Health inspection·July 6, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review the facility failed to prevent employee to resident verbal abuse abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 3. Residents Affected - Few Findings include: R3's Baseline Care Plan, dated 7/1/2023, documents that R3 is alert to time, self, others, place, and memory is ok. R3's Face Sheet, not dated, documents R3's admit date as 6/21/23. On 7/3/2023 at 9:55 AM R3 stated that the staff threatened him with bodily harm, talked bad about his hair and called him (expletive) nuts. R3 stated that the staff wanted him to take a shower and gave multiple reason why he should take a shower. R3 stated that he told them he didn't want to take a shower because he has the wounds to his butt. R3 stated that he would take a bed bath. R3 stated that (V5, Minimum Data Set Coordinator (MDSC)) began telling R3 that his hair was greasy and that there was an odor in his room. R3 stated that he told V5 that the odor was coming from V5. R3 stated that V5 told him that she would take him to the shower kicking and screaming and that he was getting a shower. R3 stated that he told her he was not taking a shower. R3 stated that V5 then called him (expletive) nuts. On 7/3/2023 at 1:30 PM V5, MDSC, stated that the staff came and got her because R3 was refusing his shower. V5 stated that the staff come get her because she has a motherly approach. V5 stated that she went to the room and told him he needed to take a shower. V5 stated that she told him that he was dirty, had an odor, his hair was oily and dirty. V5 stated that R3 refused to take the shower. V5 stated that R3 responded that she (V5) was the one with the odor. V5 stated that she told R3 that he was in the same clothes for 5 days and the bed needed changed. V5 stated that they offered to put R3 in a wheelchair and give him the shower and R3 continued to refuse. V5 stated that she said she was done and left the room. V5 stated that she did not threaten R3 with physical harm. V5 stated that she did not call R3 a name and did not say He was (expletive) nuts when in R3's room. V5 stated that she did say that R3 was (expletive) nuts in the hallway. V5 stated We all said it. On 7/5/2023 at 1:31 PM V10, Certified Nurse's Aide, CNA, stated that this all started with a shower. V10 stated that initially she went into the room and was talking with R3. V10 stated that R3 had a foul body odor and was dirty. V10 stated that she informed him that she had found a wheelchair that he can be on his side so that he doesn't have to sit on his bottom and experience pain. V10 stated that initially R3 stated yes. V10 stated that went and got everything ready and when she went to get him for the shower he refused. V10 stated that she notified V8 of R3's refusal. V10 stated that Page 1 of 6 146040 146040 07/06/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0600 Level of Harm - Minimal harm or potential for actual harm someone went and got V5. V10 stated that V5 said some stuff she shouldn't have said. V10 stated that V5 told R3 that he stinks and that they would take him to the shower kicking and screaming if they had to, they would drag you in there. V10 stated that R3 then was saying that he knows his rights and that they were not going to threaten him with physical harm. V10 stated that as V5 was exiting the room, V5 stated He is (expletive) nuts. V10 stated that V1, Administrator was aware and went down to see R3 as well. Residents Affected - Few On 7/6/2023 at 2:46 PM V1, Administrator, stated that she was not notified of an allegation of abuse. V1 stated that R3 did not report to her that V5 threatened him with bodily harm and told him he was (expletive) nuts. V1 stated that she expects her staff to report abuse if they witness and/or are aware of abuse occurring. The facility's Abuse Prevention Program, dated 11/28/2016, documents Policy: This facility affirms the right of our resident to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. It also documents This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff. 146040 Page 2 of 6 146040 07/06/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

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 abuse allegations immediately to the administrator for 1 of 3 residents (R3) reviewed for reporting abuse allegation sin the sample of 3. Findings include: R3's Baseline Care Plan, dated 7/1/2023, documents that R3 is alert to time, self, others, place, and memory is ok. R3's Face Sheet, not dated, documents R3's was admitted on [DATE]. On 7/3/2023 at 9:55 AM R3 stated that the staff threatened him with bodily harm, talked bad about his hair and called him (expletive) nuts. R3 stated that the staff wanted him to take a shower and gave multiple reason why he should take a shower. R3 stated that he told them he didn't want to take a shower because he has the wounds to his butt. R3 stated that he would take a bed bath. R3 stated that V5, Minimum Data Set Coordinator, MDSC began telling R3 that his hair was greasy and that there was an odor in his room. R3 stated that V5 told him that she would take him to the shower kicking and screaming and that he was getting a shower. R3 stated that he told her he was not taking a shower. R3 stated that V5 then called him (expletive) nuts. On 7/3/2023 at 1:30 PM V5 stated that staff asked her to talk to R3 about taking a shower. V5 stated that she told him that he was dirty, had an odor, his hair was oily and dirty. V5 stated that R3 refused to take the shower. V5 stated that they offered to put R3 in a wheelchair and give him the shower and R3 continued to refuse. V5 stated that she said she was done and left the room. V5 stated that she did not threaten R3 with physical harm. V5 stated that she did not call R3 a name and