Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare At Edwardsville during CMS and state inspections, most recent first.
Failure to Use Required Transfer Equipment During Resident Transfers: Two residents with significant mobility impairment and cognitive impairment were involved in unsafe transfers. One resident was transferred without a gait belt and fell during a bear hug-style assist, sustaining a femur fracture. Another resident was lifted with a full mechanical lift when the sling hook was not securely attached, causing the resident to slide out and strike her head, resulting in a hematoma and hospital evaluation. Interviews with an LPN, DON, and CNAs confirmed the transfer errors and that facility policy required gait belts and proper mechanical lift use.
Improper Storage of Raw Food in Freezers: Raw beef patties were found stored directly on top of cookie dough in a standing freezer, and raw bone-in chicken in plastic bags was found in a deep freeze on top of pound cake and pineapple items. The cook verified the meat was uncooked, and the Administrator stated the Facility expected food storage policies to be followed.
Medication administration protocols were not followed for several residents. A resident with chronic pain had Hydrocodone left in his room and admitted to hoarding tablets, while another resident with dementia and psychiatric diagnoses was found with pills in hand and had not received scheduled meds. Other residents reported that meds were routinely passed late, and the Ombudsman and DON confirmed ongoing lateness in med administration.
Palatability and Temperature of Meals: The facility failed to provide palatable, appetizing meals for 4 residents reviewed. Residents on regular diets, including one with no added salt, one with no added sweets, and one with double portions, reported that the food was nasty, terrible, had no taste, and was often cold. Resident Council minutes also cited cold, gross, and not palatable food, and a tray check found scrambled eggs at 117 degrees F after meal service.
Failure to prevent abuse involved an agency LPN who allegedly yelled, cursed, and made obscene gestures toward two cognitively intact residents after a dispute about pain medication. One resident became tearful and fearful of staff, and the roommate reported barricading the door and lying in the fetal position because she was scared. Facility leaders acknowledged the complaint but did not document a full abuse investigation or interview other residents or staff.
Failure to investigate alleged abuse involving two residents: an agency LPN was reported to have cursed at a resident and her roommate, got in their face, and made obscene gestures after a dispute over pain medication. The Administrator stated the nurse was removed from the hall and escorted out, but no full investigation was completed, no other residents or staff were interviewed, and the residents’ notes and care plans did not address abuse.
Failure to report an abuse allegation involving two residents after an agency LPN was accused of cursing at a resident and her roommate, getting in their face, and making obscene gestures when a pain med was not given. The Administrator said the concern was addressed informally, but no full investigation was completed, no other residents or staff were interviewed, and no report was made to the appropriate agencies as required by the facility abuse policy.
Failure to Thoroughly Investigate Abuse Allegations: The facility did not fully investigate abuse allegations involving two alert residents with multiple chronic conditions, including pain management needs. One resident reported that an agency LPN cursed at both residents, got in their faces, and used a middle finger gesture after refusing pain medication for the other resident; the second resident said she was left fearful and did not receive her pain medication that night. Interviews showed the LPN, ADON, DON, and Administrator did not complete a thorough investigation, and only the LPN’s statement was documented.
A resident with severe cognitive impairment and multiple diagnoses was alleged by a family member to have not received prescribed medications, with video footage and MARs providing conflicting information. The administrator reviewed the situation but did not report or investigate the allegation as required, and key clinical leaders were not notified, resulting in a failure to follow the facility's abuse prevention policy.
A resident with severe cognitive impairment and multiple diagnoses was prescribed oxycodone, which was reported missing after a nurse failed to administer it as scheduled. The incident was brought to the attention of the facility administrator by a CNA, but the administrator did not report the alleged misappropriation to authorities or follow up with the family, contrary to facility policy.
A resident with severe cognitive impairment and dependency was reported by a family member to have not received prescribed oxycodone. The administrator reviewed video footage and MARs, but did not conduct a formal investigation or notify the DON or VP of Clinical Operations, as required by facility policy. This resulted in a failure to properly investigate an allegation of medication misappropriation.
A resident with cognitive impairment and complex medical needs was transferred to another facility following an altercation, without proper involuntary discharge paperwork or advance written notice. The resident and her family were not informed of their rights, and staff were unaware of the discharge until it was occurring. The ombudsman intervened, and an administrative law judge ordered the resident's return, highlighting the facility's failure to follow required discharge procedures.
A resident with cognitive impairment and significant care needs was discharged without the required medical information being communicated to the receiving provider. The responsible RN was unaware of the discharge until the last minute, resulting in the absence of necessary paperwork and documentation that should have accompanied the resident, in violation of facility policy.
A resident with ESRD was admitted without dialysis services being arranged, resulting in 12 days without treatment and subsequent hospitalization due to critical lab values and symptoms. Additionally, two residents with behavioral issues were involved in repeated altercations, including physical aggression and bruising, despite staff awareness and care plan updates. The facility did not ensure proper care coordination or prevent neglect and abuse as required.
