Evercare of Granite City

Inspectors wroteBased on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture.

Inspectors wroteBased on interview and record review the facility failed to implement progressive interventions to reduce falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. [...]

Inspectors wroteBased on interview and record review the facility failed to revise care plans with progressive intervention following falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to prevent abuse for 6 out of 8 residents, (R1, R2, R3, R5, R6, R7) reviewed for abuse in a sample of 8. This failure resulted in R2 being hit in the face resulting in a bruised chin, feeling uncomfortable and R5 feeling unsafe in the facility.

Inspectors wroteBased on interview and record review the facility failed to prevent a resident-to-resident altercation for 2 of 5 (R2, R3) residents investigated for abuse. This failure resulted in R3 sustaining a minimal fracture to the left nasal bone. This past non-compliance occurred from 4/30/25 to 5/13/25.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to notify the nurse of a resident having a change in condition to ensure timely assessment for 1 of 4 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in R3 not having timely assessment and subsequently having a Hypoxic/Unresponsive episode, with Cardiopulmonary Resuscitation (CPR) started, and was hospitalized . The Findings Include: R3's admission Record, dated [DATE], documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). [...]

Inspectors wroteBased on interview and record review, the facility allowed Certified Nursing Assistants (CNA) to administer Oxygen to residents for 1 of 4 residents (R3) reviewed for administration of Oxygen (O2) in the sample of 5. The Findings Include: R3's admission Record, dated 3/18/25, documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on 3/7/25. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated 2/27/25, documents R3 was alert cognitively, is a fall risk, and receives special treatment: Oxygen. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility.

Inspectors wroteBased on interview and record review the facility failed to prevent resident to resident abuse for 2 of 7 residents (R29 and R42) reviewed for abuse in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe transfer for 1 of 5 residents (R64) reviewed for transfers in the sample of 31.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and observations, the facility failed to provide a call light that was within reach of the resident for 3 of 18 residents (R5, R7, R48) reviewed for call lights in the sample of 32.

Inspectors wroteBased 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.

Inspectors wroteBased 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.