Health inspection·March 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to report a hip fracture of unknown origin for 1 of 3 residents (R7) reviewed for abuse in the sample of 13. Findings include: 1-R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including quadriplegia, muscle contractures, protein calorie malnutrition, and dementia. R7's Minimum Data Set, dated [DATE] documented R7 was moderately cognitively impaired and required substantial/maximal assistance with bed mobility and transfer. R7's Progress Note dated 3/7/25 at 1:58 PM documents R7 experienced a change of condition and was sent to the hospital. R7's (Local Hospital) emergency room (ER) Records by V30, ER Physician, on 3/7/25 at 10:47 PM document, Nursing staff noticed abnormal movement of the knee. Imaging shows fracture of the distal femur. Orthopedic surgery please patient needs higher level of care where this traumatic injury can be managed. Unsure when patient's injury may have occurred, it may be why she was diaphoretic when she was initially brought in here as she had not been that way since then. R7's Progress Note by V27, Licensed Practical Nurse (LPN), dated 3/8/25 at 4:53 AM documents (Local Hospital) called Facility stating R7 will need transfer to a different hospital for femur fracture. V2, Direction of Nursing (DON), and V6, Assistant Director of Nursing (ADON) were notified. The Facility's Initial Report dated 3/10/25 at 12:00 PM documents (Local Hospital) reported to the Facility that R7 has an acute oblique displaced fracture of the left femur. The date of the incident was 3/9/25 in the Hospital ER. Law enforcement was not notified. V1, Administrator, provided an electronic mail receipt documenting the Initial Report was actually sent on 3/9/25 at 12:50 PM. On 3/11/25 at 3:20 PM, V27 stated the hospital called and stated R7 had a femur fracture, so she contacted V2 and V6. On 3/12/25 at 9:02 AM, V6 stated R7's hip fracture was reported to her on 3/8/25, so she reported it to V1 and V2, and they said they would take care of the investigation. Page 1 of 6 145985 145985 03/14/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/12/25 at 9:18 AM, V2 stated she was informed of the fracture on 3/8/25, but was waiting on the hospital to send X-rays before reporting it in case it was pathological. On 3/11/25 at 4:19 PM, V1 stated they might have told us R7 had a fracture, but they did not send us the X-ray until 3/9/25 at noon. She stated they wait for the X-rays to come back to determine if it is pathological, but usually report abuse within 2 hours and all other reportables within 24 hours. On 3/7/25 at 3:20 PM, V14, Regional Nurse, stated in the past they have reported fractures that turn out not to be fractures; therefore, they do not take verbal confirmation on fractures, but they did report it when they finally got the X-ray results. The Facility's Undated Abuse Prevention and Prohibition Policy documents, Purpose To ensure 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. The Facility will report known or suspected instances of physical abuse, including sexual abuse, and criminal acts to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Reporting requirements are based on real (clock) time, not business hours. 145985 Page 2 of 6 145985 03/14/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide tracheostomy care as ordered and appropriate tracheostomy supplies for 1 of 1 resident (R4) reviewed for Quality of Care in a sample of 13. Residents Affected - Few Findings Include: R4's Face Sheet, undated, documents R4 was admitted [DATE] with a medical diagnosis of chronic respiratory failure with hypoxia. R4's Minimum Data Set (MDS) dated [DATE], documents R4 is cognitively intact, needs substantial/maximal assistance with personal and oral hygiene, and requires intermittent oxygen therapy, suctioning and tracheostomy (trach) care. R4's Care Plan does not address R4's tracheostomy needs. R4's Progress Note by V10, Licensed Practical Nurse (LPN), dated 3/5/25 at 4:50 AM, documents R4 was sent to hospital. R4 had pulled out trachea. On 3/11/25 at 12:50 PM, V10, LPN, stated she was rounding when she first saw R4's trach was removed. V10, LPN, stated she looked around the room from the trach that came out but couldn't find it. V10, LPN, stated she was just talking to R4 about letting her put it back in and didn't even get to the point of looking to see if there was another trach to replace it with. V10, LPN, stated she called EMS. (Local) Fire Department Emergency Medical Services Report dated 3/5/25 at 3:53 AM, documents Emergency Medical Service (EMS) attempted to locate the trach tube but could not locate the original or a replacement tube. Staff did not assist EMS and stated they did not know if there was a spare trach tube. On 3/7/25 at 3:31 PM, V21, Local Assistant Fire Chief, stated EMS was called to the facility due to R4 pulling out his trach. V21, Local Assistant Fire Chief, stated upon arrival the resident did not have an inner cannula inserted in his trach, and the facility did not have another cannula to replace the one the resident took out. V21, Local Assistant Fire Chief, stated the facility informed EMS they did not have a replacement cannula for R4. R4's Hospital Records dated 3/5/25 at 4:41 AM, documents tracheostomy was replaced using uncuffed 5.5 mm tracheostomy tube as the patient's stoma has decreased in size. R4's Progress Notes by V10, LPN, on 3/5/25 at 6:19 AM, documents this nurse received report from [NAME], Registered Nurse at local hospital that resident is set to return from. Trach was replaced with a new 5 mm cannula. On 3/11/25 at 12:50 PM, V10, LPN, stated the nurse at the hospital told her they changed R4's trach to a size 5 mm cannula in report. V10, LPN, stated she does not know if trach size should be a physician order, but normally when residents come back the accepting nurse at the facility looks through the record to see if any orders have change. V10, LPN, stated V2, Director of Nursing (DON), and V6, Assistant Director of Nursing (ADON), also review the charts. V10, LPN, stated she did