Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare Of Collinsville during CMS and state inspections, most recent first.
A resident with chronic sacral and heel pressure ulcers had multiple ordered wound treatments left undocumented on the TAR, and staff did not reposition him promptly when he reported pain from sitting up in his wheelchair. He was observed grimacing, asking to lie down, and using his call light, but a CNA turned off the light and left without helping; he remained up until later that afternoon. The DON stated staff should respond to the resident’s needs immediately and document wound treatments when provided.
A resident with severe cognitive impairment and a history of frequent falls was not properly monitored or provided with effective fall prevention interventions, resulting in multiple injuries and repeated hospital visits. Staff failed to follow care plan interventions, did not perform regular checks, and left the resident soiled in bed for hours with the call light out of reach. These actions and inactions led to a finding of neglect and Immediate Jeopardy.
A resident with severe cognitive impairment and a history of frequent falls experienced repeated injuries due to the facility's failure to implement and follow individualized fall prevention interventions. Staff did not consistently keep the call light within reach, provide adequate supervision, or update care plans after each fall, resulting in multiple injuries and emergency room visits. Observations also revealed lapses in incontinence care and improper transfer techniques, despite clear facility policies and expectations.
Two residents dependent on staff for ADLs were left in urine and feces for extended periods without timely or complete incontinent care. Staff failed to follow proper hygiene and infection control protocols, including hand hygiene and thorough peri-care, and did not check residents for incontinence as required by facility policy.
Staff failed to perform required hand hygiene before, during, and after providing care to multiple residents, including during incontinent care and G-tube procedures. CNAs and an LPN were observed not sanitizing hands before donning gloves, between glove changes, or after completing care, despite facility policy and staff knowledge of proper infection control practices.
A resident's room window was found to have a hole, allowing flies and outside air to enter due to an inadequately secured plexiglass cover. The issue was not reported through the facility's maintenance work order system, resulting in the deficiency going unaddressed until discovered during a survey. Staff interviews confirmed that the established process for reporting and repairing such issues was not followed.
A facility failed to conduct required background checks on employees with direct resident contact, resulting in a resident with mental health diagnoses experiencing verbal abuse from a staff member. The incident caused the resident significant emotional distress and reluctance to leave their room. The facility could not verify that background checks had been completed for the staff member involved, as required by policy.
The facility did not complete required background checks for several staff members who had direct contact with residents, resulting in a situation where a resident with mental health diagnoses experienced verbal abuse from a staff member. The resident reported significant emotional distress, and the facility's failure to follow its own screening policies affected all residents.
A resident experienced multiple falls, including one where he was unable to reach his call light and had to call 911 for help due to insufficient staff presence. First responders had difficulty locating staff, eventually finding a nurse and another staff member outside, both unaware of the resident's situation. Staffing records showed fewer CNAs than scheduled, and the resident was found on the floor with dried blood, having tried to get attention with a broken coat hanger.
A resident with severe cognitive impairment and a history of repeated falls experienced multiple falls over a two-month period, but the facility did not notify the resident's family of these incidents or any resulting injuries, contrary to facility policy. The family only became aware of an injury after observing it during a visit and asking staff. Staff interviews confirmed that family notification was expected but not consistently performed.
A resident's legal representative, holding power of attorney, submitted a HIPAA-compliant request for medical records after the resident's discharge. The request was received by social services and reportedly forwarded to administration, but the administrator and clinical leadership stated they never saw the form. As a result, the records were not provided within the required timeframe.
The facility did not consistently update individualized care plans or complete fall risk evaluations after multiple residents experienced falls, including unwitnessed incidents and falls occurring outside the facility. Despite documented physical and cognitive impairments, care plans and interventions were not revised as required by facility policy, and staff interviews confirmed these lapses.
Mechanical lifts used for resident transfers were not maintained in safe working order, with staff observed struggling to control malfunctioning equipment and residents expressing fear and discomfort during use. Staff reported ongoing issues with the lifts, including malfunctioning legs and dead batteries, but the facility's reporting and maintenance processes failed to address these problems, resulting in continued use of unsafe equipment.
