Inspection·August 27, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide adequate clean linen supplies for 4 of 4 residents (R7, R10, R20, R21) reviewed for clean, comfortable, homelike environment in the sample of 23.R7's Minimum Data Set (MDS) dated [DATE] documented R7 was cognitively intact.On 8/18/25 at 9:50 AM, R7 stated there are not enough towels and wash cloths in the Facility. She likes to wash her face daily, so her family has to bring in wash cloths and towels in order for her to do that.R10's MDS dated [DATE] documented R10 was cognitively intact.On 8/22/2025 at 11:00 AM, R10 stated the Facility is always out of towels and wash cloths. She has had to wait up to two weeks for a shower because staff tell her they do not have enough towels and wash cloths.R20's MDS dated [DATE] documented R20 was cognitively intact.On 8/21/25 at 11:35 AM, R20 stated there are never enough towels for bathing.R21's MDS dated [DATE] documented R21 was cognitively intact.On 8/22/2025 at 11:05 AM, R21 stated the Facility frequently runs out of towels and wash cloths and has been unable to take showers for weeks at a time for this reason.On 8/21/25 at 11:30 AM, V21, Certified Nursing Assistant (CNA) went to the Clean Utility closet where she would obtain linens. There were no towels in the closet. On 8/21/25 At 11:40 AM, V8, CNA, went to the closet where she would obtain linens. It was the same closet shown by V21. V8 stated the towels are probably down in laundry.On 8/22/25 at 1:15 PM, V27, CNA, stated there has been a shortage of towels and wash cloths in the facility which she believes is due to some CNAs throwing them in the trash instead of rinsing them and putting them in the laundry.On 8/22/25 at 8:50 AM, V2, Director of Nursing (DON), stated towels are just disappearing in the Facility. She is unsure if they are being thrown away, but suspects some residents are stashing them in their rooms.The Facility's Linen Handling-Nursing Policy reviewed 6/1/25 documents, Clean linen shall be stored in such a manner to prevent contamination. Linens shall be maintained in the linen room or in enclosed or covered carts. Laundry personnel shall be responsible for assuring adequate amounts of clean linen and personal clothing are available on each nursing unit. Event ID: Facility ID: 145981 If continuation sheet Page 2 of 13 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 08/27/2025 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to initiate, implement, and add progressive care plan intervention for 2 of 3 residents (R5 and R8) reviewed for falls in a sample of 23. This failure resulted in R5 falling and sustaining a laceration to his head and R8 falling and sustaining a fracture to her left wrist. Finding Include:1. R8's admission Record, print date of 08/05/25, documented R8 has diagnoses of but not limited to Multiple Sclerosis and other abnormalities of gait and mobility. R8's Minimum Data Set (MDS), 05/27/25, documented R8 is cognitively intact with a brief interview of mental status (BIMS) of 14 out of 15 and she requires substantial/maximum assistance from staff for toileting hygiene and she requires partial/moderate assistance with transfers from bed to chair and toilet transfers.R8's Baseline Care Plan, dated 05/16/25, documented under section Functional Abilities and Goals- Mobility for toilet transfer: The ability to get on and off a toilet or commode not assessed/no information. Under safety risks does resident have a history of falls? There was no documentation noted. R8's Care Plan, admission date of 05/16/25, documented R8 has had an actual fall with injury to left wrist Poor Balance, Poor communication/comprehension, Unsteady gait (Date initiated 07/03/25). Goal: resident's left wrist will resolve without complication by review date. Interventions include but not limited to Resident will ask for assistance with transfers.R8's Un-witnessed Fall, dated 07/02/25 at 10:50 AM, documented the nurse heard someone yelling for help, sound coming from 200 hall shower room. Resident observed sitting on the floor near toilet in shower room. No emergency light flashing for assistance at time of incident. Resident stated I fell trying to go to the bathroom. I think I broke my hands and wrists when I fell. A full body assessment was completed and there was bruising noted to the back of bilateral hands. STAT x-ray was ordered. Predisposing Physical Factors were gait imbalance, predisposing situation factors ambulating without assist and during transfer.R8's Progress Notes, dated 7/2/2025 at 11:08 AM, documented Incident Note Nurse heard someone yelling for help, sound coming from 200 hall shower room. Resident observed sitting on the floor near toilet in shower room. No emergency light flashing for assistance at time of incident. Resident stated I fell trying to go to the bathroom. I think I broke my hands & wrists when I fell. Full body assessment completed. Bruising noted to BILAT (bilateral) wrists. ROM (range of motion) WNL (within normal limits) to BILAT Upper extremities. ROM WNL to BILAT Lower extremities. Resident stated she did not hit her head. C/O (complained of) pain to wrists/hands BILAT. No other c/o pain noted. Resident assisted to toilet and into w/c (wheelchair) after. Ice applied