Evercare of Jerseyville

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure meals were being served at regular times and without long waits. This has the potential to affect all 58 residents living 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 for 4 of 25 residents (R11, R30-R32) reviewed for food temperatures in the sample of 32. Findings inclue:On 6/25/2026 at 11:30 AM, V34, Dietary Manager was placing items from the oven into the steam table. V34, took the temperatures and recorded them in her Food logbook with no issues. No additional food temperatures were taken during the entire meal service, which lasted one hour and 48 minutes for the food service for 59 residents. During the lunch service after the last person had been served on 6/25/2026 from 1:01 PM-1:19 PM, R11, R30, R31 and R32 were all served the corn. On 6/25/2026 at 1:19 PM, the temperatures were taken with a calibrated metal thermometer, and the following items were not above 135 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review the facility failed to report a change in condition to a resident's family/responsible party for one (R5) of 3 residents sampled for notification in a sample of 33.

Inspectors wroteBased on interview and record review the facility failed to provide discharge planning and a letter stating when Medicare days would be exhausted for one (R4) of 3 residents at the facility sampled for resident's discharge rights in a sample of 33.

Inspectors wroteBased on interview and record review the Facility failed to ensure Residents' allergies were being followed/honored for 1 of 3 residents (R3) reviewed for allergies in the sample of 31. This failure resulted in (R3) being exposed to bleach which was listed as an allergy for her, and being sent to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse and resident background check policies by failing to screen for potentially abusive residents during the admission process, failing to report and track residents qualifying criminal offenses, failing to ensure a risk assessment was completed, and failing to implement protective measures to prevent abuse for 1 of 3 (R54) residents reviewed for abuse in the sample of 35. This failure resulted an Immediate Jeopardy when R62 was admitted to the facility on [DATE] without appropriate screening, referrals and interventions for criminal convictions and proceeded to sexually abuse R54. This has the potential to affect all 55 residents who reside in the facility. The Immediate Jeopardy began on 9/26/25 when R62 was admitted to the facility. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure 1 of 3 (R24) resident's call light in reach in a sample of 35. This failure resulted in R24 unable to call for help for over 2 hours. This also resulted in R24 sitting in urine, feeling angry, embarrassed, unwanted, depressed and a burden.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse of a resident from another resident with a known criminal history for 1 of 4 residents (R54) reviewed for abuse in the sample of 35. This failure resulted in R62 exposing his genitals to R54 and R62 then grabbed R54's breast. A reasonable person would expect to be safe in their home and would experience fear/anxiety, humiliation, and anger if physically and sexually abused. Findings Include:R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. R54's MDS (Minimum Data Set), dated 9/17/25, documented R54 is severely cognitively impaired and dependent on staff for ADLS (activities of daily living) and mobility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely and complete incontinent care for 4 of 4 (R7, R8, R22, R24,) residents in a sample of 35. This failure resulted in R24 feeling angry, embarrassed, unwanted, depressed and a burden.

Inspectors wroteBased on interview and observation, the facility failed to post the facility staffing data daily, reviewed for staffing in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication, label and discard expired medication. This has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to dispose of expired food items, to wear proper hair nets when required, and to practice proper infection control including using clean utensils and performing hand hygiene, reviewed for the storage, preparation, and sanitary serving of food in the sample of 35. These failures have the potential to affect all 55 residents in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform hand hygiene and to don appropriate Personal Protective Equipment (PPE) for 4 of 24 residents (R7, R8, R27, R54), and the laundry staff failed to don PPE while laundering isolation linen, all was reviewed for infection control in the sample of 35. These failures have the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the continuing competence of Certified Nursing Assistants (CNAs), by providing 12 hours of education and/or training per year, including dementia management training and resident abuse prevention training, reviewed for required training for CNAs in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to answer call lights timely for 4 of 24 residents (R2, R6, R12 and R30) reviewed for call lights in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall interventions as identified in resident care plans for 4 of 9 residents (R1, R9, R33 and R53) reviewed for accidents in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to identify and monitor the use of a lap tray for 2 of 2 (R27, R54) residents reviewed for restraints in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide eating assistance for 1 of 24 residents (R9) reviewed for assistance with eating in the sample of 35. On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. At 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide feeding assistance for a resident with weight loss for 1 of 24 residents (R9) reviewed for nutritional status in the sample of 35. On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop/implement interventions for 1 of 3 residents reviewed for pressure ulcers in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to employ a Registered Nurse as Director of Nursing (DON). This failure has the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to serve food in a sanitary manner, label, and date open food, ensure equipment is clean, and perform hand hygiene before donning gloves to prevent food borne illness. This has the potential to affect all 41 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a qualified individual responsible for the Infection Prevention and Control Program. This failure has the potential to affect all 41 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide incontinent care to prevent Urinary Tract Infections for 5 of 6 residents (R4, R5, R14, R26, R30) reviewed for incontinent care in the sample of 34.

