Inspection·August 31, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Encourage to take showers and to have proper hygiene, provide preventative treatment to groin as ordered. It continues R7 requires assist with some ADLs related to impaired mobility, Diagnosis of Alzheimer's/Dementia, COPD. Interventions: Provide R7 with any and all ADLs as needed, provide R7 with set up assist and encouragement for those ADL tasks that he is able to perform independently. R7's MDS, dated [DATE], documents R7 is cognitively intact with BIMS of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7's call light was seen lying behind R7's nightstand and was not visible and unreachable for R7 to use. On 8/29/23 at 8:38 AM, R7's call light remains behind his nightstand and not visible or available for R7 to use. On 8/30/23 at 8:49 AM, R7's call light was seen in the same place, lying on the floor behind his nightstand and not visible or available to R7 to use. 3. R51's Face sheet, undated, documents R51 was admitted to the facility on [DATE]. R51's Medical Diagnosis include Osteoarthritis (OA), Idiopathic Peripheral Autonomic Neuropathy, Hyperlipidemia, Dementia, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, Anemia, HTN, Cognitive Communication Deficit, GERD, and Malignant Neoplasm of Tongue. R51's Care Plan, dated 7/24/23, documents R51 requires assist with ADLs related to impaired mobility, OA, Impaired Cognition/safety awareness due to Diagnosis of Dementia. Interventions: Provide assist with any and all ADLs as needed, provide set up assist/encouragement for those tasks that R51 is able to perform independently. R51's MDS, dated [DATE], documents R51 has a severe cognitive impairment with a BIMS of 3. R51 requires physical assistance from one staff member for bathing, supervision with set up help for personal hygiene and toilet use and is independent on dressing. R51 is occasionally incontinent of urine and always continent of bowel. On 8/28/23 at 11:12 AM, R51 call light was seen behind his nightstand and not visible and unavailable to R51. On 8/28/23 at 11:13 Am, R51 stated, I don't even know if I have a call light. On 8/29/23 at 8:48 AM, R51's call light remains on the floor and behind his nightstand, and is not visible, or available to R51 to use. On 8/30/23 at 8:47 AM, R51's call light remains lying on the floor behind R7's nightstand and is not visible or available to R51. On 8/31/23 at 10:15 AM, V1, Administrator, stated, We don't have a policy for call lights. I do expect the resident's call light to be always available to the resident and to be answered quickly once turned on. This upsets me because it is important to me. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 2 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0558 On 8/31/23 at 10:23 AM, V2, Director of Nursing, (DON), stated, I would expect all staff to make sure all residents have their call light within reach and to answer it as soon as possible. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 3 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to respect the resident's rights to receive packages and mail unopened. This failure has the potential to affect all 72 residents residing in the Facility. Residents Affected - Many Findings include: 1. On 8/29/2023 at 1:15 PM, R41 stated, I've had 6 or 8 letters opened and amazon packages opened multiple times. Maybe they thought they were opening (R41's name)'s mail. That's how it was explained to me. The package (that was opened) is what really p**sed me off. It was just coffee and sugar, not like it was heroin. On 8/31 at 11:25 AM, R41 stated, I had a Wal-Mart and Amazon package opened. Best guess is they mixed it up. There is a shipping label on the package and you could see it had been taped back up with clear tape. It really boggles my mind. It looked like someone put some real effort into opening it. The Amazon package looked like it was cut open with a razor. I know I'm not the only one but I don't remember who else had it happen. I just heard about it in passing. 2. On 8/29/2023 at 1:20 PM R37 stated, I have had letters open when I got them a couple times. On 8/30/2023 at 11:54 AM, R37 stated, Sometimes my mail is open. You can tell it has been taped back shut. It happens about twice a month. Sometimes it's from Social Security. I think it should be my business, not this places'. I don't know what they are looking for. The Resident Council Meeting Minutes dated 5/30/2023 documents the Resident Rights Reference and it includes, Right to send and receive mail unopened. The Resident Bills of Rights dated 1/23 documents, Each resident has a right to a dignified existence, self-determination, and communications with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of United States without interference, coercion including those rights specified herein. Facility residents shall have the right to: Send and receive mail promptly and unopened. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 4 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide privacy for 1 of 6 residents (R15) reviewed for incontinent care in a sample of 32. Residents Affected - Few Findings include: On 08/29/2023 at 9:35 AM, V6, Certified Nurse Assistant, (CNA), and V7, CNA unfastened R15's adult incontinent brief, exposing R15's penis, groin, abdominal fold. After incontinent care, V6 doffed her gloves, V6 then performed hand hygiene in R15's bathroom and donned gloves, leaving R15's penis and groin expose. V6 and V7 both CNAs, performed incontinent care to R15's peri rectal and buttock area and when it was complete V6 and V7, both doffed their gloves and performed hand hygiene in the bathroom. R15's private areas were left exposed. Care plan dated 07/2023 documented, provide me skin care after any incontinent episode. On 08/31/2023 at 9:10 AM V4, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/31/2023 at 9:15 AM, V17, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/30/2023 at 3:45 PM, V2, Director of Nurses, stated she would expect the CNAs to keep residents covered while performing incontinent care. The Facility's policy, Incontinent Care, dated 07/2012, documented, 6. Provide privacy. 