to BILAT wrists/hands. STAT X-rays orders of BILAT upper extremities. MD (medical doctor), DON (director of nursing), Administrator made aware immediately. POA (Power of Attorney) to be made aware.R8's Progress Notes, dated 7/2/2025 at 11:37 AM, documented Note Text: Biotech Xray Tech here to obtain x-rays of BILAT wrists/hands. Awaiting results.R8's Progress Notes, dated 7/2/2025 at 2:55 PM, documented POA contacted and given update on results (negative/no Fx's (fractures) noted) and assured that if any new orders are received, she would be notified.R8's Progress Notes, dated 7/3/2025 at 10:53 AM, documented Biotech called back with update stating that the Medical Director will be reviewing the reading we received from yesterday's x-ray since there had been a discrepancy in reading with new results stating the L (left) wrist has a transverse fracture of the distal radius.R8's X-ray report, dated 07/02/25, documented Findings: There is no significant soft tissue swelling appreciated. There is a traverse fracture of the distal radius. Impression: transverse fracture of the distal radius.R8's Progress Notes, dated 7/3/2025 at 12:56 PM, documented Ambulance arrived to transport resident to local hospital related to (r/t) left wrist swelling r/t fall. Bruising and visible swelling to Left wrist. Able to make needs know and voice discomfort upon discharge (d/c). Refused noon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 3 of 13 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 08/27/2025 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 - Actual harm Residents Affected - Few medication upon leaving. R8's Physician's Orders, dated 07/07/25, Occupational Therapy (OT) clarification order: OT to treat 3-5x/wk (times/week) x 41 days for ADL retraining, neuro re-ed, therapeutic activities, therapeutic exercise and group therapy as per Plan of Care (POC). R8's Physician's Orders, dated 07/08/25, documented Physical Therapy (PT) clarification order: Skilled PT 3-5x/week for 41 days with treatment to include therapy exercises (ex), therapy activities (act), neuro re-ed, gait training, group and manual therapy for treatment of diagnoses M62.81 and R26.81 per PT initial POC. R8's Illinois Department of Public Health Long- Term Care Facility & IID- Serious Injury Incident and Communicable Disease Report, Incident Date of 07/03/25, documented Final Report R8 had a fall with physical harm or injury. She uses a wheelchair and is a transfer with two assists. R8 is interviewable, can make informed decisions, and is alert and oriented times three. The conclusion: R8 suffered a transverse fracture of the distal radius to the left wrist during a fall where she was transferring without asking for assistance. R8 does have several diagnoses that would make her more susceptible to fractures. Root cause of that fall was due to R8 lack of safety awareness which is shown by not asking for assistance or use of a call light, nor did she turn on the lights while trying to self-transfer. R8 was educated (BIMS 14) and reminded to use call light system if needing assistance. R8 stated understanding. On 08/19/25 at 9:05 AM, R8 had an orange plaster cast on her left hand and wrist. She (R8) said she fell while trying to go to the bathroom. She said she was using the bathroom in the shower room when she fell. She said there was no handrail to help her, and she feels that is part of the reason she fell.On 08/25/25 at 11:06 AM, V10, Regional Maintenance Man said not all of the bathrooms have handrails in them. He said they would do a safety assessment on the resident first and if they had no issues with them, they would install the handrails. He said as far as he knows there is no regulation about having handrails in the bathrooms.On 8/26/25 at 1:02 PM, Follow up interview with R8. R8 was propelling self-down hall in wheelchair. Stated she goes to the bathroom by herself and went to the bathroom by herself before she broke her wrist. Denies getting any assist from staff for toileting.On 8/26/25 at 1:05 PM, V32, CNA, stated R8 is standby assist for toileting. R8 is pretty independent and likes to do things on her own but she does let us know when she needs to use the bathroom because she likes someone to be there with her. She can do just about everything, but we help her pull her pants up. R8 did not require any assist with toileting prior to breaking her wrist and was independent with toileting.On 08/26/25 at 1:41 PM, V33, Nurse Practitioner (NP) said if someone has a diagnosis of Multiple Sclerosis (MS) they are a higher risk for falls, and she would assume the facility would have something in place for falls.2. R5's admission Record, print date of 08/10/25, documented R5 has diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease, muscle weakness, and seizures.R5's MDS, 06/25/25, documented R5 is moderately cognitively impaired with a BIMS of 09 out of 15 and he is dependent on staff or requires substantial/maximal assistance with his activities of daily living (ADLs). He is always incontinent of bowel and bladder.R5's Care Plan, admission date of 01/17/25, documented R5 has had an actual fall related to (r/t) mobility, weakness. 