not recall 145985 Page 3 of 6 145985 03/14/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0695 being the receiving nurse when R4 was readmitted to the Facility. Level of Harm - Minimal harm or potential for actual harm R4's Progress Note by V6, ADON, on 3/5/25 at 11:40 AM, documents resident returned from hospital at approximately 9:25 AM by EMS. Residents Affected - Few On 3/12/25 at 9:00 AM, V6, ADON, stated she was unaware R4's trach size had changed while he was at the hospital. V6, ADON, stated if the facility would be informed that a resident's trach size changed, the facility would need order the correct supplies. On 3/11/25 at 11:04 AM, a total of 4 size 7.6 mm inner cannulas and 2 size 7.6 mm inner cannulas observed on top of R4's dresser along with trach cleaning supplies. On 3/12/25 at 11:04 AM, V13, LPN, stated she was informed by one of the Certified Nursing Assistants (CNA) that R4's trach was out. V13, LPN, stated she was able to re-insert R4's trach which was a size 5 mm. V13, LPN, found size 7.6 mm inner cannulas and size 7.5 mm cannulas on R4's dresser. On 3/12/25 at 11:08 AM, V13, LPN, stated she found the tracheostomy replacement kit in R4's roommate's dresser. V13, LPN, stated the size of the replacement trach kit that the facility has in R4's room is a size of 8.5 mm and is too big for R4's tracheostomy and would not fit in R4's stoma. V13, LPN, stated she thinks the facility ordered the correct size today for R4. V13, LPN, stated if R4's tracheostomy would come out again and the facility would be unable to replace it, R4 would have to be sent to the hospital. On 3/12/25 at 3:15 PM, V2, DON, stated there was a delay in getting R4's complete discharge orders from the hospital, but the hospital placed a size 5.5 mm inner cannula in R4's tracheostomy. On 3/12/25 at 10:47 AM, V9, Facility's Current Medical Director, stated the tracheostomy size matters due to the size of the resident's stoma. V9, Facility's Current Medical Director, stated if you have a bigger cannula or trach that you are trying to put into a resident's trach site, the hole of the site will not allow a bigger size to be put in. V9, Facility's Current Medical Director, stated a 7.6 mm cannula is bigger than a 5.5 mm cannula and would not fit into a resident's tracheostomy hole if the resident needs a 5.5 mm cannula. On 3/7/25 at 9:37 AM, R4 stated the facility staff does an okay job at taking care of his trach, but they do not clean his trach every day and he sometimes get suctioned daily. On 3/11/25 at 11:04 AM, R4 stated the hospital had put in a smaller cannula than he previously had and is now needing a size 5 mm cannula for his trach. R4 stated the facility told him that they do not have any inner cannulas for his tracheostomy. R4 stated with the facility not having the correct cannula size he needs; the facility cannot provide the care he needs. R4's Physician Orders dated 2/28/25 documents trach care and change collar daily and prn. R4's Medication Administration Record documents trach care was performed 1 out of 13 days. On 3/12/25 at 2:28 PM, V2, DON, stated once tracheostomy care is completed for R4, R4's Treatment Administration Record or Medication Administration Record should be updated with the time and date it was completed. 145985 Page 4 of 6 145985 03/14/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/12/25 at 3:33 PM, V1, Administrator, stated it is expected of staff to document a treatment is completed or medication has been given as soon as it is done. V1, Administrator, stated it is not acceptable for staff to document care was performed days after it was done. The facility's undated Tracheostomy Care Policy documents, guidelines are to remove secretions from trachea-bronchial tree. To maintain an unobstructed airway for the maintenance of ventilation. To maintain clean environment around tracheostomy opening. 145985 Page 5 of 6 145985 03/14/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure physician visits were completed within 30 days of admission and at least every 60 days thereafter for 3 of 3 residents (R1, R2, R5) reviewed for physician visits in the sample of 13. Residents Affected - Few Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, hypertension, and type 2 diabetes mellitus with diabetic chronic kidney disease. On 3/7/25 at 12:28 PM, V1, Administrator, stated she has no documentation to show R1 was seen by a physician during the first 30 days of admission. 2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, epilepsy, and intellectual disabilities. On 3/7/25 at 12:28 PM, V1 provided documentation that R2 was seen by V7, Physician, on 2/2/25, and stated that has been R2's only physician visit in the past six months. 3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including vascular dementia, protein calorie malnutrition, and cerebral infarction. On 3/7/25 at 12:28 PM, V1 provided documentation that R5 was seen by V7 on 1/8/25 and stated that has been V5's only physician visit over the last six months. On 3/7/25 at 9:35 AM, V1 stated, We have a new medical director for a reason. (V7) used to be our medical director, and he was subpar. (V9) started seeing patients in the Facility, and some residents were expressing interest in him that they wanted a change because they were not happy with (V7). The Facility's Undated Physician Visits Policy documents, Purpose: To ensure that residents are established care with primary care provider while at the nursing facility. The initial comprehensive visit in a SNF (Skilled Nursing Facility) is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident, the initial comprehensive visit must occur no later than 30 days after a resident's admission into the SNF. Once the physician has completed the initial comprehensive visit in the SNF, the physician may then delegate alternate visits to a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) who is licensed as such by the State and performing within the scope of practice in that State. Residents of a nursing facility must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. 145985 Page 6 of 6