A resident with end-stage renal disease was admitted without dialysis services being arranged, resulting in 12 days without treatment. The resident developed symptoms such as shortness of breath and jaundice, and was found to have critical lab values before being hospitalized. Facility staff did not coordinate or document necessary dialysis care, and there was no interim plan to address the missed treatments.
A resident with end-stage renal disease did not receive dialysis for 12 days due to the facility's failure to notify the physician of missed treatments, resulting in hospitalization for elevated potassium and other complications. The care plan and physician orders lacked documentation of dialysis needs, and the facility did not follow its policy for timely physician notification regarding significant changes in condition.
The facility did not provide enough licensed nursing staff during the evening shift, resulting in multiple residents with complex medical needs receiving their scheduled medications, including pain management, late—sometimes after midnight. Both residents and staff confirmed that the reduction from four to three nurses made it difficult to complete timely medication passes, and Resident Council records documented ongoing complaints about late medications and delayed call light responses.
Surveyors found that multiple residents did not receive their scheduled medications on time, with repeated late administration of pain, cardiac, and sleep medications. Residents and staff reported that the issue was due to insufficient nurse staffing during the evening shift, following a reduction in the number of nurses. Facility records and interviews confirmed that late medication administration was a widespread and ongoing problem, resulting in increased pain and frustration among residents.
A resident with a history of aggression and psychiatric diagnoses struck another resident in the face after the latter attempted to open his door to assist him. The incident resulted in physical injury and fear for the affected resident, despite prior documentation of the aggressor's behavioral risks and interventions such as frequent checks.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found that staffing levels and shift leadership did not comply with regulations.
A facility failed to prevent resident-to-resident abuse, involving three incidents where residents with cognitive impairments and behavioral issues engaged in altercations. One resident was hospitalized after being pushed, while another was struck in the face. The facility attributed these incidents to the residents' dementia and confusion, concluding they were not premeditated.
A resident experienced increased pain and discomfort due to the facility's failure to ensure timely availability of prescribed Oxycodone. The resident, who requires monthly prescription renewals for chronic pain management, was left without medication for several days due to ineffective reordering processes and communication issues between staff and the prescribing doctor. The facility's pain management policy was not adequately followed, resulting in incomplete pain assessments and lack of alternative pain relief options.
A resident experienced discomfort and withdrawal symptoms due to the facility's failure to ensure timely refills of scheduled opioid medication. Despite the resident's predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, leading to missed doses. Staff acknowledged the issue but were unable to secure the necessary prescription in a timely manner, highlighting a breakdown in communication and coordination between the facility, pharmacy, and prescribing doctor.
A facility failed to complete PASRR recommendations for a resident with intellectual disabilities and disruptive behaviors. The resident exhibited aggressive behavior, causing fear among other residents and requiring police intervention. Staff reported inadequate training and lack of policies for managing such behaviors, leading to ongoing disruptions and an unsafe environment.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in care plans and treatment. One resident's MDS inaccurately documented pain management, despite reports of significant pain and Oxycodone administration. Another resident's MDS did not reflect behaviors like wandering and potential psychosis, despite observations of such behaviors. The facility lacked a policy on assessment accuracy, contributing to these deficiencies.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed oxycodone due to unavailability. The facility faced issues with the hospice company responsible for medication refills, leading to multiple missed doses. The RN eventually administered the medication from the emergency kit after receiving approval.
Two residents in a LTC facility received inadequate incontinent care, as observed during a survey. A CNA failed to provide timely and thorough care, using incorrect cleansing methods and not adhering to the facility's perineal care policy. One resident reported long wait times for changes and had a recent history of UTI, while the other was left with feces on her skin. The facility's policy required more frequent checks and proper cleansing techniques, which were not followed.
Failure to Use Required Transfer Equipment During Resident Transfers
Penalty
Summary
The facility failed to use required transfer equipment and failed to use the full mechanical lift appropriately for two residents who needed extensive assistance with transfers. One resident had diagnoses including muscle weakness, lack of coordination, and abnormal gait and mobility, was moderately cognitively impaired, and was dependent for transfers. During a transfer from wheelchair to bed, the CNA did not use a gait belt and instead used a bear hug method, despite the facility policy requiring gait belts for physical assist transfers. The resident became weak, shifted weight to the side with an amputation, lost balance, and fell with the CNA, resulting in a left femur fracture and emergency room transfer. A second resident had diagnoses including diabetes, abnormal gait and mobility, muscle weakness, altered mental status, chronic pain syndrome, osteoarthritis, Alzheimer's disease, and hypertension. She was moderately cognitively impaired, used a wheelchair, and was dependent on staff for transfers. During a transfer using the full mechanical lift, the sling hook was not securely attached and came undone while the resident was being lifted. Staff lowered her to the floor, and she sustained a small hematoma to the back of her head and was sent to the hospital for evaluation. The facility's transfer policy stated that mechanical lifting devices are to be used for residents needing a two-person assist or who cannot be transferred safely by normal techniques, and that gait belt use for physical assist transfers is mandatory. The fall evaluation and prevention policy stated that the resident environment should be free of accident hazards as possible and that each resident should receive adequate supervision and assistance to prevent accidents. Interviews with nursing staff and the DON confirmed that the gait belt was not used for the first resident and that the second resident was transferred by one staff member when the lift hook was not completely secured.