05/08/25 actual fall, 06/15/25 actual fall, 08/09/25, actual fall. Goal: R5 will remain free from falls and injury. Interventions include but not limited to 5/8/25: Keep bed in lowest position (date initiated: 05/15/25). 6/15/25: Do not leave in room up in wheelchair if resident is restless (date initiated: 08/05/25). 8/9/25 Educate resident on allowing staff to assist with getting out of his wheelchair (date initiated 08/20/25).R5's Progress Notes, dated 05/08/2025 at 05:18 AM, documented Incident Note This Nurse was on 100 hall passing meds (medications) when notified by staff that the resident was on the floor. When this Nurse entered the room, the resident was found lying flat on his back side, head against (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 4 of 13 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 08/27/2025 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 - Actual harm Residents Affected - Few his nightstand with left leg bent up dressed in his sleepwear. This Nurse did a full head to toe assessment and found a slight lump/bump on the top of his head. No skin tears noted. Resident was unable to give description of the incident. Resident voices pain to back and neck. On the pain scale 0-10 resident stated pain was an 8. Resident is A&Ox2 (alert and oriented times two). V/S (vital signs) WNL (within normal limits). DON (Director of Nursing) notified and made aware. R5's son was contacted, no answer, message left. Local ambulance was contacted; they arrived at 23:02pm (11:02 PM). 2 EMT (emergency medical technicians) transferred resident out to local hospital for further evaluation. Report was called and given to hospital RN (Registered Nurse), ER (emergency room) charge Nurse.R5's Progress Notes, dated 6/15/2025 at 1:42 PM, documented Staff assisted resident back to own room after lunch. Resident was fidgeting in w/c (wheelchair). Resident lowered self out of w/c onto floor softly and laid down on back. Resident alert entire time and did not hit head during change of plain. Full body assessment completed. Resident assisted back into w/c and positioned. No s/s (signs or symptoms) of injury noted. No c/o (complaints of) pain noted. ROM (range of motion) WNL. 5's vital signs were stable. Administrator & Family made aware.R5's Fall Risk Evaluation, dated 06/15/25, documented R5 has had 1-2 falls in the past three months, he is chairbound/incontinent, predisposing diseases: respond based on the following predisposing conditions: hypotension, vertigo, cardiovascular accident (CVA), Parkinson's Disease, loss of limb(s), Seizures, Arthritis, osteoporosis, fractures, and delirium. It documented he had none of the predisposing conditions present. Under Gait/Balance it documented R5 has decreased muscular coordination. Under risk for falls there is no documentation noted. R5's Fall Investigation Worksheet, dated 08/09/25 at 9:50 PM, documented R5 takes antianxiety, antihypertensive, and cardiovascular medications. He was agitated, restless, and combative. It also documented R5 had an unwitnessed fall in his room, and he requires supervision. Contributing clinical factors: Hemiplegia/Hemiparesis and Cognitive impairment. Root cause of fall was he was attempting to get up without assistance. It documented he did not have a call light within reach because he was sitting in front of the television (TV). Handwritten statement by V25, CNA documented she tried to lay R5 down around 7:40 PM. R5 didn't want to go to bed at that time. Later another CNA went in to try to get him to lie down and he became combative, so she let his CNA (V25) know. V25 then went in at around 8:30 PM to see if she could get him to lie down before it was time for her to leave for the evening. It documented she went to gather her things and her, and another CNA were going to go and put R5 to bed. When they walked into R5's room at 9:46 PM R5 was on the floor face down.R5's Progress Notes, dated 8/10/2025 at 01:28 AM documented Incident Note 2150p (9:50 PM) This nurse was notified by assigned CNA (Certified Nursing Assistant) staff resident was found face down on the floor by door of assigned living area. Resident was laying prone on the floor with face (left face down) looking over right shoulder. Resident was bleeding from left side of head (unknown origin) with large hematoma on left upper forehead. Resident was conscious A/O x3 and able to respond to verbal commands. Resident was not moved from original position. Patient stated that he did not have any pain/discomfort from extremities; however, expressed discomfort when his head was touched. Resident's vitals were assessed with BP (blood pressure) 108/53 / PR (pulse rate) 68 / O2 (oxygen) 95%. Resident informed of transport and agreed to be taken to local hospital via ambulance upon arrival of local Ambulance at 10:10p. DON notified of incident at 10:15p once resident stable and assessed by EMS (emergency medical services) with neck brace applied and soft stretcher used to log roll resident to supine position. Resident further assessed and taken by ambulance. Local PD (police department) responded to call.Note: Resident has verbal challenges that made it difficult to assess situation.R5's Progress Notes, dated 8/10/2025 at 01:34 AM, documented Resident transported to local hospital via ambulance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 