Surveyors found multiple bathrooms and shower areas with visible mold, strong bleach odors, and unclean conditions, including missing tiles and crumbling walls. Residents and staff confirmed ongoing mold issues, with some residents limiting showers due to unsanitary conditions and staff reporting illness related to mold exposure. Housekeeping efforts to address mold were described as insufficient, and the facility's policy for immediate cleaning was not effectively implemented.
A resident with epilepsy did not receive prescribed anti-seizure medications for several days after staff, acting on concerns about possible double dosing by a family member, obtained an order from a covering nurse practitioner to hold the medications. The situation was not promptly assessed or clarified, and there was no direct communication with the resident's specialists. During this period, the resident experienced a seizure and required emergency treatment. The facility lacked a policy on continuity of care to guide staff in such circumstances.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to delays in refilling and lack of availability, resulting in a seizure episode that required emergency room evaluation. Facility records and staff interviews confirmed missed doses, lack of timely reordering, and absence of the medication in the emergency kit, with no documentation explaining the delay.
The facility failed to properly clean dishes and store food, risking foodborne illness for all 55 residents. A cook skipped the rinsing step in the dishwashing process due to a missing stopper, and food items in the refrigerator and freezer were not labeled or dated as per policy.
A facility failed to thoroughly investigate an abuse allegation involving a resident with multiple health conditions. The resident claimed to have been hit by a night CNA, but initial assessments showed no injuries, and camera reviews found no interaction. The administrator admitted to not asking the correct questions during interviews with other residents, leading to an incomplete investigation and a deficiency in handling the abuse allegation.
A resident's care plan failed to address pain management despite documented pain and prescribed medications. The resident reported chronic pain, and the MDS/Care Plan Coordinator acknowledged the oversight, citing frequent hospital discharges as a possible reason. The facility's policy requires comprehensive care planning, including pain management.
The facility failed to meet the required minimum floor space per resident bed, with several two-bed rooms providing less than the mandated 80 square feet per resident. Observations confirmed that 26 residents were affected by this deficiency.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting all 56 residents. Observations and interviews revealed roaches in various areas, and staff reported that the maintenance man responsible for pest control was terminated for not performing his duties. The pest control company recommended monthly services, but financial issues led to a lapse in treatment, exacerbating the infestation.
Missed Pressure Ulcer Treatments and Delayed Repositioning
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident with chronic sacral and right heel pressure ulcers. The resident’s MDS documented that he was cognitively intact and had three pressure ulcers. Physician’s orders directed staff to cleanse the sacral wound with normal saline, apply zinc barrier cream to the periwound as needed, loosely pack the wound bed with Dakin’s moistened gauze, and cover with a dry clean dressing twice daily and as needed; the right heel wound was to be cleansed with normal saline, treated with Dakin’s moistened gauze, and covered with an ABD pad and gauze wrap twice daily and as needed. The TAR showed no documentation that the sacral treatment was administered on multiple day and evening shifts, and no documentation that the right heel treatment was administered on some day and evening shifts. During observation, the resident was transferred to his wheelchair and later stated that his pressure ulcer was hurting from sitting up and that staff told him he had to remain in the wheelchair until at least 3:00 PM because his family wanted him up that long. He was observed grimacing, attempting to reposition himself, and saying he was hurting badly. When he used his call light and a CNA entered, the CNA turned the light off and left without assisting him; the resident again stated he wanted to lie down because he had been sitting up since noon. He remained in the wheelchair until a CNA supervisor and another CNA transferred him to bed later that afternoon. The DON stated she expected staff to respond to the resident’s needs immediately, to lay him down if he complained of increased pressure ulcer pain from sitting up, and that if treatments were administered they should be documented on the TAR. The facility’s wound management policy stated nursing staff would initiate treatment and use interventions for pressure redistribution and wound management.
