Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Granite City during CMS and state inspections, most recent first.
A resident with severe dementia and a history of being combative during care was injured when a CNA, working alone, attempted to reposition her during peri care. Despite care plan instructions to provide care in pairs when the resident was overly stimulated, the CNA proceeded alone, and the resident sustained a left humerus fracture during the episode. Staff interviews confirmed that care should have been paused and assistance sought when the resident became combative.
Failure to Implement Progressive Fall Interventions: A resident with Parkinson's Disease, dementia, Alzheimer's Disease, impaired mobility, and a history of falls had repeated falls despite being identified as high risk. The record shows multiple unwitnessed and witnessed falls with the resident found on the floor, on fall mats, or beside furniture, often confused or attempting to get up, reach items, or adjust the room environment. The facility repeatedly documented the same fall measures, but no new progressive interventions were implemented after several falls, and some falls had no care plan intervention documented.
Failure to revise fall care plan after repeated falls: A resident with Parkinson’s disease, dementia, Alzheimer’s disease, and a high fall risk had numerous falls over several months. Although staff documented assessments, floor mats, low bed position, wheelchair adjustments, hospice involvement, and other measures in various notes, the care plan was not consistently revised with progressive interventions after several of the falls, including events where the resident was found on the floor, on a fall mat, or beside the bed and often could not explain what happened.
Multiple incidents of physical and verbal aggression occurred between residents, including one resident striking another in the face, throwing objects, and using racial slurs and threats. Several residents reported feeling unsafe or uncomfortable, and care plans did not consistently address known behavioral risks. Staff witnessed some incidents but interventions were not effective in preventing further abuse.
Two residents with histories of behavioral and cognitive issues were involved in a physical altercation, resulting in one sustaining a nasal fracture. Neither resident had a care plan addressing abuse, despite documented aggression and combative behaviors. The incident was not witnessed by staff and was reported after the fact, with both residents separated and assessed following the event.
A resident with multiple comorbidities and on oxygen therapy reported feeling unwell to a CNA, who placed her on a portable oxygen tank that was empty or low and left her at the nurse's desk without notifying a nurse. The resident was left unattended, became unresponsive, and required CPR and hospitalization for acute hypoxic respiratory failure. Staff interviews and documentation confirmed that required notification procedures were not followed.
Certified Nursing Assistants were found to be administering oxygen therapy to a resident with complex medical needs, despite facility policy requiring only licensed nursing personnel or respiratory therapists to perform this task. Staff interviews revealed confusion and inconsistent practices regarding oxygen administration responsibilities.
The facility failed to properly store and prepare food, risking contamination for all 76 residents. Observations revealed unlabeled and undated food items, improper glove use by staff during food service, and inadequate food temperatures on the steam table, all contrary to facility policies.
A facility failed to prevent resident-to-resident abuse involving two residents. One resident, with a history of dementia and behavioral issues, hit another resident, who has severe cognitive impairment, resulting in a facial abrasion. The care plans for both residents did not address potential abusive behaviors, contributing to the incident. The facility's abuse policy was not effectively implemented, as staff did not intervene before the situation escalated.
A resident with cognitive impairments and multiple diagnoses was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring a two-person assist. The CNA acknowledged the error, and the DON confirmed the expectation for two staff members during such transfers.
Failure to Provide Safe Care During Transfer and Personal Care for a Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to provide safe care to a resident with dementia, resulting in the resident sustaining a left humerus fracture. The resident, who was severely cognitively impaired and dependent on staff for activities such as toileting, dressing, and transfers, was known to be occasionally combative and resistive to care due to her dementia. Her care plan included interventions such as approaching her later if she became combative, informing her of care tasks before performing them, and providing care in pairs if she was overly stimulated. On the day of the incident, a CNA transferred the resident from her wheelchair to bed using a full mechanical lift by himself. While providing peri care with the resident on her left side, the resident became combative and began leaning toward the edge of the bed. The CNA attempted to reposition her back to the center of the bed while she was resisting, during which he heard a pop from her arm and the resident cried out in pain. The CNA immediately notified the nurse, who assessed the resident and observed a deformity in her left arm. The resident was subsequently sent to the hospital, where she was diagnosed with an acute spiral fracture of the left proximal humerus. Interviews with staff revealed that the CNA was aware of the resident's combative tendencies but proceeded to provide care alone, contrary to the care plan's recommendation for paired care in such situations. Other staff members, including the LPN and DON, stated that if a resident becomes combative or refuses care, staff should back away and seek assistance rather than continue care. The incident was witnessed by another resident who heard the altercation and the resident's complaint of pain. Documentation and interviews confirmed that the resident's injury occurred during an episode of resistance while care was being provided by a single staff member.