5 of 13 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 08/27/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete after 911 call made due to fall. Resident refused to be placed in bed with staff reporting multiple attempts to transfer resident to bed with resident being combative. Resident was redirected several times per assigned staff resulting in resident refusing to leave position in chair. Nurse observed resident in prone position with injury to left side of head. All details of incident reported by CNA. DON notified of findingsR5's Progress Notes, dated 8/10/2025 02:38 AM, documented Resident being monitored for injury with report from hospital RN noting that resident is in the ER pending stiches/staples to laceration on left forehead. All scans returned with no fx (fracture) found. Resident is resting well awaiting discharge from ER. DON notified of all findings. R5's Progress Notes, dated 8/10/2025 at 04:29 AM, documented Per local hospital ER Resident has been treated with three steri strips to the wound on left forehead. Resident is waiting for transport by ambulance back to facility. DON updated on progress of resident.R5's emergency room Report, dated 08/09/25, documented the reason for his visit was due to a fall and his diagnoses were fall and head contusion. On 08/25/25 at 10:45 AM, V24, [NAME] President (VP) of Clinical Services said it would depend on the situation. If the resident was restless and up in their chair, she would expect them to bring the resident out to the common area unless it would upset them more. If it would cause them to become more agitated, then they should increase monitoring due to increased behaviors. She said they are wanting to change R3's wheelchair so it is more comfortable and safer for him.On 08/26/25 at 1:41 PM, V33, NP said she would expect the nursing staff to keep a close eye on him (R5) if he was restless and became combative due to not wanting to go to bed. You can't force them to go to bed so she would expect the nursing staff to keep a close eye on him.The facility's fall evaluation and prevention policy, not dated, documented Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. It further documented RESIDENTS SHOULD BE EVALUATED FOR THEIR FALL RISK *On admission/re-admission to the home, *Following any change of status that may affect balance, mobility, or safety, *Following a fall, and *Quarterly. RISK FACTORS ASSOCIATED WITH A FALL Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of common intrinsic risk factors: *Gait and balance disorders, *Muscular weakness (particularly of the lower extremities), *Stroke, *Seizure disorder, and *Previous falls. It also documented Extrinsic risk factors for falls are part of the resident's environment and are most likely to be seen in areas such as the bedroom, bathroom, dining room, and hallways. The following are typical examples of extrinsic risk factors: *Lack of or loose handrails. It also documented Fall Evaluation and Prevention Provide an elevated toilet seat and grab bars in the bathroom if indicated. Refer resident to PT or OT. It further documented Evaluate the environment where the fall occurred, noting any factors that may have contributed to the fall (i.e., wet floor, socks without skid resistant pads, assistive device out of reach). Ask the resident what happened prior to the fall or what may have caused the fall. Root Cause.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility. Event ID: Facility ID: 145981 If continuation sheet Page 6 of 13 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 08/27/2025 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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to assess and develop behavioral interventions for a resident with diagnoses of schizophrenia and bipolar disorder and notify the physician of resident having active hallucinations for 1 of 1 resident (R3) reviewed for behavioral services in a sample of 23. This failure resulted in R3 being sent out to the emergency room (ER) for evaluation and found to have a fractured nose and two fractured ribs. Findings Include:R3's admission Record, print date of 08/20/25, documented R3 has diagnoses of but not limited to Schizophrenia and bipolar disorder.R3's Minimum Data Set (MDS), dated [DATE], documented R3 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 04 out of 15, he requires supervision/touching assistance with most of his activities of daily living (ADLs), and he doesn't have any behavioral symptoms.R3's Care Plan, admission date of 08/04/25, documented Behavior Management New Delusional/hallucinations behavior related to his schizophrenia 8/16/25 resident was seeing snakes and bugs and trying to stomp on them. Resident also jumping around off and on furniture, swinging arms around swatting at birds, diving onto the floor. Goal: Cause of new onset behaviors will be evaluated/determined and undesirable behavior(s) will be monitored/managed. Interventions include but not limited to ensure the safety of resident and others and evaluate medication schedule and possible pharmacologic causes of hallucinations. The date created for this problem was 08/18/25. R3's Progress Note, dated 8/17/2025 at 01:12 AM, documented Behavior Note: Resident running up and