Inspection·July 24, 2025

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was not R5's CNA the night he passed away, but she was working so she went down to his room while CPR was in progress and before EMS came, and V7 had her perform CPR, because the nurse was getting tired. V8 stated that she couldn't answer where she would find a resident's code status.On [DATE] at 9:30 PM, V14, LPN, who was the day shift nurse on [DATE] that came in at 6:00 AM for her shift and assisted V7 with finding the code status, stated that when she came in, R5 was being coded by EMS, and that he was intubated. V14 stated that the DNR was in the miscellaneous section of his chart and that it was not on the computer screen where V7 could find it. V14 stated that she knew he was a DNR because she admitted him from the hospital on [DATE]. V14 also stated that there is a list of residents who are DNR at the nurse's station by the computer, but his name wasn't on it. V14 stated that EMS did intubate R5 and used the Ambu bag and that the doctor at the hospital told EMS to stop CPR. V14 was asked when a resident returns from the hospital, like R5 did, who gets the order from the doctor for the new code status? V14 stated that it is usually the admitting nurse, but she continued to state that she didn't think she got the order for R5's DNR nor did she put it in the computer and that was why it did not show up when V7 was looking for it. V14 stated that when she was helping V7 look for it, it was not on R5's home page in the electronic medical record and that was why V7 couldn't find it. On [DATE] at 11:55 AM, V17, Social Services Director, stated that she was not aware of R5's code status change when he returned from the hospital on [DATE]. V17 stated that no one notified her of the change of code status from full code to DNR, so a new POLST (Physician Orders for Life-Sustaining Treatment) was not made in June. V17 stated that when R5 returned from the hospital she went down to see him, and he gave her his will and the healthcare power of attorney, and she continued to state that in that paperwork there was no DNR, nor did it document a code status change. V17 then stated that you can't be a DNR and be comfort care and that she did not think this was a DNR, but she also did not approach R5 with a new POLST since she was not aware of his decision.On [DATE] at 12:25 PM, V2, Director of Nurses, stated that R5's code status was changed when he came back from the hospital on [DATE] and she did not know why an order was never written on that date. She continued to state that the social worker was given his living will, but she doesn't remember who the nurse was or what had happened to the hospital paperwork, but the DNR never was put into their computer system on [DATE]. V2 stated that the nurse started CPR on [DATE] on R5 because she couldn't find in the system where R5 was a DNR, so their protocol was to start CPR. V2, stated that 2 things happened during that code, 1. the paper was found that he was a DNR and 2. the daughter told them to stop CPR. V2 stated that the issue was that the nurse working did not see where the code status was. V2 stated that someone, could not recall which nurse, communicated with her that R5 was a DNR on [DATE], it's possible that that nurse is no longer employed at the facility, it is the responsibility of that nurse to write the order for the DNR and to make sure social services knows and then we follow up on it to make sure it was done. No one followed up on his DNR and that was why the order was written on [DATE] and back dated for [DATE]. V2 stated that R5 should not have been Coded on [DATE] but the agency nurse did not see he DNR and our protocol is to start CPR. V2 stated that agency nurses have access to the medical records system where it has code status and there was a list at the desk of who are do not resuscitate (DNR).On [DATE] at 2:00 PM, V1, Administrator, stated that what she is learning at this time was that at the hospital he decided to make that change and that paperwork, with the DNR and it was not given to social services. V1 stated that the nurse who admitted him on [DATE], should have put the DNR orders in when he was re admitted and then let social services know so a new POLST could have been done. V1 stated that she would expect the staff to know where to find a resident's DNR on the dashboard and in point click care (electronic medical records). V1 stated that R5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 2 of 8 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 07/24/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few should have been reassessed upon readmission and the breakdown in communication was that social service was not being made aware by nursing of the change in code status and that the physicians order should have been written by the nurse. On [DATE] at 3:03 PM. V12, R5's daughter and Healthcare Power of Attorney (HCPOA), stated that her father did not want to be intubated but when they called her that morning and was told they were doing CPR, she stated that she told them to stop CPR because he was a DNR. V12 continued to state that the last time her father was in the ICU, which was the end of May and early June, they, her, her sister (V13) and the doctor had a serious talk about code status and that her dad wanted CPR but did not want to be intubated and that the doctor told him one could not be done without the other. V12 stated that they all had a concern that if her father was to be intubated, then he may never get off a ventilator and he did not want that, so he decided that he would be a DNR. V12 stated that early June is when the paperwork was done, and it went back to the nursing home with him that he would be a DNR.On [DATE] at 10:35 AM, V18, R5's Nurse Practitioner, stated that code statuses are updated in the files and when she looked this morning, in his file, he was a DNR. She continued to state that they, do not have a specific procedure with DNR, if it was signed at the hospital and that it was signed by a physician there. V18, stated that she would