Failure to Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to implement progressive interventions to reduce falls for 2 of 9 residents investigated for accidents, including a resident with Parkinson's Disease with Dyskinesia, dementia, Alzheimer's Disease, cerebrovascular accident, hypertension, osteoarthritis, bipolar disorder, anxiety, major depressive disorder, incontinence, impaired mobility, and a history of falls. The resident's MDS documented moderate cognitive impairment and substantial to maximal assistance needs for bed mobility and transfers. The care plan identified the resident as high risk for falls related to multiple diagnoses and psychotropic medication use. The resident experienced repeated falls and fall-related events over several months, including unwitnessed and witnessed falls on the floor, on fall mats, beside the bed, and near furniture or a heater. Documentation repeatedly described the resident attempting to get water, reach a roommate's walker, turn off heat, pull a bedside table closer, or get up and walk, with several notes stating the resident was barefoot, confused, or unable to explain what happened. Assessments after these events often noted no injury or only minor redness, and the resident was frequently assisted back to bed or a wheelchair or Broda chair. Although the record shows various interventions were documented after individual falls, the same or previously used interventions were repeatedly carried forward, such as fall mats, low bed position, canoe mattress, Dycem, anti-roll backs, medication review, hospice consultation, frequent checks, and placing items within reach. The report specifically states that no new progressive interventions were implemented after falls on 4/21/2025, 5/17/2025, and 6/25/2025, and that no intervention was documented on the care plan for several earlier falls. The resident continued to fall despite the ongoing documentation of the same measures.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise the care plan with progressive interventions after repeated falls for a resident with Parkinson’s disease with dyskinesia, dementia, Alzheimer’s disease, cerebrovascular accident, hypertension, osteoarthritis, bipolar disorder, anxiety, major depressive disorder, incontinence, psychotropic medication use, and a documented high fall risk. The resident’s MDS documented moderate cognitive impairment and substantial to maximal assistance needs for bed mobility and transfers. The care plan identified an increased fall risk, and the record shows multiple falls over the review period, yet the care plan was not consistently updated after each event with new or progressive interventions. After an unwitnessed fall in the resident’s room, the nurse documented assessment findings and the resident’s statement that she had been trying to get her water, but no intervention was documented on the care plan for that fall. Another fall on 3/3/2025 was documented as witnessed by the roommate; the resident was found on the floor in front of the closet door, stated she was looking for food in her closet, and the notes referenced care plan updates, therapy referral, medication review, and anti-rollbacks on the wheelchair. However, subsequent falls continued to occur, including falls on 3/30/2025, 3/31/2025, 4/10/2025, 4/17/2025, 4/21/2025, 4/27/2025, and 4/30/2025, with repeated documentation of floor mats, low bed position, canoe mattress, wheelchair positioning, and monitoring, but no documented care plan intervention for several of these events. The resident continued to fall in May and June, including events on 5/17/2025, 5/28/2025, 6/4/2025, and 6/25/2025. Notes repeatedly described the resident as found on the floor or fall mat beside the bed, often unable to explain what happened or stating she tried to get up, walk, or reach items. Interventions varied in the notes, including hospice consultation, medication review, placement in a Broda chair near the nurses’ station, and ensuring items were within reach, but the record still showed repeated falls without consistent progressive revision of the care plan after each incident. On 7/2/2025, the resident again fell while trying to turn over in bed, and the record documented that a new electric hospital bed with air mattress was being ordered through hospice. The resident had another fall on 9/5/2025 while in bed eating breakfast, and the note ended mid-entry after staff assisted the resident off the floor.
Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving physical and verbal aggression. One cognitively intact resident with a history of delusions, daily behavioral symptoms, and worsening aggression was involved in several altercations. This resident struck another cognitively intact resident in the face with an object and a cup of water, resulting in a visible bruise and discomfort for the victim. The incident was witnessed by an LPN, and the aggressor had recently been removed from 1:1 supervision. The victim reported feeling unsafe and uncomfortable in the facility, and had previously received verbal threats from the aggressor. Additional incidents included verbal and physical altercations between residents, such as one resident yelling, cursing, and threatening another, which escalated to the throwing of a cup of ice and physical intimidation. Another resident reported being subjected to physical aggression, including having cold coffee thrown on him while sleeping, and described ongoing verbal abuse and theft of personal items by his former roommate. This resident expressed feeling unsafe and mistrustful of the aggressor. Other altercations involved racial slurs, threats of violence, and the brandishing of a butter knife, which was retrieved by staff after being observed by a visitor. Care plans for several residents did not document risks for abuse, despite known behavioral histories and previous incidents. The facility's policies state a commitment to protecting residents from abuse by anyone, and staff are responsible for providing a safe environment. However, the repeated incidents of physical and verbal aggression, lack of effective interventions, and failure to update care plans to address abuse risks contributed to the deficiency in protecting residents from abuse and ensuring their safety.
Failure to Prevent Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, resulting in one resident sustaining a minimally displaced fracture to the left nasal bone. One resident, who had a history of hemiplegia, hemiparesis, and unspecified psychosis, was documented as being verbally aggressive toward others but had no care plan addressing abuse. This resident reported being physically attacked by his roommate, who struck him multiple times, prompting him to retaliate with a single blow. Both residents were separated immediately after the incident, and assessments were conducted. The other resident involved had a history of cerebral infarction, major depressive disorder with psychotic features, and significant cognitive impairment, as indicated by a low BIMS score. This resident was known to resist care and had a history of making false statements about being hit by others, but there was no care plan addressing abuse for this individual either. During the altercation, this resident sustained a nasal fracture, as confirmed by a CT scan, and required emergency medical evaluation and treatment. Documentation indicated that this resident was combative with care on a daily basis and had functional limitations on both sides. The facility's records and interviews revealed that neither resident had a care plan specifically addressing abuse, despite documented behavioral concerns and histories of aggression or combative behavior. The incident was not witnessed by staff, but was reported and documented after the fact. The facility's policy stated a commitment to protecting residents from abuse by anyone, including other residents, but the lack of individualized abuse prevention care plans contributed to the failure to prevent this altercation.
Failure to Notify Nurse of Resident's Change in Condition Resulting in Hypoxic Episode
Penalty
Summary
Facility staff failed to notify a nurse of a resident's change in condition, resulting in a lack of timely assessment and intervention. The resident, who had multiple significant diagnoses including COPD, heart disease, and required oxygen therapy, expressed feeling unwell to a CNA after being assisted to her wheelchair. The CNA placed the resident on a portable oxygen tank, which was later found to be empty or low, and left her at the nurse's desk to wait for a nurse, rather than directly notifying nursing staff of the resident's complaints and oxygen needs. The resident remained unattended at the nurse's desk for an extended period, during which time she became unresponsive and hypoxic. Staff interviews revealed that the CNA did not check the oxygen tank to ensure it contained oxygen and did not immediately inform a nurse of the resident's symptoms or the need for oxygen. The nurse assigned to the resident was on lunch break at the time, and coverage procedures were not effectively implemented, as the covering nurse was not made aware of the resident's condition or oxygen needs. When the resident was finally assessed, she was found unresponsive, with no respirations and a faint pulse, requiring CPR and emergency intervention. The resident was subsequently hospitalized with acute hypoxic respiratory failure and other complications. Documentation and interviews confirmed that facility policy required staff to notify a nurse of any resident reporting feeling unwell or experiencing a change in condition, which did not occur in this instance.