9. Avoid unnecessary exposure of the resident during the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 5 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R24's Face Sheet dated 8/30/2023 documents, R24 has had a stroke. Residents Affected - Some R24's MDS dated [DATE] documents, R24 is cognitively intact and requires extensive assistance with personal hygiene needs. R24's Care Plan dated 11/10/2022 documents, R24 requires assist with ADL related to impaired mobility. Provide assist with any and all ADLs as needed. On 8/29/2023 at 1:21 PM, R24 stated, I don't have anyone to do it (nails). I don't have strength in my left hand and I'm left-handed. R24 looked at her nails and stated, They need fixed. I used to always keep them nice and painted. They need trimmed quite a bit. R24's nails were observed to be long, some being one centimeter past the fingertip, jagged, uneven and with faded nail polish. On 8/29/2023 at 3:15 PM, V18, Certified Nursing Assistant stated, R24's shower days are Wednesday and Saturday evenings. On 8/31/2023 at 10:30 AM, V2 Director of Nursing, (DON), stated, nails care should be done on shower days. 4. R57's Face Sheet documents, R57 has a diagnosis of osteoarthritis and neuropathy. R57's MDS dated [DATE] documents, R57 is cognitively intact and requires extensive assistance with personal hygiene needs. R57's Care Plan dated 8/9/2022 documents, R57 requires assist with Activities of Daily Living related to neuropathy, osteoarthritis, and impaired cognition/safety awareness. Provide assist with any and all ADLs as needed. On 8/28/2023 at 2:03 PM R57's nails to bilateral hands were long, a half of a centimeter past his fingertips and had a dark substance underneath. R57 had concerns with how long his nails were. R57 stated, he has scratches on his back, because he has neuropathy and cannot feel when he is scratches himself. R57 stated, I've asked them to clip them, but I guess they forget. On 8/30/2023 at 10:00 AM, R57's nails remained long and unkempt. R57 stated, They still need cut. On 8/31/23 at 10:27 AM V2, Director of Nursing, (DON), stated, I saw (R57's) nails yesterday, I had the CNA clean them up. On 8/31/2023 at 11:16 AM, R57 stated, he felt much better about his nails after they were clipped. R57's nails were observed to be shorter and clean. 5. R21's Face sheet, print date of 08/31/23, documents R21 has diagnoses of but not limited to hyperlipidemia, old myocardial infarction, hypertension, obstructive and reflux uropathy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 6 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R21's Minimum Data Set (MDS), dated [DATE], documents R21 is severely cognitively impaired and requires extensive assistance, one-person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and physical help in part of bathing, one-person physical assist. He has an indwelling catheter and is always incontinent of bowel. R21's Care Plan, admission date of 08/08/23, documents I (R21) request assist with my ADLs related to (r/t) impaired mobility, impaired cognition, diagnosis (dx) dementia, and Congestive Heart Failure (CHF). I will choose not to shave. Provide me assist with any and all ADLs as needed. Provide me set up assist and encouragement for those tasks that I am able to perform independently. On 08/28/23 at 10:46 AM, R21 was observed lying in his bed with his head elevated. His hair was disheveled/unkept, his beard was long, his fingernails were long, and his toenails were observed to be long, thick, brown in color, and curled under. His feet were dry and scaly with skin flaking off them. R21's shower sheets for the month of August 2023 were reviewed and document the following: 08/10/23- no shower sheet was found in the shower book. 08/14/23- documents he refused a shower. 08/17/23- no shower sheet was found in the shower book. 08/21/23- documents he was in the hospital. 08/24/23- documents he refused. 08/28/23- no shower sheet was found in the shower book. 08/31/23 10:30 AM V2, Director of Nursing (DON) stated she would expect the showers to be given per the shower schedule if the resident will let them give it. She said she would expect the fingernail and toenail care to be done at the same time as the showers and as requested by the resident. The facility policy Bath/Shower-Dependent, undated, documents Policy: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. Responsibility: Nursing Assistants or Licensed Nurses monitored by Charge Nurse. It further documents Equipment: 3. Soap/shampoo 4. Shower/tub chair 5. Gloves It also documents Procedure: 4. Apply gloves. 5. Assist resident to shower/tub chair, if appropriate. It further documents 11. Wash face with warm washcloth. 12. Shampoo hair unless done by beautician. 13. Bathe, rinse, and dry upper body with special attention under breast. 14. Bathe, rinse, and dry lower body with special attention to groin, skin folds and between toes. The facility policy A.M. Care, undated, documents Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants. Equipment: 1. Wash basin (for bed resident) 2. Washcloth and towel 3. Soap 4. Comb and brush 5. Toothbrush, toothpaste, drinking glass and emesis basin 6. Shower chair or wheelchair 7. Razor, shaving cream Procedure: 4. Provide oral hygiene. 5. Resident to wash, rinse, and dry face and hands if able. 6. Wash, rinse, and dry underarms (also under female breast). Wash perineal and rectal areas. 8. Apply deodorant as needed. 9. Dress or assist resident to dress include shoes, stockings, and undergarment. 