Failure to Prevent Neglect and Address Fall Risks
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including schizophrenia, malnutrition, and a history of frequent falls, was not adequately monitored or provided with appropriate interventions to prevent neglect and injury. Despite being identified as a high fall risk and having a care plan that documented numerous falls, staff repeatedly failed to implement or update fall prevention interventions after each incident. The resident experienced multiple falls, some resulting in injuries that required emergency room visits, yet new or effective interventions were often not put in place, and fall risk assessments were missing after several incidents. In addition to the failure to address fall risks, staff did not consistently follow existing care plan interventions such as frequent toileting, ensuring the call light was within reach, and performing regular checks. The resident was observed on several occasions lying in bed for extended periods, saturated in urine and feces, with the call light out of reach and the door closed, making the resident not visible to staff. Staff members were seen opening the door, looking in, and leaving without providing care or cleaning the resident, even after being aware of the resident's condition. The resident remained soiled for at least five hours, and staff failed to respond to his needs despite clear evidence of incontinence and discomfort. Interviews with staff and medical professionals confirmed that the standard of care was not met, as the resident was left unattended and in an unhygienic state, and interventions to prevent falls and address incontinence were not followed. The facility's own policies defined such actions as neglect, including inadequate provision of care, poor hygiene, and leaving someone unattended who needs supervision. The repeated lack of appropriate response and disregard for the resident's care, comfort, and safety led to the identification of neglect and the declaration of Immediate Jeopardy.
Removal Plan
- R2 was provided with 1:1 sitter.
- DON/ADON completed skin assessment on R2 with no negative outcomes noted.
- Administrator, DON & ADON were in-serviced by the RNC on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Administrator in-serviced all department heads on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Department managers in-serviced department staff members on the Abuse Prevention and Prohibition Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- Staff will not work until in-serviced on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- DON/ADON/Department Manager will in-service any future agency employees on the Abuse Prevention Program with an emphasis on coordination of care and providing adequate/appropriate care to all residents.
- The DON/ADON/Licensed staff completed skin assessment on residents requiring incontinent care.
- A quality assurance tool was implemented: DON/ADON/CNA Supervisor will conduct audits on residents requiring incontinent care and completed in timely manner.
- A quality assurance tool was implemented for SSD (Social Service Director) or designee to conduct resident interviews to ensure there are no concerns related to Abuse/Neglect.
- The DON/ADON will complete audit review during daily morning clinical meeting to ensure compliance.
- Audit tool will also include review of new/re-admit fall risk assessments for resident high risk to ensure prevention measure are in place.
- Root cause analysis completed for neglect related to coordination of care provided to residents.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to provide effective fall prevention and adequate supervision for a resident with a documented history of frequent falls and severe cognitive impairment. This resident experienced 50 falls over an eight-month period, many resulting in injuries such as hematomas, lacerations, and head injuries, some of which required emergency room visits. Despite being identified as a high fall risk and having multiple interventions listed in the care plan, staff did not consistently implement or update these interventions after each fall, and several falls were not addressed in the care plan at all. Additionally, fall risk assessments were not completed after every incident as required by facility policy. Observations and interviews revealed that staff often failed to keep the resident's call light within reach, did not maintain the resident in visible areas for supervision, and did not follow specific care plan interventions such as increased toileting rounds or ensuring environmental safety (e.g., removing nightstands, keeping doors open for visual checks). On multiple occasions, the resident was found lying on the floor or in bed with saturated linens, indicating a lack of timely assistance with activities of daily living and incontinence care. Staff were observed opening the resident's door to check if he was breathing but did not provide further care or ensure his safety, and transfers were performed without the use of gait belts or proper technique, increasing the risk of falls and injury. Interviews with facility leadership and clinical staff confirmed that there was an expectation for staff to follow all care plan interventions and maintain resident safety, but these expectations were not met. The facility's own policies required prompt response to resident needs, regular fall risk assessments, and implementation of individualized interventions, none of which were consistently followed. The failure to implement and monitor effective fall prevention strategies and provide adequate supervision directly resulted in repeated injuries and placed the resident in Immediate Jeopardy.
Removal Plan
- A fall risk assessment was completed for R2 and placed on 1:1 supervision.
- 1:1 sitters were in-serviced on 1:1 expectation related to coordination of care for R2.
- IDT team reviewed R2 falls to ensure that appropriate current interventions are in place.
- Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.
- In-service front-line staff on Fall Prevention Policy and where to verify Care Plan Interventions.
- In-serviced Nursing staff on how to find care plan/fall interventions in EHR. Staff will not work next shift until Fall Prevention In-service is completed.
- An initial audit will be completed of all falls to ensure current interventions are initiated and effective. Care plans will reflect interventions that are effective.
