6/26/25 at 11:16 AM V1 Administrator stated the facility never made the appointment for R2's discharge to be evaluated at the Memory Diagnostic Center. V1 stated she does not know why it was not made because the prior transport aide quit with no notice.On 6/26/25 at 12:27 PM V1 Administrator stated all resident discharge orders from hospitals including orders for follow up appointments should be added the resident's physician orders upon admission.R2's hospital progress notes/referral documents, dated 5/15/25, documented CT (computed tomography scan) head without contrast. History: [AGE] year-old female presenting with altered mental status. Findings: encephalomalacia in the right occipital lobe. According to the National Institutes of Health (NIH.gov) encephalomalacia is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. According to NIH.gov symptoms of encephalomalacia include memory loss, difficulty concentrating, difficulty with reasoning and judgment, and impaired problem solving. NIH.gov noted brain tissue damaged by encephalomalacia cannot regenerate and results in permanent brain damage. It continues, assessment/plan: AMS (altered mental status) - patient is poor historian and unwilling to participate in interview but based on collateral from friend patient with 3-5 years of worsening delusions and paranoia, has filed multiple police reports against neighbors. It continues, unclear if this is patient baseline, or gradual worsening of chronic condition vs (versus) acute presentation at this time. It continues, delirium precautions, elopement precautions. R2's hospital internal medicine daily progress notes, dated 5/12/25, documented interval history: afebrile, hemodynamically stable. Remains intermittently confused, although cooperative with staff and exam. R2's facility admission notes, dated 5/21/25 at 3:43 PM, documented resident transferred to facility via ambulance. This nurse received report from (nurse) at (regional hospital). Resident is a [AGE] year-old female. Alert, confusion at times, early onset dementia. Resident was found at an airport. Resident didn't remember how she got to the airport; told hospital staff she was kidnapped. Resident noted to have delusions at times. R2's facility progress note, dated 5/22/25 at 12:38 AM, documented alert with intermittent confusion. High elopement risk. Staff has to monitor very closely. Resident approached side doors several times during the shift but easily redirected. R2's progress note, dated 5/27/25 at 5:34 AM, documented resident walked around all night with no recollection of previous encounters with staff seen within 30-minute time frame. Resident seemed angry and distressed. Resident stated that she was looking for something and stood in the dining area for one hour under supervision until moved back to room. Resident became very angry if touched all efforts redirected by letting resident move when ready. Sign has been placed on door to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 3 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few help resident identify living area. R2's Nurse Practitioner progress note authored by V22, dated 5/28/25, documented [AGE] year-old female presents to me today at NF (nursing facility) as new patient. She admitted from hospital after paranoia, AMS (altered mental status), and HF (heart failure) exacerbation. It continues, she is A&O (alert and oriented) to self. Cognitive status: confused. R2's progress note, dated 6/11/25 and authored by V22 Nurse Practitioner, documented R2 presents to me today at NF for nursing reports that R2 has been refusing medications and her sister is here and concerned about her edema. Her sister wants her to go to ER d/t (due to) the refusal of meds and her edema. She is adamant she does not wish to go. She is very agitated and paranoid this am. She will not answer ROS (review of systems) questions and only allows for limited exam. Sister wants me to give her something to be more compliant, explained that is not possible. She is also requesting (regional) hospital. Explained EMS makes that call. Also explained if she refuses when EMS arrives there is strong chance, they will not take her. She is up in chair. She is A&O (alert and oriented) to self. R2's behavior progress note, dated 6/9/25 at 3:20 AM, documented resident attempted several times to leave facility and had to be redirected multiple times. Resident states that she cannot stay here because her house is waiting for her. It continues, resident is starting to wander in the room of other residents. R2's progress note, dated 6/11/25 at 10:08 AM, documented resident out in dining room during breakfast with x2 family members present. Resident having increased behaviors, yelling, cursing, refusing medications and meal. DON (Director of Nursing), Administrator, ADON (Assistant Director of Nursing), and NP (Nurse Practitioner) present and aware. Orders received per NP to send resident to ER (emergency room) for evaluation. Resident refusing all care. Family requesting resident may need to be sent to psych (psychiatric) eval (evaluation) for AMS (altered mental status) and increased behaviors, plus refusal of medications and care. It continues, resident currently ambulating self around facility, staff supervision/monitoring continues. R2's next progress note following the 6/11/25 progress note was on 6/14/25 at 12:57 PM and it documented resident