10. Provide nail care as needed. 11. Provide/ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 7 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assist with shaving (male and female) as needed. 12. Position resident for comfort. Place call light within easy reach. Based on observation, interview and record review, the facility failed to provide assistance with grooming and hygiene to dependent residents for 5 of 8 residents (R7, R21, R24, R51, R57) observed for Activities of Daily Living, (ADL), in the sample of 32. Findings include: 1. R7's Face sheet, undated, documents, R7 was admitted to the facility on [DATE]. R7's Medical Diagnosis, Chronic Obstructive Pulmonary Disease, (COPD), Alzheimer's Disease, Dementia, Arteriosclerotic heart disease, (ASHD), Major Depressive Disorder, Anemia, Hypertension, (HTN), Alcohol Dependence, and Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents, R7 is at risk for skin issues related to, impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin, due to my hygiene practices. Encourage me to take my showers and to have proper hygiene, provide me preventative treatment to my groin as ordered. It continues R7 requires assist with some ADL related to, impaired mobility, Diagnosis Alzheimer's/Dementia, COPD. Interventions: Provide me with an and all ADLs as needed, provide me with set up assist and encouragement for those ADL tasks that I am able to perform independently. R7's Minimum Data Set, (MDS), dated [DATE], documents, R7 is cognitively intact with Brief Interview for Mental Status, (BIMS) of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7 was seen sitting in his wheelchair with a strong odor of urine and body odor that was smelled from outside his door. R7 appears dirty, clothes are soiled with a t-shirt which was yellow and stained in color, and soiled pants. R7 stated he uses the restroom himself and showers maybe once a week. R7 said he changes his clothes himself. On 8/28/23 at 10:24 AM, V4, Certified Nursing Assistant, (CNA), stated, I know that (R7) gets his showers, I make sure of it. I worked Saturday and he got one then. I can't help it if the other shifts don't change his clothes. On 8/29/23 at 8:38 AM, R7 wheeling himself around in wheelchair with a strong body/urine odor and the same clothes that he had on yesterday. R7's sweatpants appear soiled and urine stains from his groin to his knees. On 8/29/23 at 11:58 PM, V9, Licensed Practical Nurse, (LPN), saw R7 on his way to the dining room for lunch and noticed he was saturated in urine, had very soiled clothing on, and had a strong odor coming from him. V9 took R7 to his room and alerted V6, CNA, who assisted R7 to get cleaned up. V6 put R7 in the restroom, gave R7 wet washcloths sprayed with peri-cleaner, with which R7 wiped himself. V6 gave R7 a clean pair of pants and a clean shirt, and R7 put them on. R7 stated he has not changed clothes yet today. The Facility's Shower schedule documents, R7's showers are scheduled on Wednesdays and Saturdays on Days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 8 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0677 Level of Harm - Minimal harm or potential for actual harm The Facility's Shower sheets were reviewed for the past two weeks with R7 having a shower sheet completed on 8/16/23 (Wednesday), 8/19/23 (Saturday), 8/23/23 (Wednesday), and the one undated which is a blank page - in the 8/26/23 section of book. The 8/19/23 sheet documents, Will only do on Weds. The 8/23/23 sheet documents, shower given with clothing clean and dry, hair washed and combed, nails cleaned and trimmed, dentures cleaned and in place. Residents Affected - Some 2. R51's Face sheet, undated, documents R51 was admitted to the facility on [DATE]. R51's Medical Diagnosis include Osteoarthritis, Idiopathic Peripheral Autonomic Neuropathy, Hyperlipidemia, Dementia, Type 2 DM, Major Depressive Disorder, Anemia, HTN, Cognitive Communication Deficit, GERD, Malignant Neoplasm of Tongue. R51's Care Plan, dated 7/24/23, documents, R51 requires assist with ADLs r/t impaired mobility, OA, Impaired Cognition/safety awareness d/t Dx Dementia. Interventions: Provide assist with any and all ADLs as needed, provide set up assist/encouragement for those tasks that I am able to perform independently. R51's MDS, dated [DATE], documents, R51 has a severe cognitive impairment with a BIMS of 3. R51 requires physical assistance from one staff member for bathing, supervision with set up help for personal hygiene and toilet use and is independent on dressing. R51 is occasionally incontinent of urine and always continent of bowel. On 8/28/23 at 11:12 AM, R51 wheeling himself around the facility in his wheelchair, appears with greasy hair, strong odor of urine. R51 stated he's wet now and he is incontinent in his brief. R51 stated he can use restroom himself but is incontinent at times. On 8/29/23 at 8:48 AM, R51 was seen in the dining room in wheelchair, appears to have greasy hair, same clothes as yesterday, rolling around facility. R51 stated he didn't get a shower yesterday and doesn't remember the last one he got. R51 stated he is wearing the same clothes as yesterday because they seem clean to him. On 8/29/23 at 1:38 PM, V7, CNA, stated, I gave (R51) a shower on Saturday (8/26/23). I start with his hair and go to his face and work my way down. I was supposed to complete the shower sheet, but I did not that day. (R51) has thin hair and I think his scalp is oily and that is why he looks greasy. The Facility's Shower schedule documents, R51's showers are scheduled on Wednesdays and Saturdays Evenings. The Facility's Shower sheets were reviewed for the past 2 weeks with R51 having two shower sheets, one on 8/16/23 documenting, a shower with hair washed, nails cleaned, and clean clothing on. The other shower sheet was on 8/26/23 and only has the