Evercare at Stearns

Inspectors wroteBased on interview, observation, and record review, the facility failed to Implement fall interventions to reduce falls for 2 of 5 residents (R3, R7) reviewed for resident safety in the sample of 59.

Inspectors wroteBased on interviews, observations and record review, the facility failed to provide complete incontinent care for 4 out of 5 residents (R8, R3, R19, R36); reviewed for incontinent care in a sample of 59.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a comfortable and good repair environment for 1 of 3 (R3) residents reviewed for bed mobility in a sample of 59.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from resident-to-resident abuse for 3 of 3 residents (R2, R7, and R9) in a sample of 24. This failure resulted in R3 physically assaulting R7 and R7 being sent out to the hospital and receiving staples for a head laceration, R9 being slapped on the right side of his face and a red area appearing, and R2 being struck in the face with a cane and sustaining a laceration to her right jawline. Findings Include: R3's Local Hospital Referral, admission date of 09/30/25, documented the following: History of Present Illness (HPI)/Subjective. Patient (Pt) is a [AGE] year-old African American male with past medical history of dementia and Traumatic brain injury. Patient currently lives with wife at home. Per wife patient gets more confused as the day goes on. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure sexual abuse did not occur for 1 of 4 residents (R3) reviewed for abuse and neglect of a sexual nature in the sample of 6. This failure resulted in R2 touching R3 inappropriately when R3 could not deny the advances or give her approval or consent. R3 was incapable of declining to participate in the sexual act and lacks the ability to understand the nature of the sexual act.

Inspectors wroteBased on observation, interview, and record review the facility failed to operationalize their abuse policy and procedures for 2 of 4 reviewed (R2 and R3) for policies in the sample of 6. On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant (PNC) for F600 abuse even though through their investigation they had no findings. V1 stated they did not believe the abuse occurred because (R2) use to be a certified nursing assistant, at this building. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure all alleged violations are thoroughly investigated for 2 of 4 residents (R2 and R3) reviewed for abuse investigations in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to label medication per current standards of practice. This has the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of a resident's narcotic pain medication for 1 of 3 (R3) residents reviewed for liquid narcotic medication in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to document an appropriate reason for discharge from the facility, the specific needs of the resident that could not be met at the facility, the services available at the receiving facility and issue a notice for 1 of 3 (R2) resident's reviewed for Admission, Transfer & Discharge Requirements.

Inspectors wroteBased on Interview, Observation, and Record Review, the Facility failed to maintain a resident's privacy and dignity for 4 of 6 residents (R18, R38, R56, R63) reviewed for resident privacy and dignity in the sample of 79. This failure resulted in R18 and R63 feeling embarrassed and uncomfortable. A reasonable person would expect to have privacy in their home and would experience anxiety, humiliation, and embarrassment if their privates were exposed. The Findings Include: 1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) residents reviewed for abuse in the sample of 79. This failure resulted in R36 suffering psychosocial harm and feeling scared, unsafe, unable to protect himself and less of a man. This failure also resulted in R90 suffering harm and being hit in the face, stomach and leg by another resident and R88 having a scratch to upper lip. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], moderately cognitively impaired. On 4/21/2025 at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. [...]

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 residents (R18) reviewed for wound care in the sample of 79. This resulted in R18 experiencing severe excoriation, including skin breakdown and pain. The Findings Include: R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safety as indicated per plan of care for 4 of 4 (R11, R17, R53, R72) residents reviewed for accidents and hazards in the sample of 79. This failure resulted in R72 suffering multiple falls and receiving a skin tear to her right knee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and discard expired medications for 30 of 32 residents (R11, R15, R18, R23, R27, R29, R30, R31, R32, R35, R39, R40, R41, R43, R44, R45, R46, R48, R58, R60, R63, R65, R81, R82, R86, R94, R96, R97, R101, R357) reviewed for medication storage in the sample of 79.

Inspectors wroteBased on Interview, Observation, and Record Review the Facility failed to provide timely and complete incontinent care for 4 of 5 residents (R18, R41, R42, R63) reviewed for incontinent care in the sample of 79. The Findings Include: 1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. [...]

Inspectors wroteBased on Interview, Observation, and Record Review, the Facility failed to provide a humidified bottle of water and to date the nasal cannula for 4 of 5 residents (R63, R65, R43, R13) reviewed for residents on Oxygen (O2) in the sample of 79. The Findings Include: 1. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen (O2), Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily living) related to impaired mobility. Diagnosis CVA/hemiplegia. [...]