has refused all medications, including blood glucose monitoring/insulins for this nurse today. Several attempts to offer medications during scheduled times refused and resident stated, I don't take medicine.R2's initial psychiatric evaluation, date of service 6/13/25 and authored by V28, documented per staff patient wanders a lot and voice thoughts indicative of delusions and paranoia. Per staff patient voiced she was kidnapped and feels that she is not safe because someone wants to kill her. Patient also believes that her credit card was used to fund breakfast. Per staff patient believes she has been to jail and works at the airport. Patient appears to be exit seeking at times as she believes she needs to get to work at the airport. Per staff patient can be irritable and has been refusing to take her medication. She appears suspicious of staff and paranoid. Upon assessment today patient was not cooperative. She states, I already have a doctor I don't need to talk to you. Denied feelings of anxiety and depression. Denies concerns with sleep or appetite. When asked about hallucinations patient states I am done with you go on Per documentation/chart review patient was recently discharged from the hospital for bizarre behaviors, delusions, and agitation and was started on medication management. Per staff family would like for patient to get [NAME] (long acting injectable). Mental status examination documented Thought Process: disorganized, Associations: loosening associations, Thought Content: paranoia and delusions elicited, Mood: irritable, Attention: impaired, Insight: poor, Judgement: poor, Orientation: person. R2's progress note, dated 6/15/25 at 10:32 AM, with a created date of 6/16/25 at 10:34 AM, and authored by V1 Administrator, documented R2 exited the facility without signing out. This writer remined R2 of the importance of signing out with the nurses and showed her where the sign out book was located. R2 has a BIMS of 13 and voiced understanding. R2's incident progress note, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 4 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 6/15/25 at 1:16 PM, documented resident exited building and went outside. Staff with resident and assisted resident back in facility. Resident educated and reminded to sign out when going outside of building and tell staff before exiting. Resident verbally agreed. Enhanced supervision provided. R2's behavior progress note, dated 6/16/25 at 5:39 AM, documented resident A/O X 2 did not sleep well in assigned area with consistent ambulating to dining hall and sleeping on couch. Pt (patient) was redirected several times to assigned living area. Pt is pleasant but confused on why she is living here. Pt is exit seeking and sleeps no more than three to four hours late nights. It continues, resident has been placed with safety protocols. Will continue with plan of care. R2's behavior progress note, dated 6/16/25 at 6 AM, documented resident attempted exit and redirected to unit 200. Returned to hallway seeking exit 5 per staff. R2's progress note, dated 6/17/25 at 1:35 PM, documented upon return from LOA (leave of absence), residents sisters voiced that resident will be leaving facility and not returning. Family refused to wait until MD (medical doctor) notified. Family also refuses to make facility staff aware of where resident is discharging to. On 6/18/25 at 8:25 AM V7 LPN (Licensed Practical Nurse) stated R2 discharged from the facility yesterday and R2's family did not say where she was going. V7 stated she was not working when R2 left the building, but she heard R2 eloped and was by the highway. V7 stated a CNA noticed R2 on her way back from lunch and picked her up. V7 stated the times she cared for R2 in the last 2 weeks R2 was paranoid and combative. On 6/18/25 at 8:30 AM V5 CNA approached surveyor and stated, I was working last weekend, I was returning from lunch around 11:20, and I saw (R2) down the street. V5 stated she did a u turn, stopped, and said to (R2) I will take you home. V5 said (R2) replied I know you from somewhere. and then got into the car with her and she brought her back to the facility. V5 stated she does not know how long (R2) was gone but she did see her at breakfast that day. V5 stated she called and reported the incident to the DON (Director of Nursing).On 6/18/25 at 8:45 AM V9, Activity Director, stated she was not at work when R2 eloped last weekend and stated R2 was confused at times during her stay at the facility.On 6/18/25 at 8:52 AM V10, Social Service Director, stated R2 was at the facility for 2 or 3 weeks, she was very confused, combative, and non-compliant. V10 stated she completed her community assessment, and she was not safe to be out of the facility by herself. V10 stated R2 could not have signed herself out because she came to the facility after she was found at the airport claiming she was kidnapped.On 6/18/25 at 8:57 AM V1, Administrator, stated she did not report R2's elopement because she looked at her (cognitive assessment) and she was a 13. Surveyor asked V1 if she looked at R2's community/elopement assessment and V1 stated no.On 6/18/25 at 9:03 AM V11, [NAME] President of Clinical Services, stated based on R2's (cognitive assessment) and cognition at that time they don't think it was an elopement.On 6/18/25 at 11:43 AM V12 CNA stated she was not at work last weekend when R2 eloped. V12 stated R2 was very