word shower written on it with nothing else documented. On 8/31/23 at 10:27 AM, V2, Director of Nursing, (DON), stated, I would expect the staff to provide the residents a bath as scheduled and a clean change of clothes daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 9 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely and complete incontinent care for 4 of 5 (R7, R15, R59, R65) residents, reviewed for incontinent care in a sample of 32. Findings includes: 1. On 08/30/2023 from 10:00 AM until 1:20 PM, using 15-minute intervals, R59 was up to her wheel chair in an activity and then was taken out to the dining room for lunch. At 1:10 pm R59 head was lowered towards the dining room table. A staff member was sitting next to R59 assisting another resident with eating. At 1:15 PM, R59 was taken out of the dining room, by a staff member and placed at the nurse's station. At 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room and R59 stated she was tired. V14 stated she was not able to check R59 because she was busy taking care of and getting other residents up for therapy. V14, CNA unfastened R59's urine-soaked adult incontinent brief and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold and labia. V14, then took another hand full of disposable wipes and in a circular motion cleansed R59 right buttock, vaginal and rectal area with the same wipes and not folding them over or getting a new disposable wipe. R59's Face sheet, dated 08/31/2023, documented, diagnoses of cognitive communication deficit and a history of falling. R59's Physician orders, dated 08/2023, documents, an order for Barrier cream to buttock daily, (as needed). R59's Minimum Data Set, (MDS), dated [DATE], documented R59's cognition was severely impaired. R59 requires extensive assistance of 2 staff members for transferring to and from wheelchair to bed, toileting and personal hygiene. R59's MDS, documents R59 is always incontinent of bowel and bladder. R59's Care Plan, dated 12/30/2022, documented, Assist me with repositioning as needed. Provide me skin care after any incontinent episode. Provide me assist with any and all, (activity of daily living), as needed. 2. On 08/30/2023 at 9:35 AM, V6, CNA, took a disposable cleansing wipe and cleansed R15's right hip from back to front twice without using a clean wipe or turning the wipe over. R15's Care plan, dated 07/2023, documented, Provide me skin care after any incontinent episode. R15's Face sheet, dated 08/31/2023, documented, diagnoses of Overactive bladder, history of falling, and chronic kidney disease, stage 3 unspecified. R15's MDS, dated [DATE], documented R15's cognition was severely impaired, requires extensive assist of 2 staff members for toileting and extensive assist of 1 staff member for personal hygiene. On 08/31/2023 at 09:10 AM, V4, CNA stated residents are checked for incontinence, turned and reposition every 2 hours or sooner and that residents are cleansed from front to back when doing incontinent care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 10 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0690 Level of Harm - Minimal harm or potential for actual harm On 08/31/2023 at 09:20 AM, V17, CNA stated residents are checked for incontinence, turned and repositioned every 2 hours. V17, also stated, that residents are cleansed from front to back when doing incontinent care. 3. R7's Facesheet, undated, documents, R7 was admitted to the facility on [DATE]. Residents Affected - Some R7's Medical Diagnosis, COPD, Alzheimer's Disease, Dementia, ASHD, Major Depressive Disorder, Anemia, HTN, Alcohol Dependence, HTN, Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents, R7 is at risk for skin issues r/t impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin d/t my hygiene practices. I will refuse to allow staff to assist me. Encourage me to take my showers and to have proper hygiene, provide me preventative treatment to my groin as ordered. R7 requires assist with some ADLs r/t impaired mobility, Dx Alzheimer's/Dementia, COPD. I will often refuse to allow staff to assist me with grooming and hygiene. I frequently refuse to shower. Interventions: Provide me with any and all ADLs as needed, provide me with set up assist and encouragement for those ADL tasks that I am able to perform independently. R7's MDS, dated [DATE], documents, R7 is cognitively intact with BIMS of 13. R7 requires physical help of one staff member for bathing and set up and supervision of one staff member for personal hygiene and toilet use. On 8/28/23 at 9:40 AM, R7 was seen sitting in his wheelchair with a strong odor of urine and body odor that was smelled from outside his door. R7 appears dirty, clothes are soiled with a white t-shirt which was yellow in color and soiled pants. R7 stated he uses the restroom himself, and showers maybe once a week, and he changes his clothes himself. On 8/29/23 at 8:38 AM, R7 was seen wheeling himself around in his wheelchair, with a strong smell of urine odor, with the same clothes that he had on yesterday, grey sweatpants appear very soiled with urine stains from the groin to the knees. On 8/29/23 at 9:25 AM, R7 sitting in his wheelchair in his room, with the front of his sweatpants wet and soaked with urine, a strong urine odor noticed upon entrance to room. On 8/29/23 at 10:30 AM, R7 continues to sit in his wheelchair with same soiled sweatpants and strong odor of urine. On 8/29/23 at 11:20 AM, R7 sitting in his wheelchair, now pants are soaked from crotch to knees. Strong odor of urine. On 8/29/23 at 11:58 PM, V9, Licensed Practical Nurse, (LPN), saw R7 on his way to the dining room for lunch and noticed he was saturated in urine. V9 took R7 to his room and alerted V6, CNA, who assisted R7 to get cleaned up. V6 put R7 in the restroom, gave him wet washcloths sprayed with peri cleaner. R7 wiped himself up. V6 gave clean pair of pants and he put them on, gave R7 deodorant to use and a clean shirt. R7 stated he has not changed clothes yet today. 