down the hallway screaming rat's, snakes and birds were in his room. resident jumping up and down stomping on the floor saying he is stomping the rats. Resident re-directed back to his room.R3's Progress Notes, dated 8/17/2025 at 02:33 AM, documented Note Text: Resident came out of his room with blood on his face and nose. Resident nose twisted to the right. Local ambulance called to transport resident to local hospital. Call placed to Power of Attorney (POA) with no answer. Message left to call the facility.R3's Physician's Orders, dated 08/06/25, documented R3 has an order for Ziprasidone Mesylate (Geodon) Intramuscular Solution Reconstituted 20 milligrams (MG) (Ziprasidone Mesylate) Inject 0.5 milliliters (ml) intramuscularly as needed (PRN) for extreme agitation. R3's Medication Administration Record (MAR), for the month of August 2025 had documentation he was given his PRN Geodon on 08/11/25 and on 0813/25. There was no documentation he received his any PRN medication on any other days.R3's Progress Notes were reviewed and had no documentation the physician was notified of R3 having active hallucination. R3's emergency room History and Physical Report, dated 08/17/25, documented R3 is a [AGE] year-old male patient with a medical history significant for but not limited to bipolar disorder, schizophrenia, dementia, hypertension, anemia presents to the ED via EMS from local nursing home with a chief complaint of facial injury. R3's Computed Tomography scan (CT-scan) of Facial Bones, dated 08/17/25, documented R3' findings as a minimally impacted anterior nasal bone fracture. R3's CT-scan of the Cervical Spine, dated 08/17/25, documented R3 had findings of Other osseous structures: Mildly impacted fractures of the right 2nd and 3rd ribs.On 8/21/25 at 1:10 PM, V8, Certified Nursing Assistant (CNA) stated V2, Director of Nursing (DON) asked her about R3, but she wasn't here that day. She said he had been running around, chasing snakes, hallucinating, jumping around, wandering into other resident rooms. V8 doesn't know what happened to R3. He could have run into a wall or something, the way he was acting. He had been like that since he got to the facility but hadn't been there too long. She said maybe this facility was not a good fit for him.On 8/21/25 at 1:13 PM, V25, CNA, stated R3 was always running everywhere. He was a safety risk to himself and may have been better in a lockdown unit. V8, CNA was standing in the area and stated We do have a lot of guys that can get angry and territorial around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 7 of 13 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 08/27/2025 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 0740 Level of Harm - Actual harm Residents Affected - Few here.On 8/21/25 at 3:52 PM, V30, CNA stated she did not see it happen, he had gone to his room, came out, stood at nurse's station, and she asked what happened to his nose because it had blood at the bridge of it. R3's nose looked crooked, so the Nurse assessed him and made some calls. One was to the sister, there was no answer, so a message was left. Then they called 911. V30 said she hadn't worked with R3 before. She said he was up and down the halls, around nurse's station, sitting on floor, in hallway, stating he saw bugs or a snake, saw a bird. She said R3 was bad, and he had been acting like that all shift. She saw him go towards a few doors but never actually went in that she saw. V30 said she had never seen him that bad, never seen him act like that. He would walk up and down the halls and around the nurse's station. DON interviewed me about this.On 8/21/25 at 4:00 PM, V29, CNA said R3 was acting different, running around nurse's station, skipping, wasn't saying anything to nobody. When you told him to slow down or to sit down, he would for about two minutes and then he would get back up. He was really fidgety that night. She gave R3 a snack and some water and when he was done, he said he was going to bed. He would go to his room and then he would come right back out. V29 said around 3:00 AM she went to the bathroom and she heard a bump in his room due to it is right next to the bathroom wall. She said she came out and he was coming out of his room and another CNA asked what was wrong with his nose. The nurse said it was crooked and it had some drops of blood on it. V29 said they just thought he may have hit it on the headboard or maybe he fell and hit his nose. She said they had never seen him act like that before. On 8/22/25 at 8:14 AM, V28, Licensed Practical Nurse (LPN) stated R3's fall and bloody nose were two separate incidents. R3 fell earlier in the night around 7:30 PM. He had been running up the hall toward the 100 hall and ran into her. He fell on his bottom. No injuries. Around 3AM he came out of his room after being in there about 45 min and he had blood on his face. She said she was cleaning him up and noticed his nose was crooked, so she sent him out because she assumed it was broken. V28 called an ambulance and tried to call the family several times with no answer and left a message to call the facility back. R3 told V28 a man picked him up and threw him and when asked who he said he didn't know, it was dark. V28 said she went in his room and