Inspectors wrote4. On 8/27/2024 at 8:50AM during incontinent care V8, CNA gloved when providing incontinent care to R14. After providing incontinent care to V8 and while wearing the same gloves, V8 put on protective cream on R14's buttocks and place a new incontinent brief on R14 without changing gloves. V8 then put on R14's TED (Thrombo-Embolic Deterrent ) hose, put clothes on and placed a mechanical lift sling under R14 while wearing these same gloves. Based on interview, observation, and record review, the facility failed to perform hand hygiene, wear personal protective gowns, disinfect multi-use equipment, and post isolation signs for 6 of 16 residents (R4, R5, R14, R26, R30, R38) reviewed for infection control in the sample of 34.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to report an alleged allegation of abuse to Illinois Department of Public Health for 1 of 1 resident (R35) reviewed for reporting of alleged abuse in a sample of 34.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R35) reviewed for abuse investigations in a sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow plan of care and provide supplements as ordered to maintain acceptable parameters of nutrition for 1 of 4 residents (R1) reviewed for nutrition in the sample of 34.

Inspectors wroteBased on interview, observation, and record review, the facility failed to check the residual from a Gastrostomy tube (G-tube) before administering a water flush and medications and turn off the feeding pump while R4 was lying flat for 1 of 1 resident (R4) reviewed for tube feeding in the sample of 34.

Inspectors wroteBased on observation, interview the facility failed to provide assistive device or adaptive eating equipment resulting in R22's inability to use eating utensils effectively and eating with hands for 1 of 16 residents (R22) reviewed for assistive devices/eating equipment/utensils in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to post ombudsman contact information. This has the potential to affect all 41 residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to post survey results. This failure has the potential to affect all 41 residents residing at the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide and implement interventions to prevent resident falls for 4 of 4 residents (R11, R19, R29, R32) reviewed for resident safety in the sample of 27. This failure resulted in R32 transported to the hospital for a facial laceration with sutures and a fractured humerus on one incident, and a fractured hip with surgery on another incident. The Findings Include: 1. R32's Face Sheet, undated, documents R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. The facility's Fall Analysis Log, undated, documents, R32 had a fall on 7/26/23, 7/27/23, and 8/28/23. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain the medication refrigerator at the proper temperature. The failure has the potential to affect all 35 people living in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to store food to prevent contamination and food borne illness, ensure the dishwasher, refrigerator and freezer are operating properly and ensure the refrigerators, freezers, equipment, and walls are clean. This failure has the potential to affect all 35 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a Licensed Nursing Home Administrator as V1's temporary license expired on 5/2022 and has not been working with a current license since. This has the potential to affect all 35 residents in the facility. The Findings Include: On [DATE] at 1:38 PM, V1, Administrator, stated, I was working under a temporary license, and it expired in May of 2022. I took the Federal test and passed it, but I failed the state test. I am working under the Regional Director of Operations, who is in the facility once a month. I am aware that I am listed as the Licensed Administrator for this facility. On [DATE] at 12:45 PM, V1, stated, We really don't have a policy that states, the Administrator must be licensed. We have a Staffing Policy that states, Licensed Nurses are required to be licensed by the State in which they are practicing. [...]

Inspectors wroteBased on interview and record review, the facility failed to disclose Quality Assurance and Performance Improvement, (QAPI) documents to verify the facility is actively participating in a QAPI program. This failure has the potential to affect all 35 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors to problems. This failure has the potential to affect all 35 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have the Medical Director attend meetings and have input into the Quality Assurance (QA) meetings and to hold quarterly meetings. This failure has the potential to affect all 35 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a program to ensure water safety. This failure has the potential to affect all 35 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide Alzheimer's Dementia training for nursing staff.

Inspectors wroteBased on observation, interview and record review the facility failed to provide complete and timely incontinent care for 3 residents (R21, R27 and R32) of 4 residents reviewed for incontinence in the sample of 27.