4. R65's Facesheet, undated, documents, R65 was admitted to the facility on [DATE]. R65's Medical Diagnosis include Dementia, Type 2 Diabetes Mellitus, (DM), Major Depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 11 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0690 Disorder, Hyperlipidemia, Cerebral Infarction, Hypertension, (HTN), and Benign Prostatic Hyperplasia. Level of Harm - Minimal harm or potential for actual harm R65's Care Plan, dated 7/26/23, documents, R65 is at increased risk for skin issues related to impaired mobility, impaired cognition/communication, Dementia, and Incontinence. Interventions: Provide with skin care after each incontinent episode. Residents Affected - Some R65's MDS, dated [DATE], documents, R65 has a severe cognitive impairment with a Basic Interview for Mental Status, (BIMS), of 3. R65 requires extensive assistance from one staff member for all ADLs. R65 is always incontinent of bowel and bladder. On 8/29/23 at 10:18 AM, R65 was seen lying in bed. When V4, CNA, and V6, CNA, entered to provide incontinent care all supplies were already sitting on the bedside table. Both CNAs washed hands in restroom sink and donned gloves. V4 used wet disposable wipes to wipe R65's penis, scrotum, and groins. V4 doffed her gloves, wiped her face with her hands and then washed her hands in the restroom sink. V4 donned clean gloves and wiped R65's buttocks and anal area from back to front, (crease of buttocks to scrotum). V4 did not change her gloves and continued to tuck the soiled incontinent brief under R65, then a clean incontinence brief was tucked under R65. R65 was rolled onto the new brief and the brief was secured. During the incontinent care, V6's cell phone rang and V6 pulled it out of her pocket with her gloves on and stopped the ring and placed it back in her pocket, then continued to assist in the incontinent care. On 8/31/23 at 10:24 AM, V2, Director of Nursing, (DON), stated, I would expect the staff to provide timely and complete incontinent care to all residents. The Facility's Incontinent Care Policy, dated 7/2012, documents, To provide routine, preventive skin, perineal care to residents after an incontinent episode. 6. Provide Privacy. 7. Put on gloves before removing wet and/or soiled items. 9. Avoid unnecessary exposure of the resident during the procedure. 11. When washing perineal area, wash the entire area moving from front to back. For male residents retract the foreskin while using a clean area of the washcloth for each stroke. 12. Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back. 14. Dry the perineal area front to back and all skin surfaces washed. 16. Remove gloves and discard. Wash hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 12 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the daily nursing staff posting was current for 2 of 4 days of the survey. This failure has the potential to affect all 72 residents residing in the facility. Residents Affected - Many Findings include: On 08/28/23 at 08:30 AM, an observation was made of the daily nursing staff posting, dated 08/21/23, located inside of the main entrance doors. It documents there were currently 72 residents residing in the facility at the start of the shift. It specified the Registered Nurses, (RNs), and Licensed Practical Nurses, (LPNs), work 12-hours shifts but did not specify the times of the shifts. It did not specify the times or shifts the Certified Nursing Assistant, (CNAs), were to work. On 08/29/23 at 11:04 AM, and observation was made indicating the daily nursing staff posting had not been changed. On 08/29/23 at 11:15 AM, V1, Administrator stated the daily staffing should be updated every day. V1 said she currently doesn't have anyone to update the sheet but she will get it changed. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 13 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/30/2023 at 9:35 AM, V7, Certified Nurse Assistant, (CNA), donned gloves, pulled privacy curtain with her right hand that was gloved, and retrieved Neosporin (antibiotic ointment) out of R15's nightstand drawer. V7, CNA then applied Neosporin ointment just below R15's dressing to his coccyx. V7 placed the opened tube on R15's bed with the lid off. V7, CNA, stated R15's wife wants it on him and it helps with keeping the pressure off it. V7 then, with gloved hands, replaced the cap to the Neosporin ointment and placed it back in R15's nightstand drawer. R15's Physician orders, dated 3/29/2023 documented, Cala zinc cream to buttock and peri area daily as needed. There was not an order for the Neosporin ointment for the resident. R15's Care plan, dated 07/2023, documented, Provide me skin care after any incontinent episode. On 08/31/2023 at 9:10 AM, V4, CNA, stated she would not put medication on a resident because she is not a nurse. On 08/31/2023 at 9:15 AM, V17, CNA she would not put medication on a resident because she is not a nurse. On 08/30/2023 at 3:45 PM, V2, Director of Nurses stated the CNA's are not to put antibiotic ointment on any residents because it is beyond their Scope of Practice. Based on observation, interview, and record review, the facility failed to remove expired medications from the medication cart; failed to store Tuberculin (TB) Solution at the proper temperature; failed to discard the TB solution after 30 days as documented on the TB solution box in 1 of 2 medication carts inspected. Medications were left on three different resident's bedsides tables (R6, R15, R54) during med pass. This failure has the potential to affect all 72 residents residing at the facility. Findings included: 1. On 08/28/23 at 09:45 AM, The medication cart on the 200 hallway was inspected. The medication cart contained the following: 1. A bottle of Folic Acid 400mcg with an expiration date of 04/23. 