Improper Storage of Raw Food in Freezers
Penalty
Summary
Food was not stored in a manner that prevents foodborne illness. During observation on 3/17/26 at 6:55 AM, two boxes of uncooked beef patties were found stored directly on top of a box of cookie dough in the standing freezer. During observation on 3/17/26 at 7:00 AM, multiple bags of food in plastic gallon storage bags were found in the deep freeze, including three bags labeled bone in chicken with red frozen liquid inside, stored directly on top of bags labeled pound cake and brown sugar pineapple. The cook stated this freezer is primarily used for leftovers and asked whether the chicken should be moved, and verified that the chicken and the beef in the other freezer were uncooked. The Administrator later stated she expected the Facility to follow its food storage policies. The Facility's Food and Supply Storage Policy dated 8/1/25 states that food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. The Facility's CMS 671 dated 3/17/26 documents 91 residents living in the Facility.
Medication Administration Not Followed as Ordered
Penalty
Summary
The facility failed to ensure that medication administration protocols were followed for 4 of 4 residents reviewed for pharmacy services. The facility’s medication administration policy stated that medications would not be left at bedside, would be administered by licensed nursing staff, and the licensed nurse would remain with the resident until the medicine was actually swallowed. Despite this, multiple residents reported that medications were being left with them or administered late, and staff interviews confirmed that medication handling practices were inconsistent with the facility policy. For one resident with chronic pain related to a T-12 compression fracture and low back pain, the physician ordered Hydrocodone 7.5 mg four times daily. The resident stated that nurses left medications at bedside and that he sometimes did not need the pain medication, so he placed tablets in a secret place in his room. He reported giving two Hydrocodone tablets to a CNA who said she was in pain, and staff later found additional Hydrocodone tablets, along with other medications, hidden in his room. The DON stated that the resident’s Hydrocodone must have been left in the room over a period of time because narcotics were supposed to be stored under double lock and no order allowed Hydrocodone at bedside. Another resident with dementia, developmental disorder, bipolar disorder, depression, and other psychiatric diagnoses was identified as being at risk for medication noncompliance due to hoarding. The resident was found with four pills in hand and had not yet received morning medication; the resident stated the pills were from the prior two days and included pain pills and trazodone. The resident expressed suicidal thoughts and was sent for psychiatric evaluation. A separate resident stated medications were routinely late by about two hours or more, and another resident reported that night medications were often passed late, sometimes around 11:30 PM or later. The Ombudsman also stated residents complained that medications were being administered late frequently, and the DON acknowledged that acceptable medication administration times were within one hour before or after the scheduled time.
Palatability and Temperature of Meals
Penalty
Summary
The facility failed to provide palatable meals for 4 of 4 residents reviewed for food and nutrition services. R4, who was cognitively intact and ordered a regular diet, stated the food was "nasty," that complaints had been made repeatedly without change, that the steam table did not work, and that the food was usually cold. R24, who was moderately cognitively impaired and ordered a regular diet with no added salt, stated the food was terrible, had no taste, and was cold much of the time. R34, who was cognitively intact and ordered a regular diet with no added sweets, stated the food was terrible. R50, who was cognitively intact and ordered a regular diet with double portions, stated the food was not good, the menu was terrible, and the food was usually cold. Resident Council Meeting Minutes documented ongoing concerns about cold food, gross food, and food that was not palatable. During observation, test tray temperatures were taken after the last resident hall tray was passed, and scrambled eggs measured 117 degrees Fahrenheit on the B Hall. The Administrator stated the facility used to have more homestyle cooking and more options before the new company took over, and residents were accustomed to that. The facility's undated Food Preparation: Taste-Testing document stated food items would not be served unless palatable and pleasing to the eye.
Failure to Prevent Verbal Abuse by Agency LPN
Penalty
Summary
The facility failed to protect residents from abuse for 2 of 6 residents reviewed for abuse, including two cognitively intact residents with diagnoses such as anxiety, depression, malnutrition, debility, cardiorespiratory conditions, COPD, anemia, respiratory failure, cancer, and renal insufficiency. One resident’s care plan did not address abuse, and the other resident’s nurse progress notes for the month reviewed contained no documentation of allegations of abuse by staff toward the resident. The deficiency was based on an incident involving an agency LPN and the two residents, one of whom was tearful and scared of staff after the event. According to resident interviews, the agency LPN became upset when a resident was concerned that her roommate was not receiving pain medication. The resident stated the LPN yelled and cursed at both residents, got in their faces, and flipped them off with her middle finger in the room and again in the hallway. The resident said she was shocked, felt the behavior was abusive, and was scared of the LPN because she was a nurse in charge of residents’ lives. The roommate stated the LPN cursed at both residents, refused to give her pain medication that night, and that both residents barricaded their door with shelves because they were fearful the LPN would return and hurt them. Facility staff confirmed the incident was reported after the resident confronted staff about the LPN working on the hall again. The LPN was escorted out of the building after the complaint, and staff statements showed the LPN denied cursing or making the gesture. The ADON, DON, and Administrator each stated they did not know the exact date or full details of the incident, and they did not interview other residents or staff about what occurred. The ADON stated she did not document the resident interview, and the DON stated she did not know what shift the LPN worked when the incident occurred. The Administrator stated the situation was 'squashed immediately.'