CNAs Administered Oxygen Therapy Contrary to Facility Policy
Penalty
Summary
Certified Nursing Assistants (CNAs) were observed administering oxygen to a resident with multiple complex medical conditions, including COPD, heart disease, and a history of coronary artery bypass graft. The resident was dependent on staff for most activities of daily living and required continuous oxygen therapy as ordered by a physician. The resident reported that after being transferred to a wheelchair by a CNA, the CNA placed the nasal cannula and informed the resident that the oxygen tank was empty, instructing the resident to wait for a nurse to refill it. The resident also stated that both CNAs and nurses would put the oxygen on her, and that she was kept on oxygen at all times. Interviews with multiple CNAs and licensed nursing staff revealed inconsistent understanding and practices regarding who is authorized to administer or adjust oxygen therapy. Some CNAs reported routinely placing residents on portable oxygen tanks, while others were unsure if this was within their scope of practice. Licensed staff and the Director of Nursing provided conflicting statements about whether CNAs were permitted to perform this task, despite facility policies specifying that only licensed nursing personnel or respiratory therapists are responsible for administering oxygen and medications. The facility's policies clearly state that medication administration, including oxygen therapy, is restricted to licensed personnel, yet CNAs were observed and reported to be performing these duties.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and preparation, leading to potential contamination risks for all 76 residents. During a kitchen tour, it was observed that several food items, including drinks, rice, Panko breadcrumbs, beans, and cornmeal, were stored in containers without proper labeling or dating. The Dietary Manager acknowledged that these items should have been labeled and dated to prevent any guessing about their freshness or safety. Additionally, during breakfast service, a staff member was observed handling food with gloves that had been contaminated. The staff member did not change gloves or wash hands after cleaning a dirty bowl before continuing to serve food. Furthermore, the temperatures of scrambled and boiled eggs on the steam table were found to be below the required 135 degrees Fahrenheit, which could allow bacteria to grow and potentially cause foodborne illness. The facility's policies require food to be stored and served at safe temperatures, with proper labeling and dating to ensure food safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, R29 and R42. R42, who has a history of dementia with behavioral disturbances, bipolar disorder, and other mental health conditions, was involved in an incident where she hit R29 in the face. R42's care plan did not address potential abusive behaviors, despite her history of verbal outbursts and inappropriate behaviors. On the evening of the incident, R29 reported to a CNA that R42 had slapped her while she was in bed. As R42 walked past, she reacted to R29's accusation by hitting her in the face, resulting in a 0.5 cm abrasion on R29's left cheek. R29, who has severe cognitive impairment and uses a wheelchair, was also not protected from abuse as her care plan did not address potential abuse despite her history of becoming angry and confrontational when confused. After the incident, R29 was assessed for injuries, and it was noted that she had a small abrasion on her cheek. The facility's response included separating the residents and notifying the necessary medical and administrative personnel, but the lack of preventive measures in the care plans contributed to the occurrence of the incident. The facility's abuse policy, which aims to protect residents from abuse by anyone, was not effectively implemented in this case. The Director of Nursing acknowledged that resident-to-resident altercations should be avoided and that staff should intervene before situations escalate. However, the incident highlights a failure in the facility's systems to prevent such abuse, as evidenced by the lack of specific interventions in the residents' care plans to address their behavioral issues and protect them from harm.
Failure to Ensure Safe Resident Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident diagnosed with Down's syndrome, hypothyroidism, major depressive disorder, dysphagia, and cognitive impairments. The resident, who was nonverbal and dependent on staff for most activities, was observed being transferred using a mechanical lift by a single Certified Nursing Assistant (CNA), despite the requirement for a two-person assist. The CNA admitted to not having a valid reason for performing the transfer alone, acknowledging that two other aides were available at the time. The Director of Nursing confirmed the expectation that at least two staff members should be present during transfers involving a mechanical lift, with no exceptions for single-person transfers. The resident's care plan and transfer documentation clearly indicated the need for a two-person assist, aligning with the facility's policy for using the mechanical lift. This incident highlights a breach in protocol, as the CNA did not adhere to the established guidelines for safe resident transfers.
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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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Nursing homes near Granite City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare At Stearns | 1.8 mi | ★★★★★ | 7 | 0 |
| Estates Of Spanish Lake, The | 4.3 mi | ★★★★★ | 0 | 0 |
| Hillside Health Care Center | 5.6 mi | — | 16 | 1 |
| Hidden Lake Health Care Center | 6.3 mi | ★★★★★ | 2 | 0 |
| Estates Of St Louis, Llc, The | 6.7 mi | ★★★★★ | 3 | 0 |
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