2. A bottle of Vitamin B12 100mcg with an expiration date of 06/23. 3. A bottle of Geri Dryly allergy relief 25mg with an expiration date of 04/23. 4. A bottle of TB solution located in the medication drawer with an open date of 05/03/23. The package documents, store at 35 degrees to 46 degrees Fahrenheit (F), and discard after 30 days. On 08/28/23 at 09:55 AM, V3, Licensed Practical Nurse, (LPN), verified the above medications were expired and the TB solution should have been stored at a temperature of 35 to 46 degrees F and should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 14 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0761 have been disposed of after 30 days of opening. Level of Harm - Minimal harm or potential for actual harm On 08/31/23 at 10:25 AM, V2, Director of Nursing, (DON), stated she would expect the expired medications to not be on the medication cart. V2 stated the TB solution should not be on the medication cart, it should be kept in the refrigerator unless it is expired and then disposed of appropriately. V2 stated the TB solution is used for everyone in the facility. Residents Affected - Many 3. R6's Facesheet, undated, documents R6 was admitted to the facility on [DATE]. R6's Diagnosis include Cerebral Vascular Accident, (CVA), Hemiplegia, Idiopathic Peripheral Autonomic Neuropathy, COPD, Major Depressive Disorder, (MDD), Bipolar Disorder, Convulsions, Schizophrenia, Falls, Traumatic Brain Injury, HTN. R6's Care Plan, dated 8/11/23, documents R6 requires assist with ADLs related to Diagnosis of CVA left side hemiplegia, COPD. Interventions: I transfer independently, provide me assist with any and all Activities of Daily Living, (ADLs), as needed, encourage me to wait for assistance to ambulate. It continues R6 has a diagnosis of MDD, insomnia, bipolar disorder with use of psychotropic medication. Interventions: Administer medications as ordered, evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. It continues R6 requires healthcare monitoring related to Diagnosis of seizure disorder, Interventions: Administer medications as ordered. R6's MDS, dated [DATE], documents, R6 is cognitively intact with a BIMS 13 and is independent on bed mobility, transfers, and toilet use. R6 requires supervision for ambulation and locomotion and assist of one staff member for bathing. R6's MAR, dated August 2023, documents, Atorvastatin 10 MG, (milligram), Q, (every), Day at 8:00 AM, Fenofibrate 160 MG Q Day at 8:00 AM, Meloxicam 15 MG Q Day at 8:00 AM, Gabapentin 800 MG TID, (three times a day), at 8:00 AM, 12:00 PM, and 8:00 PM, Keppra 500 MG BID, (twice a day), at 8:00 AM and 8:00 PM, Fluphenazine 5 MG BID at 8:00 AM and 8:00 PM, and Fluoxetine 20 MG Q Day at 8:00 AM. On 8/28/23 at 10:10 AM, R6 was seen lying in bed with a medicine cup sitting on his bedside table with seven pills in it. On 8/28/23 at 10:11 AM, R6 stated, They put my medicines there on my table and I must have fallen asleep. They leave them there and I take it when I get up. On 8/29/23 at 11:30 AM, V9, Licensed Practical Nurse, (LPN), stated, Medications are never left at the bedside. I stand there and make sure the resident takes the medications before I leave. 4. R54's Facesheet, undated, documents, R54 was admitted to the facility on [DATE]. R54's Medical Diagnosis include Chronic Obstructive Pulmonary Disease, (COPD), Malnutrition, Major Depressive Disorder, Hypertension, (HTN), and Cognitive Communication Deficit. R54's Care Plan, dated 7/26/23, documents, R54 has a diagnosis of COPD and require healthcare monitoring. Interventions: Administer medications, inhalers, nebs as ordered. R54's Minimum Data Set, (MDS), dated [DATE], documents, R54 is cognitively intact with Basic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 15 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview for Mental Status (BIMS) of 15. R54 requires extensive assistance from one staff member for toileting and bathing. R54 requires limited assistance from one staff member for ambulation/locomotion. R54 is independent for bed mobility, transfers, and dressing. R54 is always continent of bowel and bladder. R54's Medication Administration Record, (MAR), dated August 2023, documents, Flonase one spray each nostril every Day at 8:00 AM. On 8/28/23 at 10:25 AM, R54 stated, The nurse has dropped my meds off at my table and did not wake me up. I woke up and my cup of meds were here. I woke up once and knocked the cup of meds off, and luckily, I found all of them on the floor. Flonase spray was seen sitting on R54's bedside table. On 8/29/23 at 8:30 AM, R54 stated, They took my Flonase that I always keep on my table to use. On 8/31/23 at 10:26 AM, V2, Director of Nursing, (DON), stated, I would expect the nurses to stay by the resident during medication pass to ensure that the resident takes all medications given. The nurses should not be leaving any medications at the bedside. The Facility's Medication Administration Policy, dated 8/2016, documents, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. 5. All current medications and dosage schedules are listed on the resident's medication administration record eMAR, (electronic medication administration record), /eTAR, (electronic treatment administration record), and administered timely according to facility policy. 15. For residents in the facility not in their rooms or otherwise unavailable to receive medication on the pass, the MAR/TAR is flagged. When a resident is unavailable, the medication will be administered as near to the scheduled time as able. for the eMAR, the nurse reviews my unsigned records. The Facility's Medication Storage Policy, dated 11/2010, documents, Medication supply must be accessible only to Licensed Nursing Personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. 