Failure to Investigate Alleged Abuse Involving Two Residents
Penalty
Summary
The facility failed to follow its abuse policy regarding allegations of abuse involving 2 residents, R4 and R10. R4’s records showed she was alert and had diagnoses including anxiety, depression, malnutrition, debility, cardiorespiratory conditions, COPD, and anemia. R10’s records showed he was alert and had diagnoses including anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, COPD, cancer, anemia, and renal insufficiency, and he received scheduled and PRN pain medication. Neither resident’s nurse progress notes for 2/2026 documented allegations of abuse or mistreatment, and neither care plan addressed abuse. During a resident council meeting, R4 reported that an agency LPN cursed at her and her roommate, got in her face, and flipped her the middle finger several times, and that the LPN later returned to work at the facility. R4 stated the conflict involved the LPN refusing to give R10 his pain medication. The Administrator stated she did not know exactly what occurred, that the nurse was removed from the hall and escorted out of the building, and that the situation was handled immediately without a full investigation. She stated she did not interview other residents or staff, and no statements other than the LPN’s were documented. The NP stated she was not aware of abuse or mistreatment and expected the facility to follow its abuse policy, which required prompt and thorough investigation of abuse and mistreatment reports.
Failure to Report Allegation of Abuse Involving Two Residents
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, R4 and R10, after R4 stated during a resident council meeting that an agency LPN, V23, cursed at her and her roommate, got in her face, and flipped them off several times. R4 said the incident occurred because V23 would not give R10 her pain medication, and she stated that V23 later returned to work at the facility. R4 was alert and cognitively intact, with diagnoses including anxiety, depression, malnutrition, debility, COPD, and anemia. R10 was also alert and cognitively intact, with diagnoses including anxiety, malnutrition, respiratory failure, debility, COPD, cancer, anemia, and renal insufficiency, and had a scheduled hydrocodone order for pain. The Administrator stated she did not know exactly what occurred between V23, R4, and R10, but acknowledged that staff were aware of the concern when V26 called to report that R4 was upset about V23 passing medications on her hall and believed V23 should not be working at the facility because she mistreated R4 and R10. The Administrator stated V23 was immediately escorted out of the building and not allowed to return, but also stated no full investigation was completed, no other residents or staff were interviewed, and no statements other than V23's were documented. The facility's Abuse Prevention and Prohibition Policy states that staff must not permit verbal abuse or mistreatment and that the Administrator is responsible for coordinating abuse investigations and providing written reports of the results and consequent actions to the appropriate agencies.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse involving 2 residents, R4 and R10. R4’s quarterly MDS documented that she was alert and had diagnoses including anxiety, depression, malnutrition, debility, cardiorespiratory conditions, COPD, and anemia. R10’s quarterly MDS documented that he was alert and had diagnoses including anxiety, malnutrition, respiratory failure, debility, cardiorespiratory conditions, COPD, cancer, anemia, and renal insufficiency, and that he received scheduled and PRN pain medication with pain present occasionally and rated 3 out of 10. Neither resident’s care plan addressed abuse. During a resident council meeting, R4 reported that an agency nurse, V23, cursed at her and R10, got in her face, and flipped them off with her middle finger several times after refusing to give R10 pain medication. R4 later clarified that the incident occurred on a Saturday day shift, that V23 yelled and cursed at both residents, and that she felt shocked, scared, and upset by the interaction. R10 stated that V23 snapped on her and R4, cursed at them, flipped them off multiple times, and did not give her pain medication that night, leaving her fearful and lying in the fetal position all night. R10 also stated that no staff spoke to her about what occurred. The facility’s interviews and documentation showed the allegation was not fully investigated. V26, LPN stated she only spoke with R4 and did not interview R10, other residents, or staff. V3, the ADON, stated she interviewed R4 but did not interview R10, other residents, or staff. V2, the DON, stated she did not document the interviews with R4 and R10 and did not interview other residents or staff. V1, the Administrator and abuse coordinator, stated there was no full investigation completed, that she did not interview any other residents or staff, and that only V23’s statement was documented. The facility abuse policy stated that the Administrator is responsible for abuse prevention systems and that the facility promptly and thoroughly investigates reports of resident abuse and mistreatment.