did not say He was (expletive) nuts when in R3's room. V5 stated that she did say that R3 was (expletive) nuts in the hallway. V5 stated We all said it. On 7/5/2023 at 1:31 PM V10, CNA, stated that this all started with a shower. V10 stated that initially she went into the room and was talking with R3. V10 stated that R3 had a foul body odor and was dirty. V10 stated that she informed him that she had found a wheelchair that he can be on his side so that he doesn't have to sit on his bottom and experience pain. V10 stated that initially R3 stated yes. V10 stated that went and got everything ready and when she went to get him for the shower he refused. V10 stated that someone went and got V5. V10 stated that V5 said some stuff she shouldn't have said. V10 stated that V5 told R3 that he stinks and that they would take him to the shower kicking and screaming if they had to, they would drag you in there. V10 stated that R3 then was saying that he knows his rights and that they were not going to threaten him with physical harm. V10 stated that as V5 was exiting the room, V5 stated He is (expletive)nuts.V10 stated that V1, Administrator was aware and went down to see R3 as well. On 7/6/2023 at 2:46 PM V1, Administrator, stated that she was not notified of an allegation of abuse. V1 stated that R3 did not report to her that V5 threatened him with bodily harm and told him he was (expletive) nuts. V1 stated that she expects her staff to report abuse if they witness and/or are aware of abuse occurring. V1 stated that she would then initiate the abuse policy. The facility's Abuse Prevention Program, dated 11/28/2016, documents Policy: This facility affirms 146040 Page 3 of 6 146040 07/06/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the right of our resident to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. It also documents This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff. It also documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. IV Employees are required to immediately report an occurrence of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. VI. Once the Administrator or designee receives an allegation of mistreatment, exploitation, neglect or abuse the administrator appoint a person to take charge of the investigation. VII. The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect, or abuse, are reported immediately to the administrator of the facility and to other officials in accordance with Stated law through established procedures. A written report shall be sent to the Department of Public Health. 146040 Page 4 of 6 146040 07/06/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to provide pain management for 1 of 3 residents (R3) reviewed for pain management in the sample of 3. Residents Affected - Few Findings include: R3's Baseline Care Plan, dated 7/1/2023, documents that R3 is alert to time, self, others, place, and memory is ok. R3's Face Sheet, not dated, documents R3's admit date as 6/21/23. R3's Physician Order Sheet, dated 6/21/23, documents Oxycodone (narcotic pain medication) immediate release, 10 milligram (mg) 1 tablet orally every four hours as needed. R3's signed script, dated 6/21/23, documents Oxycodone 10mg oral every four hours as needed. Dispense #12 (12 tablets). No refills. R3's Controlled Substance Record, dated 6/22/23, documents Oxycodone immediate release10mg take 1 tablet by mouth every 4 hours as needed for pain. 6/22/23 8 PM #12 arrived. 6/22/23 8PM first dose given. 6/25/23 4 AM last dose was given. R3's Nurse's Note, dated 6/22/23 at 8:25 AM, documents that R3 was already requesting refills on oxycodone and the nurse explained the process. On 7/5/2023 at 11:10 AM R3's medical record was reviewed. R3's medical record did not have a Pain Assessment Form. As of 7/6/2023 the facility did not provide the pain assessment form. On 7/3/2023 at 9:55 AM, R3 stated that when he came from (Rehab Facility) he came with a script for Oxycodone. R3 stated that this was for a specific number of pills. R3 stated that once at the facility the facility doctor would then extend the prescription. R3 stated that he was informed by the facility that the house doctor had to see him before he would prescribe more of the pain medication. R3 stated that he was ok with this. R3 stated that he thought it would be before he ran out. R3 stated that he was told that the doctor only comes once a month. R3 stated that he was out of pain medicine for 2 days. R3 stated that he has a huge wound on his butt that causes him pain and he needs his medication. On 7/3/2023 at 1:20 PM V8, Licensed Practical Nurse, stated that R3 did run out of his Oxycodone. V8 stated that R3 was taken over by the V15, Facility Physician. V8 stated that R3 would have to be seen by V15 before a script for Oxycodone would be written. V8 stated that V15 had not been in yet to see R3. On 7/5/23 at 9:37 AM V2, Director of Nursing, stated that the facility process is that the resident is seen by the doctor before a script can be written. V2 stated that V15 likes to see his patients before prescribing pain medication. V2 stated that V15 had not made it in yet. On 7/5/2023 at 4:08 PM V16, Regional Clinical Nurse, stated that some physicians like to see their patients before prescribing narcotic medication. When asked that this would be before the resident ran out of pain medication, V16 responded yes. 146040 Page 5 of 6 146040 07/06/2023 Evercare of Jerseyville 410 Fletcher St Jerseyville, IL 62052

F 0697 Level of Harm - Minimal harm or potential for actual harm The facility's Pain Prevention and Treatment policy, dated 12/7/2017, documents It is the facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (activities of daily living) functioning and enhance quality of life. Residents Affected - Few 146040 Page 6 of 6