Evercare at Edwardsville

Inspectors wroteBased on interview and record review, the facility failed to use the required equipment (gait belt) during transfer and appropriately use the full mechanical lift to prevent falls in 2 of 3 residents (R3, R29) reviewed for accidents and hazards in the sample of 38. These failures resulted in R3 sustaining a left femur fracture and R29 sustaining a hematoma to her head and requiring emergency care.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure food was stored in a manner that prevents foodborne illness. This has the potential to affect all 91 residents living in the Facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medication administration protocols were followed in 4 of 4 residents (R11, R21, R32, and R74) when reviewed for pharmacy services in the sample of 38.

Inspectors wroteBased on interview, observation, and record review, the Facility failed to provide palatable meals for 4 of 4 residents (R4, R24, R34, R50) reviewed for food and nutrition services in the sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent abuse for 2 (R4, R10) of 6 residents reviewed for abuse in the sample of 38. This failure resulted in R4 being tearful and scared of staff.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the facility's abuse policy regarding abuse for 2 (R4, R10) of 6 residents investigated for abuse in the sample of 38.

Inspectors wroteBased on observation, interview and record review the facility failed to report an allegation of abuse for 2 (R4, R10) of 6 residents reviewed for abuse in the sample of 38.

Inspectors wroteBased on observation, interview and record review the facility failed to investigate abuse for 2 (R4, R10) of 6 residents investigated for abuse in the sample of 38.

Inspectors wroteBased on interview and record review, the Facility failed to follow their abuse policy by reporting and investigating allegations of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the Facility failed to report an allegation of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the Facility failed to investigate an allegation of misappropriation for 1 of 3 residents (R3) reviewed for abuse in the sample of 8.

Inspectors wroteBased on interview and record review, the Facility failed to allow resident to remain at the Facility and failed follow proper procedures for discharge for 1 of 3 residents (R2) reviewed for discharge in the sample of 8.

Inspectors wroteBased on interview and record review, the Facility failed to communicate required resident information to the receiving provider for 1 of 3 residents (R2) reviewed for discharge in the sample of 8.

Inspectors wroteDeficiencies at this level require two deficient practice statements. A. Based on interview and record review the Facility failed to ensure residents were free of neglect for 1 of 3 residents (R2) reviewed for neglect in the sample of 16. This failure occurred when (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was put into place while the facility was waiting for the new provider to perform treatment. R2, who was receiving dialysis 5 days per week prior to her facility admission, subsequently did not receive dialysis services for 12 days, experienced shortness of breath, sweating, weakness, jaundice eyes, and critical lab levels (potassium levels (6.2 mEq/L - milliequivalents/Liter) (normal 3.4-5.0) ; [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure coordination of care for a resident to receive medically necessary hemodialysis for 1 of 3 residents (R2) reviewed for dialysis services in the sample of 16. This failure occurred when (R2) was admitted to the facility on [DATE] and did not receive dialysis services for 12 days. R2 was sent to the hospital per family request where she was found with critical lab values, shortness of breath and had a 5 day hospital stay.

Inspectors wroteBased on interview and record review the Facility failed to notify the physician for 1 of 3 residents (R2) reviewed for notification in the sample of 16. This failure resulted in R2's Physician not being notified when R2 did not receive dialysis for 12 days resulting in R2 being hospitalized .

Inspectors wroteBased on interview and record review the facility failed to provide enough licensed nursing staff to adequately meet the needs for 4 of 4 (R3, R10, R12, and R13) residents reviewed for staffing in the sample of 13. These failures have the potential to affect all residents residing at the facility.

Inspectors wroteBased on record review and interview the facility failed to administer medications at the scheduled times for 4 of 4 (R3, R10, R12, and R13) residents reviewed for medication administration in the sample of 13. These failures have the potential to affect all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R2), reviewed for abuse in the sample of 5. This failure resulted in R2 being hit in the face by R1, which resulted in redness and R2 feeling fearful of R1. Findings Include:On 8/6/25 at 3:35 PM, R1 was observed, when surveyor knocked on his door, R1 cracked the door, the surveyor asked if she could come into his room, he stated no, when asked if she could talk with him, he stated no and shut the door. R1 appeared paranoid. On 8/6/25 at 3:37 PM, R2 was observed in his room, in a wheelchair, calm, and pleasant. R2 stated he had an incident with R1 a while ago, he had opened R1's room door for him, to be nice, and R1 was cussing at him and hit him upside the head in the face and scratched his arms. R2 stated his head bled where R1 had hit him. [...]

Inspectors wroteBased on interview and record review the facility failed to perform timely incontinent care for 1 of 3 residents (R3) reviewed for incontinent care in the sample of 3. This failure resulted in R3 feeling embarrassed, ashamed, demeaned, disrespected, unwanted, and less than a man.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff to assist residents with incontinent needs to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident for 1 of 3 (R3) reviewed for staffing in a sample of 3. This failure resulted in a delay in incontinent care for R3 causing him to feel embarrassment, ashamed, demeaned, disrespected, and unwanted.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse for 3 of 3 residents (R71, R77, R78, R80) reviewed for abuse in the sample of 44. This failure resulted in R80 being pushed by R40 causing R80 to be sent out to the hospital.

Inspectors wroteBased on interview and record review, the Facility failed to ensure pain medications were readily available for administration in order to prevent increasing pain/discomfort for 1 (R1) of 3 residents reviewed for opioid medications, in the sample of 6.