expect the facility to honor the residents wishes with their code status.R5's Progress Note, dated [DATE], at 6:35 AM, written by V7 documented, This nurse started CPR until (Local) police arrived with paramedics and this nurse was instructed to stop CPR. This nurse left out of the room and continued to find polst form for code status. Another nurse came in and went into computer and located DNR paperwork and this nurse went and took paperwork to medical staff assisting with the code. This nurse called POA, and she stated that the resident just signed DNR forms and to stop CPR. The physician that called time of death is (Hospital Doctor) with (local) hospital. Time of death called at 6:07 am. Daughter is in route to facility. DON called and informed of resident expiring awaiting daughter to arrive. This nurse spoke with coroner (County Coroner). Oncoming nurse aware that she will need to call coroner with name of funeral home once next of kin arrives.The Facility's policy, Advance Directives, undated, documented, 1. At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. 2. The Social Service and/or Admissions Director will be responsible for providing copies of state statutes, regulations, and information regarding Advanced Directive(s), to resident, legal representatives upon admission, and also to families who wish to receive such information and assistance regarding Advanced Directive(s) and decisions regarding life sustaining measures and in no event shall give legal advice on the need for medical care directives. 3. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry, and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall then be included in the resident's medical record. It continues, 6. Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder.The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy:1) A) Admin/SSD were in-serviced by the VP of clinical services on POLST forms, updating in medical records, timeliness of updating medical records. Completed [DATE].B) Admin will in-service IDT on POLST forms, expectations, where to locate code status of residents, and who can perform CPR, what to do when resident is found to be in distress. Completed [DATE].C) Current staff in-serviced on code status, where to find in residents' chart. Completed [DATE].D) Current licensed staff in-serviced on code status, where to find in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 3 of 8 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 07/24/2025 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 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents' chart, who can perform CPR, and who to inform if a new code status when resident is admitted /readmitted . Completed [DATE].2) A) All residents that reside in the facility will have their POLST forms audited within the last 30 days. Completed on [DATE] by RNC & Administration. From [DATE]-[DATE]. Completed on [DATE]. B.) All residents will have a code status order and care plan updated within the last 30 days related to their POLST forms. Completed by RNC and Administrator on [DATE].C) Review of policy and procedure of advanced directives and system that is in place for updating code status. Residents that do not have a POLST form will remain a full code until POLST form can be obtained. Completed by VP of Clinical Services on [DATE]. 3) All working staff have been in-serviced on where to locate code status, who to give POLST forms to when a new admission or re-admission changes code status. Currently all staff on shift are in-serviced. Total facility will be 100% by 7.22.25. If staff are not in-serviced, they will be in-serviced prior to working their next shift.4) No staff will work before being in-serviced on code status. Ongoing being completed by IDT (Interdisciplinary team) or designed by start of next working shift. 5) A quality assurance tool was implemented; Daily audit will be completed of the 24-hour report to see if there are any new admissions &/or readmissions, POLST status will be reviewed, and if it a part of the medical record. Audit will continue daily x 4 weeks to ensure that code status is updated timely and located within the medical chart. Ongoing. Audits to be completed by Administrator/Designee.6) Root Cause Analysis Completed for POLST Forms.Deficiency: failed to follow POLST form that reflected residents wishes.Root Cause: Attached. Initiated on [DATE] and completed 100%. Event ID: Facility ID: 145981 If continuation sheet Page 4 of 8 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 07/24/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from misappropriation of property for 1 of 6 residents (R10) reviewed for abuse in the sample of 17.1.R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced dementia and need for assistance with personal care.R10's Minimum Data Set (MDS) dated [DATE] documented R10 was moderately cognitively impaired with inattention and disorganized thinking and ambulated with walker.R10's Care Plan does not address risk of abuse and neglect.The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 2/18/25 documents R10 notified V17, Social Services Director, of allegation of misappropriation of money, and an investigation was initiated.The Facility's Abuse Investigation Report by V46, Former Administrator, documents, On 2/18/25 (V17) made a phone call when (R10) was in her office to (V36, R10's Family) regarding (R10)'s debit card due to it not working. (V36) has (R10)'s bank statement and informed (V17) and (R10) that the debit card had been used in (four various cities). (V36) named multiple places it was used, including (Real Estate Company). (V36) included the phone number for the real estate group. He stated (R10) had no money because of this. The Facility's Summary of Investigators Findings documents, (V17) discovered (R10)'s debit card was used on multiple dates in January (2025). Per real estate group, debit card was used on 1/17/25 to pay rent in the amount of ($)209.99 for (V25, Certified Nursing Assistant, CNA). On 7/18/25, V25 and V46 were no longer working in the Facility.The Facility's 2/20/25 