6. Medications will be stored on the medication cart, or in other designated area for extra supply of medications, except for those requiring refrigeration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 16 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure that all required Professional Department Heads were present at their Quality Assurance meetings at least quarterly. This failure has the potential to affect all 72 residents residing in the facility. Residents Affected - Many Findings include: On 8/31/2023 the Facility's Monthly Facility Quality Assurance, (QA), and Meeting Minutes from January 2023 through August 2023 were reviewed. There was only one month, (June), that had been signed by V14, Medical Director, (MD). V11 Infection Preventionist, (IP), was not listed or included on any of the forms. On 8/31/2023 at 9:30 AM, V22 stated, she oversees the Quality Assurance Program and they meet monthly. V22 stated, I will go through them with you, (the Monthly Facility Quality Assurance and A Minutes). Is (V11, Infection Preventionist) supposed to be on this form? There is infection control stuff on here but the DNS, (Director of Nursing Services, V2), puts it into the minutes. You're right. There is only one (month signed by V14). The Monthly Facility QA and A form is dated 7/30/2022, but V22 stated, it was 7/30/2023 and corrected it on the form. The Facility's Quality Improvement Program dated 10/22 (October 2022) documents, The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identity potential problems and/or opportunities for improvement. The committee will implement and systemically evaluate programs and processes to identified problems in order to proactively improve health care delivery. On 8/31/2023 at 11:33 AM, V1, Administrator, stated she would expect anyone in attendance at the QA meeting to sign the form, to document that they were present. The Resident Census and Conditions of Residents form (CMS-672), dated 08/28/23, documents, there are 72 residents residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 17 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0880 Provide and implement an infection prevention and control program. 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 perform appropriate hand hygiene and glove changes for 4 of 6 (R15, R34, R59, R65) residents observed for infection control, in a sample of 32. Residents Affected - Some Findings include: 1. On 08/30/2023 at 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room, donned gloves without benefit of hand hygiene. V12, Licensed Practical Nurse, (LPN), entered R59's room, donned gloves without benefit of hand hygiene. V14 was able to unfasten R59's urine-soaked adult incontinent brief, and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold and labia. V12, LPN and V14, CNA, with the same gloved hands laid R59 to her left side. V14 took another hand full of disposable wipes and in a circular motion cleansed R59 right buttock, vaginal and rectal area with the same wipes and without benefit of hand hygiene or glove change. V14 then removed the urine-soaked adult incontinent brief and threw it on to the floor and placed a clean adult incontinent brief on the resident. 2. On 08/29/2023 at 9:35 AM, V6 and V7, both CNAs, performed hand hygiene, donned and gloves. V6, then took a folded-up piece of paper out of her shirt pocket and placed it on the nightstand. V6 then took the trash bag, and after V7 CNA pulled R15's covers back, V6 placed the trash bag on the bed, unfastened R15's adult incontinent brief, exposing R15's penis, groin, abdominal fold. V6, then took a wipe that was already on the overbed table and cleansed front to back R15's abdominal folds, bilateral groins, with a different wipe each time. V6 then doffed her gloves, performed hand hygiene, doffed her right glove then with her gloved hand pulled the privacy curtain so she could get back by R15's bed. R15 was then placed on his right side. V6 and V7 performed incontinent care, both doffed gloves and performed hand hygiene. V6 then donned her glove to her right hand and again pulled the privacy curtain with her gloved hand. V6 and V7 performed more incontinent care on R15. V7, then doffed her gloves, performed hand hygiene and donned gloves. With gloved hands V7 pulled R15's privacy curtain with her right hand that was gloved, retrieved Neosporin, (antibiotic ointment) out of R15's nightstand drawer and placed it on R15's bed. V7 then performed hand hygiene with alcohol-based hand rub (ABHR), and donned gloves. V7, CNA then applied Neosporin ointment just below R15's dressing to his coccyx. V7 placed the opened tube on R15s bed with the lid off. V7, then with the same gloved hands, replaced the cap to the Neosporin ointment and placed it back in R15's nightstand drawer. On 08/31/2023 at 09:10 AM, V4, CNA stated she washes her hands and changes gloves about 2 to 3 times during incontinent care and also if she touches a curtain with gloved hands, she would change gloves and wash her hands before she performs care on the resident. 08/31/2023 at 09:20 AM, V17, CNA stated she would wash her hands after incontinent care to the peri area was done as long as she did not cross contaminate. V17 stated she would change gloves and wash her hands if she touched an inanimate object, like a privacy curtain with a pair of gloves on before she provides incontinent care. 3. On 08/30/2023 at 10:30 AM V13, LPN performed hand hygiene and put gloves on. V13 then sprayed wound cleanser from a bottle that was used for multiple residents, on to 4x4 gauze pad and cleansed R34's pressure area. V13 then removed her gloves and performed hand hygiene and donned new gloves. V13 opened the calcium alginate with silver with her gloved hands and placed it in R34's wound bed. V13 then retrieved the bordered dressing out of an open package and placed it on top of the wound all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 18 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without benefit of hand hygiene and glove changes. V13 doffed gloves, performed hand hygiene, donned gloves. V13, LPN then touched the left side of her nose and with donned gloves, opened the calcium alginate package and applied the dressing to R34 wound. On 08/31/2023 at 09:15 AM, V16, Registered Nurse, (RN), Wound Nurse stated she would leave the dressings in the sterile packaging and when she was ready to use them, she would open them, performed hand hygiene and put on new gloves. 