much confused all the time when she saw her or took care of her during her stay at the facility. On 6/18/25 at 11:51 AM V10 Social Service Director stated she completed R2's cognitive test, and R2 could answer those questions but she was absolutely not safe to go outside on her own. V10 stated she does not know what door R2 exited the facility from, but she was in room [ROOM NUMBER] which is located 2 doors down from that hall exit door. V10 stated R2 never left the faciity on her own and she would not have known to sign herself out to leave the building.On 6/18/25 at 12:17 PM V1, Administrator, stated she believes R2 exited the front door when she left the facility. Surveyor asked how she reached that conclusion and V1 replied a nurse saw her by the front door around 11 AM on 6/15/25. V1 stated she did a timeline, and she thinks R2 was only out of the facility for approximately 5 minutes. Surveyor requested a copy of the timeline and V11, Regional Director, stated we are working on it. Surveyor asked if someone deactivated the door alarm without checking to see why (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 5 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few it went off and V1 replied she assumes so.On 6/18/25 at 12:23 PM V11, [NAME] President of Clinical Services, stated she knows the facility did have elopement risk binders for the residents at risk for elopement because she is the one who put them together. V11 stated she does not know if R2 had an elopement risk binder or not. V11 stated R2 was cognitively intact based on her cognition score and with resident rights she had the right to leave if she wanted to. Surveyor questioned V11 regarding the reason R2 was admitted to long term care after she was found at the airport with confusion and claiming she was kidnapped. V11 replied R2 had a hospitalization following that. Surveyor then questioned if V1 and V11 had reviewed R2's chart as it documented R2 had confusion throughout her stay at the facility and her community assessment documented she is unsafe to be out on her own. V11 replied I am confused at times and residents still have rights.On 6/18/25 at 12:43 PM V1, Administrator, provided R2's elopement evaluation dated 5/21/25 with a score of 6. Surveyor asked V1 if a score of 6 indicates R2 was at risk for elopement. V1 replied let me look and left the room. This form documented score value of 1 or higher indicates risk of elopement. On 6/18/25 at 12:46 PM V1 returned and stated it doesn't say she is high risk for elopement. Surveyor asked V1 if a score value of 1 or higher as documented on the elopement evaluation indicates R2 was at risk of elopement and V1 replied yesOn 6/18/25 at 2:34 PM V13 LPN stated she did not write a written statement regarding R2's elopement from the facility but she did document it in her progress notes. V13 stated she was R2's nurse on 6/15/25 and she last saw her before she started her medication pass before 11 AM on 6/15/25. V13 stated she did not see R2 again until she was returned to the facility by a CNA around 11:20 AM. V13 stated she did not document an assessment of R2 upon her return to the facility. V13 stated R2 was confused on the morning of 6/15/25, was carrying some of her belongings around in bags, and stated she was leaving. V13 stated she had previously cared for R2 on 2 other shifts at the facility and R2 was also confused during those shifts.On 6/18/25 at 2:53 PM V1 Administrator stated R2 did not have a photo taken during her admission to the facility nor did she have an elopement risk binder per the facility missing resident/elopement policy.On 6/18/25 at 3:13 PM surveyor asked V1 what enhanced precautions were put into place for R2 as documented in R2's progress notes upon her return to the facility after being found walking up the street and V1 replied we just checked on her frequently, I don't know if it was documented or if her care plan was updated. I will checkOn 6/24/25 at 10:37 AM V11 Regional Clinical Director stated if residents are at risk for elopement, then they do not have an elopement binder but if they are high risk then they do have an elopement binder. V11 stated the facility did have binders for the high-risk residents but they were misplaced when surveyor requested them, so she redid them. V11 stated she does not know why R2 did not have an elopement binder and was unaware of her history of wandering.V11s tated she would expect all staff to immediately respond to door alarms except the dining room door because there is usually a staff member outside with the residents and it is fenced in. Surveyor asked if the gate is locked as it is a fire egress and V11 stated she does not know if it is locked or not. On 6/24/25 at 10:40 AM surveyor asked V2 DON if she considered R2 high risk for elopement and V2 replied R2 wanted to go home, she went to the doors and looked out. Surveyor then asked V2 if R2's memory diagnostic appointment was completed as documented in R2's facility admission orders from the regional hospital and V2 replied she does not know if the appointment was made or not. Surveyor asked if a physical assessment of R2 was completed following R2's elopement from the facility and V2 stated she would look and see if there is one in R2's medical record. On 6/24/25 at 11:01 AM V13 LPN stated she was R2's nurse when R2 left the building on 6/15/25 without the knowledge of staff and she does