interview with V47, CNA, documents R10 asks people all the time to go to the store for him.The Facility's 2/20/25 interview by V48, CNA, documents R10 is always giving out his (debit) card.The Facility's 2/21/25 interview by V40, Housekeeper, documents R10 asks anyone and everyone to go to the store for him.On 7/22/25 at 12:50 PM, V33, CNA/Transportation, stated R10 has asked her to buy him things with his debit card.V17's Written Statement documents V36 reported all R10's money was gone and stated it looked like it was spent in four different towns, beginning on 1/16/25. V36 stated there was a $209.00 payment made to a phone number on 1/17/25 for which a reverse search listed a (Real Estate Group). R10 stated he did not remember who he gave his card to, when he gave it to them, or what they looked like.On 7/18/25 at 1:50 PM, V17 stated it was reported several months ago that V25 took money from R10. The allegation was reported and investigated, and V25 was terminated. V17 stated (R10) has alcoholic dementia, and he always wants to give his debit card to people. We try to remind him to only give his card to me to purchase items for him, but he forgets. The Facility's 2/21/25 Abuse Allegation Interview with V25 documents R10 is always asking people to go to the store for him. V25 was asked whether she had ever purchased anything for herself with resident money, and she stated, No, my hands have not been on his debit card. V25 was informed that a transaction was made on the debit card in her name for rent. She stated, I didn't touch his debit card, but I can give it back. I can bring it to you.On 7/18/25 at 2:07 PM, V25 was not available for interview by phone.On 7/22/25 at 2:45 PM, V33, CNA/Activities, stated V25 used R10's debit card, then ended up getting fired. The Facility's Final Report sent to IDPH on 2/24/25 documents during the investigation, it was noted that R10's debit card was compromised and had been used in the (Local) area. R10 is known to give money or debit card to anyone, including other residents and visitors if he feels they will purchase items for him at the store. There was one possible purchase that could be linked to a facility member in January 2025. On 7/23/25 at 11:55 AM, V1, Administrator, stated she was not the administrator at the time of R10's investigation, but stated it looked like it happened, and the detective said who came out to the Facility to follow up on the case stated V25 used R10's debit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 5 of 8 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 07/24/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete card to pay rent. She stated she would expect the Facility to follow its abuse policy.The Facility's Undated Abuse Prevention and Prohibition Program Policy documents each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. Event ID: Facility ID: 145981 If continuation sheet Page 6 of 8 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 07/24/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement its written policy by not ensuring that required background checks were completed prior to allowing direct care staff to work with residents. This failure had the potential to place all 52 residents living in the facility. Findings include:V37's, Certified Nursing Assistant, CNA, personnel file documented R37 was employed by facility beginning on 3/3/2025 through 5/15/2025. There was no Criminal Background Check completed by the facility; however, the facility did have a background check from previous employer dated 11/27/2024. V1, Administrator, stated Ideally this facility should've done a background check. V1 stated (V37) came from a sister facility and just kind of showed up one day. V2, Director of Nursing, DON, stated Typically when a staff member requests a transfer from a sister facility, we would call that facility and let them know the staff is requesting a transfer. There are new procedures put in place now that onboarding and background checks are to be done. Facility's undated abuse policy states To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.Facility's resident roster dated 7/14/2025 documents 52 residents residing in the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 7 of 8 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 07/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report allegations of exploitation immediately to the Executive Director for 1 of 3 residents (R5) reviewed for reporting of abuse in the sample of 17.Findings include:R5's incident note dated 7/17/2025 at 2:30PM documents R5 was a resident at this facility with a BIMS of 15 and diagnosed with the following but not limited to: Major Depressive Disorder, recurrent moderate Chronic Obstructive Pulmonary Disease, Unspecified Type 2 Diabetes with Hyperglycemia, and essential primary hypertension, Chronic Congestive Heart Failure. At approximately 2:30PM on 7/17/2025, an Illinois Department of Public Health surveyor reported to V1, Administrator, that there was an allegation of an inappropriate relationship between R5 and former staff members V37, V35, Certified Nurse's Aides, CNAs, and an unknown staff member. On 7/22/2025 at 11:35AM V32, CNA, stated There were 2 staff that would make R5 food, and he would pay their bills, give them gifts, give them the keys to his house, put money in their cash app. The staff were V35 and V37. R5 paid V37's insurance premium. I told the administration before the facility was bought out. On 7/22/2025 at 3:30PM V37, CNA, stated (R5) and I were just really good friends. He sent me money to my cash app a couple of times for coffee and donuts but that was it.On 7/23/2025 at 12:00PM V1, Administrator, stated I found out about the abuse of R5 when the surveyors told me. V37 had already been terminated for tardiness. I was not the Administrator yet, but I would've expected the outgoing Administrator to have passed that information along to me. Facility's undated abuse policy states To ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Event ID: Facility ID: 145981 If continuation sheet Page 8 of 8