bathroom and the only person in there was his roommate who is not steady enough to stand up and do that. She said there were a couple drops of blood on the floor, so she knows whatever happened, happened in his room. She said he was hallucinating all night, beating on the floor to kill snakes and he was seeing birds. She said he always runs but he was different that night and she had never seen him act that way. V28 said R3 doesn't bother anybody, he just walks around and sometimes looks in rooms but doesn't go in and he is easily redirected. V28 said R3 is always confused and doesn't sleep good at all and is usually up all night. He has PRN Geodon, but it only works for about 10 minutes. doesn't work. V28 said she did not contact the Nurse Practitioner (NP) or the Medical Doctor (MD) regarding R3's unusual behaviors.On 08/26/25 at 1:41 PM, V33, Nurse Practitioner said if someone has hallucinations, they are a harm to themselves. She said she would expect the nursing staff to notify her or the physician if the resident was getting worse. She said if the resident had PRN medication that was ordered she would expect it to be given.The facility's Behavior Management Policy, review date of 08/01/25, documented Purpose To implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. PolicyThe concept of behavior management is an interdisciplinary process. The key components of this process are: Identifying residents whose behaviors may pose a risk to self or others; Developing individual and practical care strategies based on assessed needs; Implementing the behavior management program; and Ongoing assessment, monitoring and evaluation of the effectiveness of the behavior management program (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 8 of 13 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 08/27/2025 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 0740 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete including the effectiveness of psychoactive drugs.The goal of any behavior management process is to maintain function and improve quality of life. The goal of the Intradisciplinary Team (IDT) team is to promptly identify behavior management issues and develop an effective management program. It further documented When a resident displays adverse behavioral symptoms (e.g. Crying, yelling, hitting, biting etc.), Licensed nursing staff will assess the behavioral symptoms to determine possible causal factors, contact the attending physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s).The facility must provide necessary behavioral health care and services which include: Ensuring that the necessary care and services are person-centered and reflect that resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well- being; Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being. Providing an environment and atmosphere that is conducive to mental and psychosocial well-being; and Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated. ProcedureI. Assess Causal Factorsa. When a resident exhibits adverse behavioral symptom (e.g., crying, yelling, hitting, biting, etc.) licensed nursing staff will document those behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible causal factors and interventions attempted.b. Upon observing the adverse behavioral symptom, staff will do the following as indicted:i. Ensure the safety of the resident as well as all other residents.ii. Document notification of attending physicianiii. Document notification of resident's family and/or responsible party about the change in behaviors and the attending physician response.iv. Document the incident. c. The charge nurse will assign a staff member(s) to monitor/shadow the resident as needed.i. Such monitoring is for the protection of the resident as well as all others and is not meant to restrict their movement or mobility.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility. Event ID: Facility ID: 145981 If continuation sheet Page 9 of 13 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 08/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to store food in a manner that prevents foodborne illness. This has the potential to affect all 56 residents living in the Facility.On 8/20/25 at 8:53 AM, in the refrigerator/freezer unit on the wall of the kitchen entryway, there was a large package of uncooked beef patties in the freezer stored directly above a box of popsicles. On 8/20/25 at 8:55 AM, in the standing refrigerator on the adjacent wall, there was a plastic tub of sour cream with manufacturer's Best By date of 7/2/25. There was a clear container with hamburger patties that was not labeled or dated. There was a container labeled banana pudding with a prepared date of 8/12 and no discard date. There was a container labeled chocolate pudding with prepared date of 8/11 with no discard date. There was a container labeled tuna with a prepared date of 8/13 and no discard date. V19, Dietary Manager, stated someone did not write the discard date on the label. On 8/20/25 at 9:00 AM, in the dry storage room refrigerator, there was a package labeled turkey with a Use By date of 1/2/26.On 8/20/25 at 9:38 AM, R12's personal refrigerator in her room was inspected. There was a carton of 2% milk with Use By