not know how long she was gone from the facility although she recalls seeing her 15 to 20 minutes prior to the CNA bringing her back in. V13 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 6 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few did not complete nor document a skin nor any type of assessment on R2 after R2 eloped. V13 stated R2 was absolutely unsafe to go out of the facility on her own due to her psychiatric issues, periods of confusion, and poor safety awareness and stated when she cared for R2 she was fixated on wanting to leave the facility. V13 stated she does not know what door R2 left from, but she would guess door 10 as her room was just 2 doors down from that exit. V13 stated R2 didn't recall leaving and stated she didn't leave when she got back. On 6/24/25 at 2:24 PM V1, Administrator, stated R2 does not have an incident report, nursing assessment, nor skin assessment for the day she exited the building alone.On 6/25/25 at 8:59 AM V22 Nurse Practitioner stated she assessed R2 on two separate dates during her stay at the facility. V22 stated R2 was very paranoid and when she saw her on 6/11/25 she wanted to send R2 to the hospital but R2 refused. V22 stated R2 was tearing up V22's papers while she was assessing her and that R2 had been refusing medications. V22 stated R2 was confused both times she assessed her and R2 was not safe to leave the facility on her own.On 6/25/25 at 11:06 AM V5 CNA stated R2 was standing on the corner of the parking lot of the apartment building on Pawnee drive and north Illinois street when she spotted R2 as she was returning from her lunch break. V5 stated R2 seemed confused when she gave her a ride back to the facility.On 6/26/25 at 10:23 AM V24 RN (Registered Nurse) stated R2 was very confused and exit seeking every time she was R2's nurse. V24 stated she was R2's nurse multiple times. V24 stated she did not know anything about R2's order to be seen at a memory diagnostic center.On 6/26/25 at 12:31 PM V28 PMNHP (Psychiatric Mental Health Nurse Practitioner) stated she evaluated R2 on 6/13/25 and based on that evaluation and information provided by facility staff R2 was not safe to leave the facility on her own. V28 stated R2 was oriented to self only on 6/13/25, R2 did not want to speak to her, and R2 was very paranoid. V28 stated the facility staff reported R2 had been delusional, confused, exit seeking, and non-compliant with PO (by mouth) medications.On 6/26/25 at 12:48 PM V11, [NAME] President of Clinical Services, stated she did not review R2's hospital records prior to R2's admission to the facility. V11 stated based on what she knows about R2 now, R2 should have had elopement risk interventions, R2's care plan should have been updated, the hospital discharge orders for R2 to follow up with specialists should have been put onto R2's physician orders, and those appointments should have been made. Surveyor asked V11 why R2 was placed in a room [ROOM NUMBER] doors down from an exit as the facility elopement policy documents room placement close to common area and away from exits. V11 replied based on what she knows now R2 should have been placed in a room closer to the nurse's station.Facility plans to remove immediacy: Description of Occurrence:Facility failed to ensure residents were supervised to prevent elopement.Action Taken Completion Date1) R2 is no longer in the facility 6.25.252) a) Admin/ DON were in-serviced by the VP of clinical services. a) Completed 6.25.25b) Admin in-serviced the IDT team. b) Completed 6.25.25c) Current staff in-serviced on elopement policy and procedure. c) Completed 6.25.25 EOD by IDT team.3) a) All residents that resided in the facility will have an elopement risk assessment completed within the last 30 days. a) Completed by VP of clinical services, DON, & administrator by 6.25.25b) Elopement Binder will be updated based on those risk assessments. b) Completed by VP of clinical services, DON, & administrator by 6.25.25c) Review of policy and procedure completed to reflect current practice. c) Completed by VP of clinical services by 6.25.25. 4) All working staff have been in-serviced on elopement, monitoring, and procedures on what to do if a resident is at risk. Currently all staff on shifts are in-serviced. Total facility staff will be 100% by 6.25.25.On-going- being completed by IDT team or designee by start of next working shift.5) No staff will work before being in-serviced on elopement procedures.6) A quality assurance tool was implemented; daily audit of the 24 hour report for wandering/elopement risks. Daily audit for elopement risk assessments completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 7 of 17 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 07/09/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete within 72 hours of admission. Audits to continue daily x 4 weeks to ensure that elopement risk is documented. On-going. Audits completed by: Admin/ Designee 7) Root Cause Analysis completed for elopement.Deficiency: Failed to prevent elopement. Root Cause: Attached. Initiated- 6.25.25 Completed 100% Completed by:[NAME]- VP of Clinical ServicesYehuda [NAME]- CEOMonica [NAME]AdministratorTracey Berry- DON2.)R22's clinical census sheet, print date of 7/8/25, documented R22 was admitted to this facility on 7/1/25. R22's medical diagnosis sheet, print date of 7/8/25, documented R22 has diagnoses of paranoid