- Initial audit completed of fall risk assessments to ensure that appropriate prevention interventions are in place and care plans are reflecting those interventions.
- A quality assurance tool was implemented: An audit will be completed during clinical meeting to ensure that any fall has a root cause analysis, progressive intervention, and care plan is updated.
- A root cause analysis for Fall Prevention and interventions being placed on care plan and physically in place will be reviewed weekly during Facility Risk Meeting.
- Review of the Fall Prevention Policy.
Failure to Provide Timely and Complete Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. One resident with severe cognitive impairment and multiple diagnoses, including schizophrenia and diabetes, was observed lying in bed for several hours in saturated sheets with urine and feces. Despite staff entering the room multiple times, the resident was not cleaned or checked for incontinence, and the door was repeatedly closed without intervention. The resident confirmed not being cleaned or checked during this period, and staff acknowledged not having time to provide care due to staffing issues. When incontinent care was eventually provided, staff failed to follow proper infection control and hygiene protocols. Hand hygiene was not performed before or after glove changes, and soiled gloves were used to handle clean supplies. The resident's peri-care was incomplete, as the penis and testicles were not cleaned, and soiled clothing was not promptly removed. The process lacked the use of a gait belt for safe transfer, and contaminated gloves were used to search for clean clothing, further breaching infection control standards. A second resident, cognitively intact but dependent on staff for toileting, also received incomplete peri-care. During observed care, staff failed to retract the foreskin to clean the entire penis and did not dry the resident after cleaning. The facility's own policies require residents to be checked for incontinence at least every two hours and for complete peri-care to be provided, including proper hand hygiene and cleaning techniques. Interviews with staff and the DON confirmed expectations for timely and thorough care, which were not met in these instances.
Failure to Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care for three out of four residents reviewed for infection control. In multiple observed instances, staff members, including CNAs and an LPN, did not perform hand hygiene before donning gloves, between glove changes, or after completing resident care and leaving the room. These lapses occurred during the provision of incontinent care and gastrostomy tube (G-tube) care. One resident with severe cognitive impairment and total dependence for activities of daily living was observed receiving incontinent care from two CNAs who donned gloves without prior hand hygiene, changed gloves multiple times without hand hygiene between changes, and left the room without performing hand hygiene. Another resident, also dependent on staff for ADLs and with a history of bowel and bladder incontinence, received peri-care from CNAs who failed to perform hand hygiene before care, between glove changes, and after care. Additionally, an LPN providing G-tube care to a resident did not perform hand hygiene before donning PPE, between tasks, or after doffing PPE and leaving the room. Interviews with facility staff, including the Director of Nursing and CNAs, confirmed the expectation that hand hygiene should be performed before and after resident care, as well as between glove changes. Facility policies also require hand hygiene at these critical points. However, direct observations and record reviews demonstrated that these protocols were not consistently followed during the care of residents with complex medical needs and high dependency.
Failure to Maintain Resident Room Window in Safe and Homelike Condition
Penalty
Summary
A deficiency was identified when a resident's room window was found to have a hole, allowing flies to enter the room. The resident's daughter reported the issue and took temporary measures by taping the hole and using a fly swatter. The Maintenance Director was unaware of the problem, stating that he typically addresses work orders the same day they are submitted, but no work order had been received for this issue. Upon inspection, the window was found to be inadequately covered with a piece of plexiglass that was not properly secured, leaving visible gaps and allowing outside air to enter the room. The plexiglass was attached with only one screw and loose duct tape, which was no longer effective, resulting in the wind blowing the plexiglass inward. Staff interviews revealed that the process for reporting maintenance issues involves filling out a work order and notifying maintenance, but in this case, the process was not followed, and the deficiency went unaddressed until it was observed during the survey. The facility's policy emphasizes the importance of maintaining a safe, clean, and homelike environment, but the failure to promptly identify and repair the window compromised these standards for the resident involved.