Inspectors wroteBased on interview and record review, the Facility failed to ensure the availability of scheduled opioid medication for 1 of 3 residents (R1) reviewed for pharmacy services, in the sample of 6. This failure caused R1 to miss several doses of pain medication, resulting in discomfort and experiencing symptoms of withdraw.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure the Pre-admission Screen Resident Review (PASRR) recommendations were completed for a resident with a qualifying diagnosis and disruptive behaviors, ensure the resident assessments were accurate, as well as ensure the interventions for behaviors were successful for 1 of 3 residents (R4) reviewed for behavioral health services, in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure assessments were accurately completed to reflect the residents' current status for 2 of 3 (R1, R4) residents, reviewed for Resident Assessments, in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to administer ordered medications to 1 of 5 residents (R2) reviewed for pharmacy services in the sample of 9.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely and thorough incontinent care for 2 of 4 residents (R1 and R5) reviewed for incontinent care in the sample of 6.

Inspectors wrote2. R53's Face sheet documented an admission date of 6/6/2023. Diagnoses included Dysphasia, Chronic Atrial Fibrillation, Lymphedema, Type 2 Diabetes. R53's Minimum Data Set, MDS, dated [DATE], documented that R53 is significantly cognitively impaired. R53 is dependent on staff for rolling left to right, sitting to lying and sitting up on bedside. R53's Care Plan, dated 3/13/2024, documented, I have experienced an actual fall on 8/19/23, 1/2/24, 1/25/24, 3/12/24. Interventions include geri care to be ordered by hospice, dycem added to wheelchair, interdisciplinary to review fall and provide interventions as indicated, increased supervision, laid down after meals. R53's fall risk assessments, dated 3/12/2024, documented, (R53) is at high risk for falls. R53's fall risk assessments, dated 1/2/2024, documented that R53 was at high risk for falls. [...]

Inspectors wroteBased on interview and record review the facility failed to provide consistent pain relief and timely management of pain pump for 1 of 2 residents (R138) reviewed for pain management in the sample of 38. This failure resulted in R138's pain not being managed properly. Findings Include: R138's Face sheet documented that he was admitted on [DATE]. R138's Minimum Data Set (MDS), dated [DATE], documented that R138 was moderately cognitively impaired. R138's Pain Care Plan, dated 3/9/24, documented, Problem: I have potential for pain/discomfort R/T (Related to) Acute and chronic respiratory failure with hypoxia and weakness. Approach: Record/report to Nurse any s/sx (signs and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 85 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 85 residents living in the facility.

Inspectors wroteBased in interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 85 residents living in the facility. Findings Include: The facility's February 2024 Infection Log documented that R64 had a diagnosis of UTI (Urinary Tract Infection) and was given Cefdinir 300mg (milligrams) QD (daily) from 2/18/24 through 2/23/24. The February Infection Control Log did not document the organism and surveillance was not completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide/ensure the arbitration agreements were complete before the residents or resident representatives signed them for 5 of 5 residents (R28, R53, R70, R73 and R78) reviewed for arbitration in the sample of 38.

Inspectors wroteBased on interview and record review the facility failed perform antibiotic stewardship for 4 of 4 (R143, R142, R64, R28) residents reviewed for antibiotic stewardship in the sample of 38. Findings Include: 1. The facility's December Infection Control Log, documented that R143 was diagnosed with a Urinary Tract Infection UTI, and he was placed on Cipro 500mg twice daily (BID) from 12/8/23 through 12/22/23. The Organism was not documented on the December Infection Control Log so surveillance could be completed. R143's Physician Order Sheet (POS), dated from 12/1/23 through 12/31/23, documented, Cipro 500mg Twice daily from 12/9/23 through 12/11/23 at 8:00AM and 8:00PM. R143's Medication Administration Record for the month of December, documented that Cipro was given from 12/8/23 through 12/11/23. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and have a treatment in place to a new pressure ulcer for 1 of 5 residents (R40) reviewed for pressure ulcers in the sample of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is prescribed antipsychotic medications has specific, targeted behaviors warranting a need for that medication for 1 on 5 residents (R70) reviewed for unnecessary medications in the sample 38.

Inspectors wroteBased on interview and record review, the facility failed to notify the residents representative/POA (Power of Attorney) with a change in condition in 1 of 4 residents (R2) reviewed for Physician/Family notification in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to monitor, assess, and notify the physician of an acute change in condition to ensure timely medical treatment for 1 of 3 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in an Immediate Jeopardy when R3 began having ongoing respiratory distress with no medical monitoring resulting in death from pneumonia and acute respiratory failure. The Immediate Jeopardy began on [DATE] at 9:51 AM, when staff identified that R3 was having respiratory distress, failed to provide ongoing assessment/monitoring to address respiratory distressed caused by pneumonia. At 7:10 PM, R3 was found unresponsive, and the facility called 911. R3 expired at the hospital. V1, Administrator, and V2, Director of Nursing, were notified of the Immediate Jeopardy on [DATE] at 2:05 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Primary Care Physician of ongoing respiratory distress for 1 of 3 residents (R3) reviewed for notification in the sample of 5. This failure resulted in R3 having a delay in treatment and subsequent death.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 residents (R3) reviewed for neglect in the sample of 5. This failure resulted in R3 having ongoing respiratory distress from 8:00 AM until 7:10 PM without physician consultation and medical treatment. R3 expired from pneumonia and acute respiratory failure.

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage 8-hours daily, 7 days per week in the facility. This has the potential to affect all 82 residents in the facility.