4. R65's Facesheet, undated, documents, R65 was admitted to the facility on [DATE]. R65's Medical Diagnosis include Dementia, Type 2 Diabetes Mellitus, (DM), Major Depressive Disorder, (MDD), Hyperlipidemia, Cerebral Infarction, Hypertension, (HTN), and Benign Prostatic Hyperplasia. R65's Care Plan, dated 7/26/23, documentsR65 is at increased risk for skin issues related to, impaired mobility, impaired cognition/communication, Dementia, and Incontinence. Interventions: Provide with skin care after each incontinent episode. R65's MDS, dated [DATE], documents R65 has a severe cognitive impairment with a Basic Interview for Mental Status, (BIMS), of 3. R65 requires extensive assistance from one staff member for all ADLs. R65 is always incontinent of bowel and bladder. On 8/29/23 at 10:18 AM, R65 was seen lying in bed. When V4 and V6, both CNAs, entered to provide incontinent care all supplies were already sitting on the bedside table. Both CNAs washed hands in restroom sink, both donned gloves. V4 used wet disposable wipes to wipe R65's penis, scrotum, and groins. V4 doffed her gloves, then wiped her face with her hands, and then washed her hands in the restroom sink. V4 donned clean gloves and wiped R65's buttocks and anal area from back to front, (crease of buttocks to scrotum). V4 did not change her gloves and continued to tuck the soiled incontinent brief under R65. Then a clean incontinence brief was tucked under R65 and he was rolled onto the new brief and the brief was secured. During the incontinent care, V6's cell phone rang and V6 pulled it out of her pocket with her gloves on and stopped the ring and placed it back in her pocket, then continued to assist in the incontinent care. On 8/31/23 at 10:25 AM, V2, Director of Nursing, (DON), stated, I would expect all staff to change their gloves when soiled, and to perform hand hygiene before care, during glove change, and after care. The Facility's Standard Precautions Policy, dated 9/2019, documents, Standard precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious, (HAI), agents among patients and healthcare personnel. 2. Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. Wear gloves when touching blood, body fluids, secretions, excretions, contaminated items with mucus membranes and non-intact skin. If hands move from a contaminated site to clean body site during care, wash hands using a non-antimicrobial soap and water, antimicrobial soap and water or alcohol-based hand rub. Wash hands before direct contact with patients. 5. Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. 6. Environmental control follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 19 of 20 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 146075 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Granite City 3500 Century Drive Granite City, IL 62040 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow up with hospital orders and clarify the need for an antibiotic for 1 of 4 (R33) residents reviewed for unnecessary mediations in the sample of 32. Residents Affected - Few Findings include: The Facility's Infection Control Log dated 8/1/2023-8/25/2023 documents, R33 had a urinary infection, no culture was performed and R33 was prescribed an antibiotic. R33's Progress Notes 8/1/2023 documents, R33's suprapubic catheter became clogged and R33 was sent to the local hospital. R33's Urinalysis dated it was collected 7/31/2023. It further documents R33's urine had >100,000 mixed urogenital flora (common bacteria). R33's Patient Visit Information documents, R33 was prescribed an antibiotic every 12 hours for 3 days for an acute UTI. R33's Medication Administration Record (MAR) dated August 2023 documents, R33 received this antibiotic. On 8/31/2023 at 1:00 PM, V23, Regional Nurse stated, It was normal flora so they wouldn't have prescribed an antibiotic. On 8/31/2023 at 1:10 AM, V2, Director of Nursing (DON) stated, We had already did a urine on her, went out to the hospital before we had the sensitivity. 08/31/23 10:30 AM V2, Director of Nurses stated for the infection control log, they refer to the lab results and don't order antibiotics unless the Medical Director orders the antibiotics for a resident. VS stated they will not give antibiotics until the culture and sensitivity are back from the lab and that the infection control nurse keeps record of all of it and calling the hospital for laboratory result and cultures. V2 stated they use the SBAR (Situation Background Assessment and Recommendation) tool for their criteria for infection control. The Facility's Antibiotic Stewardship Program dated 10/22 (October 2022) documents Actions to Improve Use -the Medical Director is the review the antibiotic Use Report and Physician's Practices Report quarterly and ensure that Physicians are following best practice. It further documents Pharmacy consultant is to review microbiology culture results and provide feedback on antibiotic selection to determine if the right drug was used to treat the infection. If continues to document microbiology culture data will be used to assess and guide future antibiotic selection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146075 If continuation sheet Page 20 of 20