schizophrenia, muscle weakness, gastro-esophageal reflux disease, primary generalized osteoarthritis, and drug induced subacute dyskinesia. R22's MDS, dated [DATE] at 12:53 PM, documented R22 is moderately cognitively impaired. This assessment was completed by V10 Social Service Director. R22's progress note, dated 7/8/25 at 1:02 PM and authored by V9 Activity Director, documented a second cognitive assessment with a higher score indicating R22 is cognitively intact. R22's clinical resident profile/face sheet, print date of 7/8/25, does not have R22's photo. R22's care plan, print date of 7/8/25, documented R22 is at risk for wandering/elopement with goals of the resident will not leave facility unattended and the resident's safety will be maintained. Interventions are schedule time for regular walks/appropriate activity. R22's care plan, undated, documented 7/8/25 actual elopement: placed on 1:1, will be supervised when outside, elopement risk assessment reassessed. Placed in elopement binder. Date initiated: 7/8/25. Elopement risk assessment will be completed within 72 hours of admission, readmission, and quarterly. Engage resident in purposeful activity, identify if there are triggers for wandering/eloping, provide reorientation to surroundings, and schedule time for regular walks/appropriate activity. R22's fall risk evaluation, dated 7/8/25 at 8:39 PM, documented R22 has intermittent confusion.On 7/8/25 at 10:32 AM two surveyors observed facility staff walking at a fast pace up and down the halls looking for a resident. At 10:38 AM V1 Administrator was in the conference room with the surveyors and unaware other facility staff were looking for a resident. Surveyor then alerted V1 that staff were looking for a resident. The facility does not have an overhead paging system, so surveyors did not hear any facility employees including the leadership team announce code pink per the facility policy when a resident is missing. At 10:43 AM V2 DON was observed walking at a fast pace down the 200-unit corridor, surveyor asked what resident is missing, and V2 replied (R22). At 11:00 AM surveyor checked the facility elopement binders and R22 did not have an elopement binder nor a photo in his EMR (electronic medical record). Multiple employees wer Event ID: Facility ID: 145981 If continuation sheet Page 8 of 17 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 07/09/2025 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings consisted of the required members. This failure has the potential to affect all 57 residents residing in the facility. Residents Affected - Many V1 (Administrator) provided an attendance record from the last QAPI meeting, which was dated 4/25/25. The provided sign in sheet does not document the line labeled as Medical Director was in attendance, as it is blank. V1 stated the last QAPI meeting at the facility was on 4/25/25 and confirms V31 (Medical Director) was not in attendance. V1 stated the meeting was last minute and V31 wasn't able to attend. Review of the facility policy titled QAPI Program with a reviewed date of 6/1/25 documented QAPI principles will drive the decision making within our organization .QAPI activities will be integrated across all the care and service areas of our organization. Each area should have a representative on the QAA (Quality Assessment and Assurance) committee. The facility census report dated 7/8/25 documented 57 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 9 of 17 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 07/09/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, clean, well maintained, homelike environment for 8 of 8 residents (R1, R6, R7, R11, R16, R19, R20, & R21) reviewed for physical environment in the sample of 23. This failure has the potential to affect all 57 residents in the facility. Findings Include: On 6/24/25 at 8:26 AM room [ROOM NUMBER] was observed with a brown sticky substance on the floor throughout the room and restroom. Dirt and debris were observed under the bed and nightstand. A large amount of dried feces and urine were observed on the toilet seat. On 6/24/25 at 8:30 AM a sign noting DO NOT USE was observed on the toilet lid of room [ROOM NUMBER] restroom. The floor along the cove base was observed with a brown/black buildup throughout the room and restroom. Debris and dirt were observed under the bed and nightstand. On 6/24/25 at 8:50 AM a dark dirty buildup was observed all around the cove base on the floor of the 200 unit. The cream-colored cove base was stained with a yellow and brown substance. Dirt and debris were observed on the floor around all the door jambs of this unit. On 6/24/25 at 8:53 AM a brown substance was observed on the floor along the cove base of room [ROOM NUMBER]. A dirty brown buildup was observed around the bottom of the room and restroom door side jambs. An oxygen concentrator was observed in use and covered in dust and dried spills. The 212 bathroom has a toilet and a shower with concrete flooring. The concrete is painted, and the paint is peeling off throughout the floor. A piece of the concrete floor is missing in the shower area and the concrete is chipped throughout the restroom resulting in an uneven surface. On 6/24/25 at 9:00 AM R7, room [ROOM NUMBER] bed 1, stated the facility is not clean and that she has seen mice running down the hallway several times. R7's MDS (Minimum Data Set), dated 5/29/25, documented