Inspectors wroteBased on observation and interview the facility failed maintain a clean, homelike environment for 2 of 3 (R13, R27) residents reviewed for housekeeping in the sample of 79. 1. R13's MDS, dated [DATE], documents that R13 is cognitively intact. On 4/23/2025 at 1:29 PM R13 stated that the facility is filthy. R13 stated that the odor in the building is overwhelming. R13 stated that it's so many people that live here and not enough staff to take care of the building. R13 stated that the staff won't help each other and housekeeping only mop the floor. R13 stated they don't scrub it they only light run the mop that's it. 2. R27's MDS, dated [DATE], documents that R27 is cognitively intact. 04/23/25 at 02:28 PM R27 stated that the facility smells of urine and poop all the time. R27's BIMS is 15. R27 stated that there was a leak last time it rained heavy. [...]

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse for 4 of 4 (R36, R38, R49, R358) residents reviewed for Abuse in the sample of 79. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], documents moderately cognitively impaired. On [DATE] at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room. [...]

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of abuse for 1 of 4 (R38) residents reviewed for allegations of abuse in the sample of 79.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to refer a resident to the appropriate state-designated mental health or intellectual disability authority for review after being diagnosed with a serious mental disorder, intellectual disability or related condition for 1 out of 1 resident, (R53); reviewed for Coordination of PASARR (pre-admission screening and resident review) in a sample of 79.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to perform hand hygiene and removal of dirty gloves for 1 out of 1 resident, (R56); reviewed for infection control in a sample of 79.

Inspectors wroteBased on interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, and intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/30/24 when the facility failed to: 1. assess, monitor, and provide timely treatment for a change in R3's condition. 2. Notify the physician of R3's decline in ADLs from 11/30 through 12/4 and being unresponsive on 12/4/24 at 9:00 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the physician of R3's change in condition and unresponsive episode for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.

Inspectors wroteBased on interview and record review, the facility neglected to provide necessary medical services including assessing a change in resident's condition and recognizing when a resident needs emergent medical intervention. This failure resulted in the medical neglect of R3, who did not receive needed emergency medical treatment in a timely manner despite, over the course of five and a half hours, R3 exhibiting a significant decline in condition and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 6 residents (R3, R5, R35, and R259) reviewed for abuse in the sample of 45.

Inspectors wroteBased on interview and record review the facility failed to prevent significant medications errors regarding insulin administration for 4 of 6 residents (R16, R41, R42 and R104) reviewed for significant medication errors in the sample of 45.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents (R46) reviewed for pharmacy services in the sample of 45.

Inspectors wroteBased on interview and record review, the Facility failed to administer insulin timely as prescribed by physician for 1 of 3 residents (R2) reviewed for medications in the sample of 4.

Inspectors wroteBased on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 8 residents (R3 and R4) reviewed for abuse in a sample of 22. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so.

Inspectors wroteBased on interview and record review the facility failed to prevent misappropriation of resident property for 1 of 1 resident (R26) reviewed for misappropriation of property in a sample of 51. This failure resulted in R26 being upset and being a victim of theft of over $2000.00. Findings Include: On 5/3/2023 at 11:00 AM R26 was sitting up in her room in her chair. R26 stated she lived at the facility in the past and was discharged home then was recently readmitted to the facility. R26 stated she noted there were fraudulent charges on her bank card, but she didn't know what was going on because she had the bank card in her possession. R26 stated her family notified the local police regarding the fraudulent charges on her bank card. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain timely emergency medical services for the treatment of a fracture for one of one resident (R62) reviewed for quality of care in a sample of 51. This failure resulted in delay of treatment after R62 fell sustaining an acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid.

Inspectors wroteA. Based on interview and record review the Facility failed to provide supervision to prevent elopement for 1 of 1 resident (R65) from eloping in the sample of 51. This failure resulted in R65 being transferred to local hospital and treated for abrasions. B. Based on interview, and record review, the facility failed to implement safe transfer techniques and implement progressive interventions to prevent falls and accidents for 4 of 4 residents (R59, R47, R62) reviewed for supervision to prevent accidents in the sample of 51.

Inspectors wroteBased on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 7 residents (R2, R28, R68 and R303) reviewed for antibiotic stewardship in the sample of 51.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to report an injury of unknown origin to the Illinois Department of Public Health (IDPH) for 1 of 3 residents (R29) reviewed for reporting of abuse allegations in the sample of 51.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to investigate an injury of unknown origin for 1 of 3 residents (R29) reviewed for investigation of abuse in the sample of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 27 opportunities with 2 errors resulting in a 7.41% medication error rate. The errors involved 2 residents (R10, R51) in the sample of 51 out of 3 residents observed during medication administration.