Failure to Report and Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of misappropriation of medication for a resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone every four hours. The resident's family member reported that the resident did not receive any medications during a specific shift, and video footage was reviewed by the administrator, who determined that the nurse had entered the room but did not verify medication administration. The Medication Administration Records (MARs) indicated that medications had been given, but the family member and oncoming nurse reported that the medications were missing and had been documented as administered. Despite the allegation and conflicting accounts, the administrator did not report the incident or initiate an investigation as required by the facility's abuse prevention policy. The Director of Nursing and the Vice President of Clinical Operations were not notified of the allegation, and standard procedures such as checking medication counts and narcotic logs were not followed. The facility's policy mandates prompt and thorough investigation of all reports of misappropriation, but this process was not initiated in this case.
Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident who was severely cognitively impaired and dependent on staff for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone. According to interviews and record review, a nurse did not enter the resident's room during her shift and informed a family member that the oncoming nurse would administer the medication. The oncoming nurse then reported that the medication was missing, although it had been documented as given. A certified nursing assistant notified the administrator of the situation, but the administrator did not follow up with the family member as promised and did not report the incident to the state health department or law enforcement, as required by the facility's abuse prevention policy.
Failure to Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of medication for one resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone to be administered every four hours. The resident's family member reported that the resident did not receive her medications on a specific date. The administrator reviewed video footage and checked the Medication Administration Records (MARs), which indicated the medications had been given, and concluded the issue was resolved without further investigation. Despite the family member's report that the nurse did not enter the resident's room and that the oncoming nurse stated the medications were missing but documented as given, the administrator did not notify the Director of Nursing or the Vice President of Clinical Operations, nor did she conduct a formal investigation as outlined in the facility's abuse prevention policy. The policy requires prompt and thorough investigation of all reports of misappropriation, including checking medication counts and documentation, and reporting findings to appropriate agencies. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Proper Involuntary Discharge Procedures
Penalty
Summary
The facility failed to follow proper procedures for the transfer and discharge of a resident with cognitive impairment and significant care needs. The resident, who had a diagnosis of malignant neoplasm of the colon and chronic pain, was admitted for long-term care and had a care plan goal to remain in the facility. After an altercation with another resident, the facility sent the resident to the hospital for a psychological evaluation and subsequently transferred her to another facility without her consent. The resident expressed distress about the transfer, and her family was not informed of their rights or provided with appropriate discharge information. Staff interviews revealed that the resident did not want to leave, and the transfer occurred without the knowledge or preparation of her assigned nurse. The facility did not provide the required involuntary discharge (IVD) paperwork to the resident or her representative, nor did they notify them in writing of the reasons for the move as required by policy. The administrator confirmed that no IVD paperwork was filed, and the social services director was unaware of the transfer until after it had occurred. The ombudsman intervened, and an administrative law judge ordered the facility to take the resident back. Documentation and interviews consistently indicated that the facility did not follow established procedures for involuntary discharge, including providing advance notice and ensuring the resident's preferences and needs were considered.
Failure to Communicate Required Resident Information at Discharge
Penalty
Summary
The facility failed to communicate required resident information to the receiving provider during the discharge of one resident. The resident, who had diagnoses including malignant neoplasm of the colon and chronic pain, was cognitively impaired and required substantial assistance with transfers. On the day of discharge, the registered nurse responsible was not aware of the discharge until informed by another staff member as the resident was preparing to leave. As a result, the nurse did not have the resident's paperwork ready and was unable to provide a report to the receiving facility. There was no documentation that the necessary paperwork, such as the medication list, progress notes, care plan, and face sheet, was sent with the resident, contrary to the facility's policy and procedures for discharge communication.
Failure to Coordinate Dialysis Care and Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from neglect during the admission process. The resident was transferred from another nursing home and had been receiving dialysis five days per week prior to admission. Upon arrival, no dialysis services were set up or scheduled, and there was no alternate dialysis treatment provided while waiting for a new provider. The resident did not receive dialysis for 12 days, during which time she experienced symptoms including shortness of breath, sweating, weakness, jaundice, and critical laboratory values such as elevated potassium, BUN, and creatinine levels, ultimately requiring hospitalization. Documentation showed that the resident's care plan and physician orders did not include dialysis, and there was no evidence of physician notification or follow-up regarding the missed treatments. Additionally, the facility failed to prevent resident-to-resident altercations involving two residents with behavioral and psychiatric diagnoses. There were multiple documented incidents where one resident was verbally and physically aggressive toward another, including hitting and pulling hair. Staff and other residents witnessed these altercations, and skin assessments confirmed bruising. Despite these repeated behaviors, care plans and interventions did not prevent further incidents, and both residents continued to have conflicts. The deficiencies were identified through interviews, record reviews, and observations, revealing lapses in care coordination, communication, and supervision. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the lack of timely action to secure necessary dialysis treatments and to prevent ongoing resident-to-resident altercations. The events led to significant harm and risk for the residents involved.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on neglect related to coordination of care by not setting up dialysis treatments.