date of 7/8/25. There were two protein shakes with Use By dates of 3/5/24 and 7/4/24. There was a Styrofoam container with a facility provided meal ticket inside dated 6/30/25. R12 stated staff do not have the time to clean out her refrigerator.R12's Minimum Data Set (MDS) dated [DATE] documented R12 was cognitively intact.On 8/22/25 at 3:16 PM, V1, Administrator, stated she expects dietary staff to follow food service policies.The Facility's Food and Supply Storage Policy dated 8/1/25 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated. If there is no expiration date on the package or container, a use-by date must be written on the product.The Facility's Long-Term Care Application for Medicare and Medicaid (CMS 671) dated 8/15/25 documents there are 56 residents living in the Facility. Event ID: Facility ID: 145981 If continuation sheet Page 10 of 13 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 08/27/2025 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. Based on observation, interview, and record review the facility failed to provide a clean and safe, sanitary environment for 4 of 5 residents (R1, R7, R10, and R11), reviewed for environment in a sample of 23. This has the potential to affect all 56 residents who reside at the facility.Findings Include:Survey Team Observations:On 08/15/25 at 11:00 AM, While touring the 100 hallways there was a room that had a large brown smear (appeared to be feces) on the floor in front of the first bed. There was trash scattered on the floor.On 08/15/25 at 11:11 AM, The main hallway of the facility had a large pink stain on the floor in front of the dining room and there were black scuff marks up and down the hallway.On 08/15/25 at 11:13 AM, V6, Housekeeping was using the wet vac to clean up water in two of the rooms on the 200 hallways. On 08/15/25 at 11:30 AM, A room on the 200 hallways had a dirty urinal lying on the floor and a box of incontinent briefs sitting on the floor in the room. There was a bag of trash tied to the handrail outside of the room door.On 08/18/25 at 9:20 AM, The floor in the dining room had salt/pepper packets and sugar packets lying on the floor. There was a large red Kool- aide spot by one of the front dining room tables. There was an orange peeling lying on the floor. There was an old Styrofoam container in a bucket that was sitting on a chair at the front of the dining room, and it had old, mashed potatoes and stewed tomatoes in it. There were multiple black skid marks all over the floor.On 08/18/25 at 10:10 AM, The shower room located on the 200 hallways was inspected at this time. There were no towels or washcloths seen in the shower room. There was dried feces in the toilet bowl, the toilet-paper dispenser was broke (no cover on it), there was no handrail to assist with getting up seen on the wall by the toilet, and behind the door to the shower room the baseboard had fallen off and was lying on the floor.On 08/19/25 at 9:15 AM, V17 said there was some mold behind the desk (same room as flooding). On the far east wall, behind an old desk. There was also stuff piled on top of the desk and this surveyor was able to see but could not reach what appeared to be black mold. This surveyor was unable to see how far it went across the wall. In the area where the dirty laundry is washed there was a hallway off to the left. In the hallway there was an area measuring approximately 8.5 feet long and 3 feet high where the wall was missing plaster. Up against the wall was a piece of some kind of paneling/board measuring approximately 2.5/3 feet x 2.5/3 feet. This surveyor pulled the board away from the wall and there was black mold covering the back of the board from halfway up the board to the bottom of the board. There was also black mold on the wall behind the board.On 08/19/25 at 2:12 PM, The employee bathroom on the 200 hallways was inspected and the following was discovered:1. Two ceiling tiles were missing from the ceiling and were broke and up against the wall.2. One ceiling tile was bulging. 3. Two ceiling tiles had water stains.4. There was a large plastic trash can with about 3 inches of water in the bottom of it.5. There was exposed duct work, exposed pipes, and exposed wiring.On 8/21/2025 at 9:46 AM R11, was not in his room, R11's floor was sticky and visibly dirty with wheelchair wheel marks. The 100-hall flooring is sticky and visibly dirty.On 08/18/25 at 9:50 AM, R7 said the week before last she had a big puddle in the middle of her floor. She said they had to put blankets down on the floor to soak up the water. She said they told her it was a pipe. R7 said it was good for about a week then it happened again.On 8/20/2025 at 3:22 PM, R1 When asked about the cleanliness of facility, R1 states Do you see these floors?. R1's eyes got big, and she stared at the floors. The floors are observed to be sticky and visibly dirty (dark brown spots.) and she said her trash doesn't get taken out very often in her room.On 8/21/2025 at 11:43 AM, When R10 was asked about cleanliness of facility, R10 states just look around. R10 states the facility is dusty. R10 states the facility was deep cleaning the floors, but the facility has cut the housekeeping staff due to budget. R10 states she has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 