R7 is cognitively intact. On 6/24/25 at 8:23 AM V4 CNA (Certified Nurse Assistant) stated the facility is filthy, the plumbing is constantly backing up, and housekeeping can't keep up due to the toilets backing up. On 6/24/25 at 8:57 AM V15 CNA stated room [ROOM NUMBER] toilet has not been flushing for a while and she has never observed any staff scrape the floors around the baseboard. On 6/24/25 at 10:05 AM V18 Housekeeping/Laundry Supervisor stated she has worked at the facility for about 2 months, she is aware the floors look bad, and she spoke to V1, Administrator, and V8, Maintenance Director, about the need for a floor tech. V18 stated the floors need stripped and scraped to get the dirt and residue off them. V18 stated she is trying to work on the floors, but she has limited time she can spare with her other duties. On 6/24/25 at 10:07 AM V19 housekeeper stated 100 hall baseboards look awful and have for a long time, management knows, and nothing has been done about it. On 6/24/25 at 10:10 AM V22 Housekeeper stated the floors were filthy when she first started working (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 10 of 17 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 07/09/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm at the facility a couple months ago. V22 stated they are a little better now, but the facility needs a floor tech because they can't get the dirt up around the baseboards without stripping and scraping them. On 6/24/25 at 10:52 AM R11 stated to surveyor look at 100 shower room, it's gross, I refuse to use it. R11's MDS, dated [DATE], documented R11 is cognitively intact. Residents Affected - Many On 6/24/25 at 10:55 AM observed the 100-unit shower room with a black and grey residue on all 3 shower walls from mid wall down to the baseboard. The painted base board was chipped throughout with black and grey residue. Multiple floor tiles were cracked with a black residue observed in the cracks of the tile. On 6/24/25 at 11:10 AM observed multiple pieces of wallpaper detached from the wall and coming down over bed 2 in room [ROOM NUMBER]. The chair rail/mid-wall molding had chipped paint throughout the length of it. Dirt and debris were observed under the furniture and a brown build up was observed throughout the room on the floor along the cove base. On 6/24/25 at 11:18 AM a brown substance was observed on the floor along the cove base on the 100-hall unit with rooms 104 to 107. The cream-colored cove base was stained with a yellowish-brown substance throughout the hall. On 6/24/25 at 12:50 PM observed multiple broken floor tiles in the restroom for room [ROOM NUMBER]. Dirt and debris were observed in the cracks of the broken floor tiles. A brown stained substance was observed around the toilet on the floor tiles. The bathroom door jamb was covered in rust. A brown buildup was observed on the floor along the cove base throughout room [ROOM NUMBER]. On 6/25/25 at 11:37 AM an approximate 1-foot piece of cove base was missing in the dining room next to exit door 4. The dry wall under the missing cove base was cracked and crumbling onto the floor. An approximate 2.5-foot piece of cove base next to the therapy entrance also in the dining room was missing exposing broken dry wall pieces with a black substance on the cracked and broken drywall. On 6/25/25 at 11:54 AM Observed a large fan sitting on the floor in the kitchen turned on, rotating, and covered in a large amount of dust and a lint like substance. The fan was blowing air onto the food preparation area. On 6/25/25 at 11:57 AM the bathroom between 201 & 203 was observed with 3 missing floor tiles approximate 12 by 12 in size next to the toilet and a black substance on the sub-floor. 2 additional tiles were broken next to the toilet. The baseboard behind the toilet was missing with cracked drywall crumbling onto the floor. The towel bar was missing with 1 towel bar holder and the other was gone resulting in dry wall damage. The light fixture cover was missing resulting in 4 exposed light bulbs although 2 light bulbs were not functioning. The bathroom had multiple ceiling tiles with brown staining observed on them. The tv stand/nightstand in room [ROOM NUMBER] was missing 2 drawer covers and in poor condition. On 6/25/25 at 12:05 PM the 100 hallway that leads to exit 3 was observed to be poorly lit and it was noted that multiple light bulbs were not functional in the ceiling light fixtures. On 6/25/25 at 12:07 PM the bathroom between rooms [ROOM NUMBERS] was observed and an approximate 3 by 3 electrical box cover missing a screw resulting in the cover to hang and electrical wires were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 11 of 17 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 07/09/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many exposed. R21 resides in 122 bed 2 and R21's medical diagnosis sheet, print date of 7/8/25, documented R21 has a diagnosis of schizophrenia. On 6/26/25 at 11:08 AM V27 Ombudsman stated she has had a lot of residents complain to her about the condition of the facility. V27 stated she has been coming to this facility for the past year and she has complained to the last 2 administrators plus the current administrator (V1) about how horrible the floors look, and the general maintenance of the building not being kept up. V27 stated she has been at the facility every week this month and she