- All department heads on abuse and neglect policy and procedure and no staff was allowed to work until they were in-serviced on abuse and neglect.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis treatment.
Failure to Coordinate Dialysis Care Resulting in Missed Treatments and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, who was dependent on hemodialysis, was admitted to the facility without any dialysis services being set up or scheduled prior to admission. The resident had been receiving dialysis five times per week at the previous facility, but upon transfer, no arrangements were made to continue this essential treatment. The facility did not implement any alternative dialysis treatment while waiting for a new provider, and there was no documentation of dialysis orders or appointments in the resident's records. The care plan and progress notes failed to address the resident's ongoing need for dialysis or any interim measures to manage her condition. During the 12 days following admission, the resident did not receive any dialysis treatments. She began to exhibit symptoms including shortness of breath, sweating, weakness, and jaundiced eyes. Laboratory results revealed critical values, such as elevated potassium, BUN, and creatinine levels. Despite these symptoms and the absence of dialysis, there was no documented follow-up or escalation of care to address the missed treatments. The resident's family ultimately requested that she be sent to the hospital, where she was found to have critical lab values and required a five-day hospitalization. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's dialysis needs. Staff members, including the DON, ADON, and Social Service Director, indicated that it is standard practice to ensure dialysis is arranged before admitting a resident who requires it, but in this case, the process was not followed. The transportation staff attempted to refer the resident to a dialysis center, but the referral did not go through, and there was no effective follow-up. The nephrologist and medical doctor both confirmed that missing dialysis treatments can cause serious harm and that the facility failed to coordinate care to prevent this outcome.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on dialysis care related to coordination of care by not setting up dialysis treatments.
- All department heads on dialysis and procedure and no staff was allowed to work until they were in-serviced on dialysis.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis needs are addressed.
Failure to Notify Physician of Missed Dialysis Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a resident who did not receive dialysis for 12 days, resulting in the resident's hospitalization. The resident had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, but the Physician Order Sheet did not include an order for dialysis, only for monitoring the dialysis catheter. The care plan also did not document that the resident was receiving or awaiting approval for dialysis treatments. Progress notes indicated that the resident complained of symptoms such as shortness of breath, weakness, and sweating, and reported missing a dialysis session. Although the physician was notified of a missed dialysis day and low glucose, there was no documentation that the physician was informed about the ongoing lack of dialysis treatments or that the resident went 12 days without dialysis. The medical director confirmed that he was not made aware that the resident had not received dialysis as recommended and stated that, had he known, he would have sent the resident to the hospital for treatment. Hospital records confirmed that the resident had not received dialysis for about two weeks since transfer to the facility, resulting in elevated potassium, BUN, and creatinine levels. The hospital provided dialysis, and the resident was hospitalized for five days before being discharged back to the facility. The facility's policy requires timely notification of the physician and family when there is a significant change in a resident's condition or a need to alter treatment. In this case, the lack of communication and documentation regarding the resident's dialysis needs and missed treatments led to a significant lapse in care and a failure to follow established protocols for physician notification.
Failure to Provide Sufficient Licensed Nursing Staff Results in Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet the needs of all residents, as evidenced by interviews and record reviews for four residents with complex medical conditions. These residents reported that their scheduled evening medications, including pain management and other critical treatments, were frequently administered late. Residents described being woken up to receive medications well past the scheduled times, sometimes after midnight, resulting in increased pain and dissatisfaction. The issue was corroborated by the residents' cognitive status, as documented in their Minimum Data Set (MDS) assessments, and by their direct statements regarding the impact of late medication administration. Multiple staff members, including LPNs and the wound care nurse, confirmed that the reduction in evening nursing staff from four to three nurses between 6 PM and 10 PM made it difficult to complete medication passes on time. Staff reported that the change was made by facility ownership to save money, and that three nurses were insufficient to manage the medication needs of the resident population during the evening shift. The facility's own policy requires staffing levels to be based on resident census and needs, and the daily census showed 100 residents at the time of the survey. Resident Council meeting memoranda further documented ongoing concerns, with residents expressing frustration about waiting until after 11 PM for medications and call lights not being answered promptly. The Director of Nursing acknowledged awareness of the issue and the difficulty nurses faced in completing all required tasks with the reduced staffing. The administrator also confirmed that medication administration times were being documented as late, consistent with resident and staff reports.