Failure to Conduct Employee Background Checks and Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse by not performing required background check screenings on current employees who have direct contact with residents. This lapse in screening had the potential to affect all 79 residents in the facility. Specifically, a resident with diagnoses of Bipolar Disorder, Depression, and Anxiety experienced verbal abuse from a staff member. The resident reported that a kitchen staff member used inappropriate language, stating he was going to 'whoop' the resident's ass after the resident complained about cold food. The incident left the resident feeling fear, anger, embarrassment, and a reluctance to leave his room while the staff member was employed. The facility's investigation into the incident was inconclusive, as there were no witnesses and the resident could not recall specific details or the exact date of the event. The staff member in question was suspended immediately and later terminated for safety reasons. During the investigation, it was discovered that the facility could not locate or verify the completion of the staff member's background checks. The administrator acknowledged responsibility for ensuring background checks are completed upon hire, as required by the facility's abuse prevention policy, but was unable to confirm that this had been done for the staff member involved.
Failure to Complete Staff Background Checks Leads to Resident Distress
Penalty
Summary
The facility failed to ensure a safe environment free from actual and potential abuse by not performing required background check screenings on current employees who had direct contact with residents. This lapse affected all 79 residents in the facility, as several staff members, including kitchen, housekeeping, maintenance, and nursing staff, were found to have worked without completed background checks or healthcare worker registry verifications. The administrator acknowledged that background checks were not completed for multiple employees, some of whom had direct access to residents, and that the issue stemmed from a lapse in service by the background check provider due to nonpayment, which was not followed up on by facility leadership. One resident, who has diagnoses of Bipolar Disorder, Depression, and Anxiety, reported experiencing verbal abuse from a kitchen staff member. The resident stated that the staff member used inappropriate language, which caused the resident to feel fear, anger, embarrassment, and reluctance to leave their room while the staff member was employed. The incident was reported and investigated, but the facility was unable to substantiate the allegation due to lack of corroborating evidence and the possibility of a misunderstanding in a noisy environment. However, the resident maintained that the incident occurred and described significant emotional distress as a result. Interviews and record reviews revealed that the facility's policies required background checks and registry verifications to be completed prior to employment, but these procedures were not followed. The administrator admitted responsibility for ensuring these checks were completed and confirmed that several staff members had worked without the required screenings. The medical director emphasized the importance of timely background checks to protect vulnerable residents, and the facility's own policies outlined a zero-tolerance approach to abuse, neglect, and misappropriation of property, which was not upheld in practice.
Removal Plan
- Administrator was in-serviced by the VP of clinical services on background checks and the need to run prior to staff member working.
- Administrator will in-service department heads on ensuring that staff will not work without background check being completed.
- All staff members that are currently on the working schedule have had a background check completed and are eligible to work in a skilled facility.
- Initial audit completed for all current employees, that a background check has been completed.
- Review of current policy and procedure to reflect current practices.
- No staff will work before having a background check.
- A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to first working day. Administrator and department manager.
- Root Cause Analysis Completed for background checks.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Response to Resident Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff, including both CNAs and nurses, to meet the needs of all residents, as evidenced by observations, interviews, and record reviews. During facility tours, staffing levels were observed to be as low as 2 CNAs and 2 nurses, and later 5 CNAs and 3 nurses, for 81 residents. Residents reported inadequate staffing, with one resident stating that increased use of agency staff indicated a need for more permanent staff. Another resident described multiple falls, including an incident where he was unable to reach his call light after falling, crawled to the hallway without finding staff, and ultimately called 911 for assistance. First responders, including fire and police personnel, reported difficulty locating staff upon arrival, eventually finding a nurse and another staff member outside smoking, both unaware of the resident's situation. Documentation showed that on the day of the incident, scheduled staffing was not met, with fewer CNAs present than planned. The resident involved in the fall was found on the floor with dried blood on his hands, face, and head, and had been attempting to get staff attention with a broken coat hanger. The nurse on duty reported last checking on the resident approximately 45 minutes before first responders arrived but did not enter the room. The facility's staffing policy requires sufficient licensed and unlicensed staff to maintain residents' well-being, but records and staff interviews confirmed that staffing levels were inadequate at the time of the incident.