spoke to facility staff every visit about the maintenance issues. V27 stated she has observed mold on the 100-unit shower for the last year, that the plumbing is frequently backing up, and she observed raw sewage on the 100-unit shower floor during one of her visits. On 7/7/25 at 10:18 AM V29, POA (Power of Attorney) for R16, stated her own concern is when she has visited, the facility is dirty. V29 stated she understands people get busy but that is something she has noticed. On 7/8/25 at 8:18 AM V1 Administrator stated she is aware of all the maintenance issues is the building. On 7/8/25 at 8:25 AM surveyor observed room [ROOM NUMBER] with V1 Administrator and V8 Maintenance Director. Surveyor observed an approximate 18-inch x 18-inch black patch on the wall behind bed 2. Surveyor asked V1 and V8 what the black patch was for. V8 pulled back the black patch from the wall revealing a hole in the dry wall. Surveyor then asked V1 and V8 if they were aware of the damage to the floor in this restroom resulting in an uneven floor surface and fall risk. V8 replied he would sand the floor down, so it is smooth. On 7/8/25 at 8:31 AM R6 was sitting in her wheelchair in room [ROOM NUMBER]. R6 stated the facility is not clean, she has seen 3 mice in the past few days, and one knocked her plant over and broke the pot. R6 stated it makes her sad to live in a dirty place. R6 stated her son recently visited and asked her why your floor isn't clean. R6 stated there has been a hole in her wall behind her bed since she moved in. R6 stated she thinks the mice are coming in the hole in the wall in the corner of her room. Surveyor observed a hole in the cove base and wall in the corner of room [ROOM NUMBER] with a pile of dirt, debris, and pieces of dry wall in the corner on the floor. Surveyor also observed dirt and dead insects in the windowsill and on the air conditioning unit. R6's MDS (Minimum Data Set), dated 1/10/25, documented R6 is cognitively intact. On 7/8/25 at 8:39 AM R20, resides in room [ROOM NUMBER], stated his bathroom is gross, the floor tiles have been missing from his bathroom floor since he was admitted to the facility, and he has never seen maintenance do anything to fix it. R20's MDS, dated [DATE], documented R20 is moderately cognitively impaired although R20 was alert and oriented during interview. On 7/8/25 at 8:45 AM R19 stated this building is dirty all over and the flies are terrible. R19's MDS, dated [DATE], documented R19 is cognitively intact. R19 resides in room [ROOM NUMBER] and surveyor observed brown stains and dirt all along the cove base on the tile floor in the restroom, the cove base was loose from the wall behind the toilet exposing damaged dry wall, the restroom floor had multiple cracked and separated tiles with dirt in the openings, a floor tile was missing next to the door jamb, the bathroom door frame was covered in rust, and rust was observed around the base of the toilet on the floor tiles. Multiple dead insects were observed on the windowsill and on top of the air unit of room [ROOM NUMBER]. Dirt and debris were observed under R19's bed. The cove base was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 12 of 17 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 07/09/2025 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 0921 stained with a brown substance throughout the room. Level of Harm - Minimal harm or potential for actual harm On 7/8/25 at 11:26 AM R1 stated her toilet has not been flushing for the last 3 days, and it's the third time it has been broke recently. Surveyor attempted to flush the toilet, it would not flush, and the handle was loose. Observed brown stains on the bathroom floor. Cove base has brown stains throughout. Observed tan liquid stains on the lower half of the wall next to the room door. R1 stated the housekeepers mop her room everyday but they are not able to get the stains and buildup on the floor clean. R1's MDS, dated [DATE], documented R1 is cognitively intact. Residents Affected - Many On 7/8/25 at 11:32 AM surveyor observed tan and yellow stains covering the length of the cove base on the 200 unit with dirt buildup on the floor along the cove base and around the resident room door jambs. On 7/8/25 at 1:05 PM observed a loose section of hand railing on the 200 unit that runs parallel to the dining room and front entrance by room [ROOM NUMBER]. The Resident Council minutes, dated 5/21/25, documented Maintenance: Need a full-time maintenance person in the building, there is too much to keep up on to only have (V8) come a couple times a week and stuff that needs fixed isn't getting done in a timely manner. The facility's Physical Plant & Environmental Policy & Guidelines, undated, documented Policy Statement: It is of the utmost importance to provide a safe, hospitable, clean, and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents. A well-maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA codes. This includes making certain a safe and hospitable environment as possible is maintained in the event of an emergency for sheltering in place. Policy Implementation: The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors, and staff. Ensure maintenance work orders are completed in a timely manner and ensure items necessary for repairs are ordered to complete repairs. Maintenance/Approved Contractors o Preventative maintenance schedules for all mechanicals - HVAC, Boilers, Water Heaters - Ensure proper water temps of 100-110 are maintained in resident areas - HVAC/Boiler systems are maintaining safe and comfortable ambient temperatures - Routine cleaning of vents and cold air returns o Routine care and repairs to interior finishings - repairing ceiling/wall damage, painting, floor o General plumbing - drains, faucets, showers are maintained o General electrical - proper lighting, safe receptacles, no permanent use of extension cords o Emergency systems - fire alarm system, sprinkler systems, generator, egress lighting o Nurse Call Light systems and door signaling systems/wander guard systems o Resident care equipment (lifts, concentrators) o Wheelchair and bed maintenance o Insect and rodent control o Secured and organized mechanical rooms and storerooms o Oxygen stored safely in designated room or outdoor storage in racks o Hallways remain clear of any clutter o Maintaining safe egress pathways to public way in inclement weather o Routine grounds clean-up of litter, maintaining landscaping, and lawn mowing o Secured exterior doors o Safe and clean designated outdoor resident and staff smoking areas o Maintain essential supplies and parts Housekeeping o Routine daily room cleaning and sanitizing o Routine daily cleaning of all common areas and dining areas o Routine daily cleaning of all shower rooms and restrooms o Deep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 13 of 17 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 07/09/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Cleaning of Shower Rooms or humid areas to ensure any possibilities or mildew and mold are eliminated. o Monthly Scheduled room deep cleaning and organizing o Routine Room Closets organized to ensure items can be stored o Monthly Scheduled Shower Room deep cleaning o Scheduled stripping and waxing of floors (if required floor type) o Carpeted areas routinely cleaned o Proper handling and cleaning of isolation rooms and waste disposal (see policy) o Immediate clean-up of bodily fluids with required Nursing staff o Ensure housekeeping carts and supplies are stored when not in use o Ensure hallways free of clutter o Spills are immediately mopped o Wet Floor signs are used when necessary and removed when areas are dry o Maintain necessary supplies of cleaning products and equipment o Chemicals stored in safe secure area, handled with proper PPE Event ID: Facility ID: 145981 If continuation sheet Page 14 of 17 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 07/09/2025 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement an infection control training program for staff. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff were trained on infection control program and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will be in-serviced on infection control at their upcoming staff meeting. V32 (Licensed Practice Nurse) is documented as being the facility's certified Infection Preventionist. On 7/9/25 at 10:25 AM, although requested, V11 (Vice President of Clinical Services) confirmed a policy regarding infection control training was not available. The facility assessment dated [DATE] documented the facility has 90 licensed beds for long term care nursing services, which includes the care of infectious organisms. The facility census report dated 7/8/25 documented 57 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 15 of 17 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 07/09/2025 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a nurse aide training program which continues competence equivalent to no less than 12 hours per year. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff received nurse aide training and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will be inserviced on nurse aide training competencies at their upcoming staff meeting. The facility assessment dated [DATE] documented the facility has 90 licensed beds for long term care nursing services. On 7/9/25 at 10:25 AM, although requested, V11 (Vice President of Clinical Services) confirmed a policy regarding nurse aide training was not available. The facility census report dated 7/8/25 documented 57 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 16 of 17 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 07/09/2025 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide behavior health training consistent with the requirements and as determined by a facility assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement a behavior training program for staff. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff received behavior training and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will receive behavior training at their upcoming staff meeting. V1 also confirms the facility currently serves residents with mental health conditions. The facility assessment dated [DATE] documents the facility accepts residents with the following psychiatric/mood disorders: Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. This same assessment documented the facility has an average number of 40-60 residents requiring behavioral health services. On 7/9/25 at 10:25 AM, although requested, V11 (Vice President of Clinical Services) confirmed a policy regarding behavior training was not available. The facility census report dated 7/8/25 documented 57 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 17 of 17