Failure to Administer Medications at Scheduled Times Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to administer medications at the scheduled times for four residents reviewed for medication administration. Documentation showed repeated late administration of critical medications, including acetaminophen, carvedilol, oxycodone, trazodone, and hydromorphone. Medication Administration Records (MARs) indicated that evening medications were often given hours after the scheduled time, with some doses administered after midnight. Residents reported experiencing increased pain and disrupted sleep due to these delays, and several stated that nurses had to wake them up late at night to take their medications. Interviews with residents and staff revealed that the late administration of medications was a persistent issue, particularly during the evening shift. Residents, including the President of the Resident Council, expressed frustration and discomfort, noting that the problem had become more pronounced in recent months. Staff members, including LPNs and the wound care nurse, consistently attributed the delays to insufficient nurse staffing during the 6 PM to 10 PM shift. They reported that the facility had recently reduced the number of nurses from four to three during this critical period, making it difficult to complete medication passes on time. Facility leadership, including the Administrator and DON, acknowledged awareness of the issue, as documented in Resident Council meeting memoranda and interviews. The facility's own medication administration policy requires medications to be given within one hour of the scheduled time, but records and staff statements confirmed that this standard was not being met. The deficiency affected all residents in the facility, as the late administration of medications was not limited to the sampled residents but was reported as a widespread concern.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving one resident who was struck in the face by another resident. The incident occurred when one resident, who has a history of inappropriate contact, physical aggression, and paranoia, reacted aggressively after another resident attempted to open his door to assist him. The aggressor, who is cognitively intact but has multiple psychiatric diagnoses including Alzheimer's Disease, psychosis, and obsessive-compulsive disorder, became agitated and hit the other resident, resulting in redness to the face and arm, as well as bleeding from the head. The affected resident, who is also cognitively intact and has diagnoses including cerebral infarction and Alzheimer's Disease, reported feeling fearful of the aggressor and stated he does not feel safe around him, although he generally feels safe in the facility when staff are present. Prior to the incident, the aggressor's care plan documented a history of physical aggression, poor impulse control, and a dislike of having his personal space invaded. The care plan also noted previous encounters with other residents and interventions such as 15-minute checks. Despite these documented risks and behaviors, the incident occurred when the other resident, unaware of the behavioral symptoms, attempted to help by opening the door, which triggered the aggressive response. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents, and defines resident-to-resident abuse as willful, deliberate actions.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three residents, resulting in one resident being sent to the hospital. The incidents involved residents with varying degrees of cognitive impairment and behavioral issues. In one case, a resident with severe cognitive impairment and a history of wandering struck another resident in the face, leading to redness and the need for medical evaluation. The facility's investigation concluded that the incident was isolated and not premeditated, attributing it to the resident's dementia and confusion. In another incident, two residents with dementia and behavioral issues were involved in an altercation. One resident attempted to take items from a table, leading to a confrontation where the other resident swung a cup, causing a minor injury. Both residents were separated and placed under one-on-one monitoring. The facility's report indicated that neither resident had a history of aggressive behavior, and the incident was not considered premeditated or targeted. A third incident involved a resident with a personality disorder and Alzheimer's disease pushing another resident, causing a fall and subsequent hospital visit. The facility did not view this as abuse, citing the resident's peculiar behavior and lack of malicious intent. Despite the incidents, the facility's staff and administration did not perceive these behaviors as aggressive or intentional, and they continued to monitor the residents involved.
Failure to Ensure Timely Pain Medication Availability
Penalty
Summary
The facility failed to ensure that pain medications were readily available for a resident, leading to increased pain and discomfort. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, resulting in the resident being without medication for several days. The resident reported severe pain and withdrawal symptoms during these periods without medication. Interviews with staff revealed a lack of clarity and responsibility in the medication ordering process. A staff member mentioned that the medication card indicates when to reorder, but there was confusion about whether the pharmacy or the doctor was at fault for the delay. The Nurse Practitioner, who was in charge, could not write prescriptions for controlled substances, and the facility's attempts to contact the doctor were not timely or effective, leading to gaps in medication availability. The facility's pain management policy requires regular pain assessments and timely interventions, but these were not adequately followed. The resident's pain assessment was incomplete, and there was no PRN Tylenol order to manage pain in the absence of Oxycodone. The Director of Nursing acknowledged the oversight in pain assessment and the need for a referral to pain management. Despite the facility's policy, the resident experienced significant pain and distress due to the unavailability of prescribed pain medication.
Failure to Ensure Timely Opioid Medication Refill
Penalty
Summary
The facility failed to ensure the availability of scheduled opioid medication for a resident, resulting in the resident missing several doses of pain medication and experiencing discomfort and withdrawal symptoms. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for a monthly prescription renewal, the facility did not manage the reordering process effectively, leading to the resident being without medication for several days. Interviews with staff and the resident revealed a lack of communication and coordination between the facility, the pharmacy, and the prescribing doctor. The resident expressed frustration over the recurring issue of running out of medication and the lack of proactive measures to prevent it. Staff members, including the Director of Nursing and the Assistant Director of Nursing, acknowledged the problem but indicated that they were unable to compel the doctor to provide the necessary prescription in a timely manner. The facility's Controlled Substance Prescription Policy outlines the process for obtaining and renewing prescriptions, but it appears that these procedures were not followed effectively. The policy requires the pharmacy to notify the facility if a prescription is not obtained before the medication runs out, but this did not prevent the resident from experiencing a gap in medication availability. The nurse practitioner involved was unable to write the prescription due to not having a DEA number, further complicating the situation.