Failure to Notify Family of Resident Falls
Penalty
Summary
The facility failed to notify a resident's family member of multiple falls experienced by the resident, despite facility policy requiring notification of the physician and responsible party after such incidents. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 6, and multiple diagnoses including catatonic schizophrenia, anxiety disorder, repeated falls, hypertension, major depressive disorder, and type II diabetes. Progress notes documented several falls over a two-month period, but there was no documentation that the family was informed of these events or any resulting injuries. The resident's family member confirmed that they had not been notified of recent falls and only learned of an injury after observing a cut above the resident's eye during a visit and inquiring with nursing staff. Interviews with facility staff indicated that the expectation was to notify families and physicians after a fall, but this was not consistently done for this resident.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide medical records to a resident's legal representative as required. The resident, who had diagnoses including metabolic encephalopathy, epilepsy, vascular dementia, and major depressive disorder, was moderately cognitively impaired at the time of discharge. After discharge, the resident's daughter, who held power of attorney, completed and submitted a HIPAA-compliant authorization form requesting access to the resident's medical records. The form, which specified that the facility must act within 30 days, was handed to a social services staff member, who stated she placed it on the administrator's desk and notified her. Despite this, the administrator and the Vice President of Clinical Services both stated they had never seen the request form and were unaware of its submission. The social services staff member confirmed receiving the form and taking steps to forward it, but no further action was taken, and the records were not provided to the resident's legal representative. This lack of follow-through resulted in the facility's failure to meet the regulatory requirement to provide timely access to resident records.
Failure to Update Care Plans and Complete Fall Risk Evaluations After Resident Falls
Penalty
Summary
The facility failed to implement and/or revise individualized care plans and complete fall risk evaluations for three out of five residents reviewed for accident hazards and supervision. One resident experienced multiple unwitnessed falls over a period of time, including incidents resulting in a hematoma, yet the care plan was not updated with new interventions after several of these falls. The resident's records indicated significant physical impairments, including lower extremity impairment, wheelchair use, and dependence on staff for transfers and toileting, but interventions remained largely unchanged despite repeated incidents. Another resident, with diagnoses including chronic obstructive pulmonary disease and mental health disorders, was identified as at risk for falls in prior evaluations but did not have a current care plan reflecting this risk. After a witnessed fall and an episode of unsteady gait possibly related to alcohol consumption, no new fall risk evaluation was completed. The resident reported frequent outdoor walks and described a recent incident where she tripped outside the facility, but there was no evidence of updated assessment or intervention following this event. A third resident, who was moderately cognitively impaired and required assistance with mobility, was documented as a high fall risk in a previous evaluation, but her care plan did not reflect this status. Family members and staff interviews confirmed that this resident had experienced falls both inside and outside the facility, with at least one incident observed by a family member and reported to emergency services. Staff acknowledged that fall risk care plans and evaluations should be updated after falls, but this was not consistently done. The facility's own policy required post-fall evaluations and care plan updates, which were not followed in these cases.
Mechanical Lifts Not Maintained in Safe Working Condition
Penalty
Summary
The facility failed to maintain mechanical lifts in safe working condition for four residents who required their use. Multiple CNAs reported and were observed struggling to maneuver a mechanical lift whose right leg would swing out unexpectedly without the use of controls, requiring staff to physically kick it back into place. The issue had been ongoing for several weeks, with the word "BAD" written on the malfunctioning leg to indicate its condition. Staff also reported that the lift sometimes failed to move up or down, possibly due to a short circuit, and that the other available lift had similar issues. Residents who depended on the lifts expressed fear and discomfort during transfers, with one resident stating she sometimes could not get out of bed for days due to lift problems, dead batteries, or lack of slings and staff. Despite these ongoing issues, the facility's process for reporting and addressing equipment problems was ineffective. CNAs stated they had notified maintenance, but the administrator was unaware of any work orders for the lifts and had not received reports of the problems. The facility's policy required routine maintenance checks by nursing and maintenance staff to ensure equipment remained in good working order, but this was not followed, resulting in continued use of unsafe equipment and inadequate communication regarding equipment failures.