11 of 13 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 08/27/2025 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 been told by staff and during resident council that housekeeping staffing has been cut due to budget. On 08/15/25 at 11:13 AM, V6, Housekeeping said the toilets have backed up and overflowed since she started working here back in February. V6 said it happens pretty much with all the toilets on the 200 hallways. She said maintenance works on it, but she hasn't seen anyone come in and look at it. V6 said there is a sewer problem in the building.On 08/15/25 at 11:20 AM, V7, Registered Nurse (RN) said the toilets overflowing happens often. She said they had someone out to look at it a couple of weeks ago but other than that the maintenance man takes care of it. She said this has been going on for years. V7 said when someone uses the bathroom and then they flush it they will have BM and urine all on the floor.On 08/15/25 at 11:25 AM, V8, Certified Nursing Assistant (CNA) said the bathroom toilets on the 200 hallways have been backing up and overflowing for a long while. She said sometimes after the residents use the bathroom (bowel movement (BM)/Urinate) and they flush the toilet it will overflow onto the floor.On 08/18/25 at 11:30 AM, V13, Housekeeping said they have had water backup here at the facility. She said it does it in most of the bathrooms here at the facility. She said they have also had it flood in the kitchen and the laundry. V13 said they have had to have someone come out and look and it a while back and then they had to come back again about two weeks ago. V13 stated she has a difficult time getting her regular cleaning done because before she can start on that she has to clean up any flooding that has happened. She said they will have to soak up the water with blankets or they will use a wet vac to get it cleaned up and it puts her behind with her regular duties. On 08/19/25 at 9:15 AM, V17, Laundry said they do have some flooding in the laundry room when it rains. She said water comes in from the bottom of a pipe that is in the other room. V17 then took this surveyor to the room where they wash the dirty cloths and said when it rains it will flood by the door that is over by the washing machines and down a hallway off to the left. She said there is also mold down that hallway.On 08/19/25 at 2:05 PM, V7, RN said the shower use to have mold in it but she believes they have taken care of that and there was a room that had mold in it but they have taken care of that and gutted out the room. She said the resident's rooms that had the ceiling caving in have been fixed already and the only ceiling left that is caved in is the employee bathroom. She said it happened about a week ago.Resident Council Minutes, dated 07/28/25, documented trash is being sat in the hallway and taken out at the end of the shift. It clutters up the hallway. It also documented the 200 hallway needs more attention and toilets need cleaned regularly.The facility's Physical Plant & Environmental Policy & Guidelines not dated 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. It further documented Maintenance/Approved Contractors Routine care and repairs to interior finishings- repairing ceiling/wall damage, painting, floor. It also documented Housekeeping Routine daily room cleaning and sanitizing, routine daily cleaning of all common areas and dining areas, routine daily cleaning of all shower rooms and restrooms. It further documented Scheduled stripping and waxing of floors (if required floor type).The facility's Housekeeper Job Summary, not dated documented Housekeepers are responsible for maintaining the facility in a clean, orderly and sanitary manner. It further documented Responsibilities: 1. Duties a) Clean, organize and sanitize each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145981 If continuation sheet Page 12 of 13 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 08/27/2025 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 resident room, all hallways, congregate areas, nursing station and offices at least once each day. b) Deep clean assigned bath/shower rooms, each resident room and all other rooms or areas at least once each month or per the cleaning schedule or as directed. It also documented d) Bath/Shower rooms are monitored for cleanliness and sanitation and the need for soap and paper products at least 4 times each shift. e) All floor surfaces are continually monitored for wet, dirty spots debris and other safety hazards. Unsafe and unsanitary conditions are corrected immediately. It also documented i) Dining Rooms and other areas used for eating will be cleaned after each meal including wiping tables and chairs with a sanitizing solution. After breakfast floors in eating areas will be wet mopped completely; after other meals floors may be dry mopped completely and wet mopped where necessary. The policy further documented k) Sweeps and wet mops every room in the facility every day (including weekends and holidays) using a cleaning/sanitizing solution. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/15/25 documents there are 56 residents living in the Facility. Event ID: Facility ID: 145981 If continuation sheet Page 13 of 13