Failure to Address Behavioral Health Needs and Ensure Accurate Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screen Resident Review (PASRR) recommendations were completed for a resident with a qualifying diagnosis and disruptive behaviors. The resident, identified as R4, had a diagnosis of mild intellectual disabilities, schizoaffective disorder, and bipolar disorder. Despite the PASRR indicating that a resident review should be completed when the short-term approval was ending, this was not done. Additionally, the resident's Minimum Data Set (MDS) inaccurately documented that R4 did not have potential indicators of psychosis, such as hallucinations or delusions, and did not reject evaluation or care, nor wander, which contradicted observations and reports from staff and other residents. Multiple interviews with residents and staff revealed that R4 exhibited disruptive and aggressive behaviors, including using foul language, making other residents feel unsafe, and requiring police intervention on several occasions. Staff and residents reported feeling intimidated and scared by R4's behavior, which included cursing, making inappropriate comments, and unpredictable actions. Despite attempts to redirect R4 and provide one-on-one care, the interventions were unsuccessful, and the behavior continued to affect the well-being of other residents. The facility lacked adequate staff training and policies related to behavioral health services, as noted by the Director of Nursing and other staff members. The facility's administrator was unaware of R4's PASRR requirements, and there was no policy in place for managing residents with behavioral health issues. The facility's failure to address R4's behavioral health needs and ensure accurate assessments and interventions contributed to the ongoing disruptive behavior and the negative impact on the facility's environment.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their care plans and treatment. For one resident, the Minimum Data Set (MDS) inaccurately documented that the resident had not received scheduled or PRN pain medications, despite the resident's reports of significant pain and the administration of Oxycodone as per physician's orders. The resident's care plan noted potential for pain and required monitoring of pain interventions, yet the quarterly pain assessment was incomplete, and the resident's diagnoses related to pain were not updated in the facility's records. The Director of Nursing acknowledged the inaccuracies in the MDS and the need for a referral to pain management. Another resident's MDS failed to reflect behaviors such as wandering and potential indicators of psychosis, despite observations and reports of the resident walking anxiously and talking to imaginary people. The care plan documented the resident's behavior of walking throughout the facility and cursing, which was not successfully managed by the interventions attempted. The facility had a behavioral health counselor available, but the resident refused to see her. The facility did not provide a policy related to the accuracy of assessments, contributing to the deficiencies noted.
Failure to Administer Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to administer prescribed medications to a resident, identified as R2, who was part of a sample reviewed for pharmacy services. R2, who was admitted with diagnoses including metabolic encephalopathy, Alzheimer's, and interstitial cystitis, was severely cognitively impaired and dependent on staff for daily activities. The care plan for R2 included monitoring for pain and ensuring medication compliance. However, the Medication Administration Record (MAR) indicated that R2's prescribed oxycodone was not administered multiple times over several days due to the drug being unavailable. Interviews and record reviews revealed that the facility experienced issues with the hospice company responsible for R2's medication, leading to a lack of timely refills. The Assistant Director of Nursing acknowledged the problem with the hospice company, and the Director of Nursing was unaware of the situation due to a lack of documentation by the RN who had been contacting hospice. The RN confirmed the absence of oxycodone in the medication drawer and the need for a prescription to access the emergency kit. Eventually, the RN received approval to administer oxycodone from the emergency kit, but this was after several missed doses.
Inadequate Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide timely and thorough incontinent care for two residents, R1 and R5, as observed during a survey. R1 reported that it sometimes takes up to two hours to be changed when incontinent and that she had not been changed since the previous night. During an observation, a CNA, V9, provided inadequate care by not checking R1's incontinence status earlier, using a soap that required rinsing without rinsing or drying the areas, and failing to clean R1's inner vaginal folds. R1's adult diaper and gown were saturated with urine, and she had redness in her groin and buttocks areas. R1 had a recent history of hospitalization for sepsis and a urinary tract infection, and her care plan did not address her urinary incontinence or UTI. R5 also experienced inadequate care, as she reported not being checked or changed since early morning. When V9 provided care, he used a no-rinse peri-wash incorrectly, did not clean R5's inner vaginal folds, and left feces on her left buttock before putting on a new adult diaper. V9 also failed to dry any areas after cleansing. R5's care plan indicated she was at risk for irritant contact dermatitis due to incontinence and required care after each incontinent episode. The facility's policy on perineal care was not followed, as it required separating the labia, washing, rinsing, and drying the area from front to back. The Assistant Director of Nurses stated that incontinent residents should be checked and changed at least every two hours and that staff should thoroughly cleanse all areas affected by urine or feces. The facility's failure to adhere to these standards resulted in inadequate care for R1 and R5.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 748 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Edwardsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eden Village Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Evercare At University | 1.9 mi | ★★★★★ | 5 | 1 |
| La Bella Of Edwardsville | 2 mi | ★★★★★ | 4 | 0 |
| Meridian Village Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Manor Court Of Maryville | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.