Failure to Maintain Sanitary and Comfortable Environment Due to Mold and Poor Bathroom Conditions
Penalty
Summary
The facility failed to provide a sanitary and comfortable environment for residents, as evidenced by multiple observations of mold, strong bleach odors, and unclean conditions in several bathrooms and shower areas. Surveyors observed black and green fuzzy substances, identified as mold by staff, on tiles, baseboards, and walls in both men's and women's bathrooms across different hallways. In some areas, tiles were missing and walls were crumbling, and there were strong bleach odors that caused discomfort to surveyors. Toilets were found unflushed, and residents reported infrequent cleaning and persistent mold issues, with some stating they only shower once a week due to the unsanitary conditions. Interviews with residents and staff confirmed ongoing problems with mold, with residents expressing concerns about the cleanliness and odor of the shower rooms. Staff members, including a CNA and the housekeeping supervisor, acknowledged the presence of mold and described efforts to clean it with bleach and water, though the issue was described as longstanding. The facility's policy requires immediate cleaning of mold and mildew with appropriate cleaners, but the observations and interviews indicate that these measures have not been effective in maintaining a sanitary environment.
Failure to Ensure Timely Assessment and Continuity of Care for Resident with Epilepsy
Penalty
Summary
A deficiency occurred when a resident with a known history of epilepsy and complex partial seizures did not receive prescribed anti-seizure medications for four days. The resident's medication orders included Lacosamide and Levetiracetam, both critical for seizure control, which were held from 3/14 to 3/17 following an order from a covering nurse practitioner. This order was based on staff concerns that the resident's daughter may have been providing additional, possibly duplicative, medication doses during a leave of absence, though there was no clear evidence or identification of the medication in question. The decision to hold the medications was made without timely assessment or clarification of the situation, and there was a lack of direct communication with the resident's specialists. The covering nurse practitioner, who was not the resident's regular provider, acted on incomplete information provided by staff, who themselves were uncertain about what medication may have been given by the family. The regular nurse practitioner was on vacation, and upon return, noted that the hold order was based on a possible risk of double dosing, but there was no follow-up or assessment to confirm this before stopping essential medications. During the period when the anti-seizure medications were held, the resident experienced a seizure and required emergency hospital treatment. Hospital records confirmed that the seizure medications had been stopped for several days per facility staff orders. Interviews with facility staff and pharmacy consultants indicated that the lack of timely review and assessment of the medication regimen contributed to the resident's adverse event. The facility did not have a policy on continuity of care to guide staff actions in such situations.
Failure to Administer Anti-Seizure Medications as Ordered
Penalty
Summary
A resident with a history of epilepsy and complex partial seizures did not receive multiple doses of prescribed anti-convulsant medications, specifically oxcarbazepine and lacosamide, as ordered by the physician. The medication administration records showed missed doses of oxcarbazepine on two occasions and missed doses of lacosamide over several days. Documentation indicated that the medications were not available in the facility, and pharmacy records confirmed delays in refilling the prescriptions. The facility's controlled drug receipt and disposition forms corroborated that the resident ran out of lacosamide and did not receive it for several days. During this period without medication, the resident experienced a seizure episode in bed, which lasted 2.5 minutes and included clonic activity and emesis. The resident was found in a post-ictal state, displaying confusion, combativeness, and inability to respond appropriately. Emergency medical services were called, and the resident was sent to the hospital for evaluation and treatment. Interviews with facility staff and pharmacy personnel confirmed that the resident was sub-therapeutic for at least one day and that missing anti-seizure medication in such a case is considered a significant medication error. The facility's policies required that controlled substances be reordered when a four-day supply remained, and that emergency pharmacy services be available 24 hours a day. However, the resident's medication was not reordered in a timely manner, and the emergency kit did not contain the necessary anti-seizure medication. Staff interviews revealed uncertainty about how or if the medication was obtained during the period it was unavailable, and there was no documentation explaining the delay in refilling the medication.
Improper Dishwashing and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper cleaning of dishes and appropriate storage of food, which could potentially lead to foodborne illness affecting all 55 residents. During an observation, a cook was seen washing food residue from a dish in the far-right compartment of a three-compartment sink, then dipping the dish directly into the sanitizing solution in the far-left compartment without rinsing it in between. The middle sink compartment, which should have been used for rinsing, was empty. The cook admitted that the usual process is to wash, rinse, and sanitize dishes, but due to the lack of a stopper for the middle sink, she skipped the rinsing step. Additionally, the facility did not adhere to its policy regarding food storage. In the walk-in refrigerator, containers labeled Super Cereal and Meat Salad were found without a 'Use By' date, despite being dated 11/3/24 and 11/5/24, respectively. In the walk-in freezer, opened and resealed bags of biscuit dough and breadsticks were not labeled or dated upon opening. The dietary manager confirmed that food should be discarded after seven days, aligning with the facility's policy that requires items in refrigerators and freezers to be covered, labeled, and dated with a system to track when to discard perishable foods.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with a history of schizophrenia, depression, anxiety, diabetes, sleep apnea, COPD, and morbid obesity. The incident was reported when the resident claimed to have been hit and scratched by a night CNA. Initial assessments by nursing staff found no signs of injury, and a review of facility cameras showed no interaction between the resident and the accused CNA. Despite this, the facility's investigation was incomplete as the administrator acknowledged not asking the correct abuse-related questions during interviews with other residents. The facility's documentation noted minimal swelling on the resident's face, but the investigation did not substantiate the abuse claim. The resident's statements were inconsistent, and during a police interview, the resident was unresponsive or provided unrelated answers. The facility's abuse prevention policy requires interviews with other residents who have regular contact with the accused, but the administrator admitted to not following this procedure correctly. Consequently, the investigation was deemed insufficient, leading to a deficiency in handling the abuse allegation.
Failure to Address Pain Management in Resident Care Plan
Penalty
Summary
The facility failed to address pain management in the care plan of a resident, identified as R3, who was part of a sample of 43 residents reviewed. Despite the resident being alert and experiencing occasional pain, as documented in the Minimum Data Set (MDS), the care plan dated June 4, 2024, did not include any interventions for pain management. The resident's Physician's Order Sheet from November 2024 listed several pain medications, indicating a need for pain management, yet the care plan lacked any mention of this issue. During an interview on November 13, 2024, the resident reported chronic pain in her legs, knees, and ankles, with a pain level of 6 out of 10. The MDS/Care Plan Coordinator acknowledged that the resident's pain should have been addressed in the care plan with both pharmacological and non-pharmacological interventions. The coordinator was unsure why the pain was not included, suggesting that the resident's multiple hospital discharges over the past six months might have contributed to the oversight. The facility's Comprehensive Care Planning Policy emphasizes the importance of addressing all resident needs, including pain management, in the care plan.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum floor space per resident bed, as mandated by regulations. Specifically, the facility has 30 two-bed resident rooms that only provide 75 square feet per resident bed, falling short of the 80 square feet requirement. These rooms measure 12 feet by 12 feet six inches and are certified for Medicare and Medicaid. Additionally, there are 8 two-bed resident rooms providing 77.5 square feet per resident bed, 3 two-bed resident rooms providing 76.5 square feet per resident bed, and 2 two-bed rooms providing 78.5 square feet per resident bed. These measurements were confirmed through historical data and current room measurements. During observations conducted from November 12 to November 15, 2024, it was noted that 26 out of 55 residents were housed in rooms that did not meet the 80 square feet per resident bed requirement. The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated November 12, 2024, documents the facility's census as 55. The deficiency affects a significant portion of the resident population, as these rooms are integral to the facility's accommodation of its residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a roach infestation that affected all 56 residents. Observations and interviews revealed that roaches were present in various areas, including the 300-hall, dining room, and individual resident rooms. Staff and residents reported seeing roaches scatter when lights were turned on, indicating a significant infestation problem. The facility's maintenance man, who was responsible for pest control, was terminated for not performing his duties, which contributed to the worsening situation. The pest control company had identified roach activity as early as February and recommended monthly services, but the facility did not follow through due to financial issues. The pest control service was put on hold, and the company was not called back until June. During their visit in June, the pest control technician found roach activity in the kitchen and other areas, confirming the ongoing infestation. The facility's policy required monthly preventative treatments, but this was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 781 citations issued within 25 miles in the last 12 months — including the 25 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Collinsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Au Well Care Home, Inc | 3.3 mi | — | 0 | 0 |
| La Bella Of Caseyville | 3.4 mi | ★★★★★ | 4 | 0 |
| Manor Court Of Maryville | 5.4 mi | ★★★★★ | 0 | 0 |
| Evercare At Stearns | 6.9 mi | ★★★★★ | 7 | 0 |
| Meridian Village Care Center | 7 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 July 2026) and official state health department websites.