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Inspection visit

Inspection

EVERCARE OF COLLINSVILLECMS #14543812 citations on this visit
12 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 12 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 5 residents (R20, R34, R40) reviewed for environment in the sample of 50. Findings include: On 11/15/23 at 10:02 AM during the Resident Council Group Meeting, R24 stated, There is mold in the bathroom, and it's gross. R34 stated the bathroom toilet needs to be replaced, and she mentions it to the Facility staff all the time. She stated the bathroom is like an old sanatorium, and the baseboards are not good. R34 also added the light in the 200 Hallway Ice Room needs to be replaced. R40 stated, The first bathroom by the offices is not good. The bottom of the floor has rot. I would rather go around (to the other side of the Facility) than have to take a shower there. On 11/16/23 at 8:10 AM, the Women's Visitor Restroom next to room [ROOM NUMBER] had an area of missing tile on the wall measuring approximately 15 inches across and 24 inches long. There was a rust-colored material on the door frame and hinges. There was plastic sheet covering one of the two toilets. There were two areas on the floor, both measuring approximately 5 inches by 7 inches, where the light-colored flooring was worn down and exposed black material underneath. There were six other areas of scraped flooring. Two of the walls had panels covering missing tiles inserted into the baseboards that were peeling away from the wall. The ceiling had a square, recessed area that was covered in dust with a plug hanging down. The overhead light did not have a cover. Areas on the ceiling and toilet seat were flaking off. There was a crack in the paper towel dispenser. On the right side of the door on the inside there was a hole where tile was missing. On 11/16/23 at 8:18 AM, the Men's Restroom across from room [ROOM NUMBER] had a black material all around the floorboard, and the shower caulking was hanging down between some of the lower tiles. The ceiling had areas that were peeling off, and the ceiling light did not have a cover. The room smelled of urine, and the shower head extended approximately one inch from the wall exposing a small amount of the pipe. On 11/16/23 at 8:19 AM the Women's Restroom across from room [ROOM NUMBER] had a black material along the edges of the shower floor. There was no cover on the lights above the mirror. On 11/16/23 at 8:45 AM the Men's Visitor Restroom next to room [ROOM NUMBER] had no shower head or knob, and there was an area of broken floor tiles measuring approximately 3 inches by 8 inches. On 11/16/23 at 12:27 PM the Utility Room on the 200 Hallway that houses the ice chest was missing a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 22 Event ID: 145438 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 covering on the light. V17, Housekeeper, stated it has been that way for some time. Level of Harm - Minimal harm or potential for actual harm On 11/17/23 at 9:02 AM, V2, Director of Nursing, (DON), stated she expects the Facility to follow its Resident Rights Policy and keep the environment clean, comfortable and safe. She stated she discusses this with staff every two weeks. Residents Affected - Few The Facility's Resident Rights for People in Long-Term Care Facilities from the Illinois Department on Aging, undated, documents, Your facility must be safe, clean, comfortable and homelike. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 2 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin on 2/16/23 for 1 resident (R44) in a sample of 50; Additionally the facility failed to report an allegation of physical abuse on 11/28/22 and 11/7/23 for one resident (R41) in a sample of 50. Findings include: 1. R44 Nurse's Progress Notes dated 2/16/23 documents that V14 granddaughter of R44 was combing R44's hair and observed a scar about 16 centimeters at the back of R44's head. No further documentation. R44's Face Sheet undated documents R44 was admitted to the facility 2/19/22 with a pertinent diagnosis of Dementia. R44's Minimum Data Set (MDS) dated [DATE] documents R44 has severe cognitive impairment and is Totally dependent for personal grooming and dressing. On 11/15/23 at 4:00 PM, V2 Director of Nursing (DON) stated I was not here then I can't tell you what happened but I will try to find out for you. On 11/16/23 at 8:10 AM, V2 DON stated the nurse on duty at the time was interviewed and stated it was a scar, she did not know how it occurred. R44 was assessed again today and there is nothing there. On 11/16/23 at 8:40 AM, V9 RN stated the granddaughter (V14) alerted me to the scar on her grandmother's head. There was no blood, it was above the nape of her neck and white. I had the nurse practitioner look at it and she said it look like a surgical scar. There was no treatment. R44 was not admitted with the scar. We did not determine the cause of the scar. We looked this morning and there is nothing. On 11/16/23 at 9:34 AM, V14 Granddaughter to R44 stated she was initially concerned about the scar on the back of of her grandmother's (R44's) head. It was scabbed over and was from ear to ear right about her hair line in the back of her head. V14 did inquire about the scar and no one could explain what happened. We were never given a definitive answer as to how the injury occurred. No staff person came to me/family and said what happened and my grandmother could not say what happened either. I have never had any concerns and that was the first time that I am aware of anything happening to her. Initially, we were the only ones combing R44's hair but the CNAs did start combing her hair also. The Facility Policy & Procedure for Injuries of Unknown Origins undated documents all injuries will be investigated to determine the potential cause of the injury. Upon identification of the cause, interventions will be established to prevent any further injury by the IDT or Administration. All Injuries of Unknown Origin will be discussed at the daily QA meeting. The following is not necessarily all inconclusive, but give guidance on the most common causes of Unknown Injuries. 2. R41's Nurse's Progress Notes dated 11/28/22 at 11:30 PM documents, R41 hit his roommate with his leg brace. Resident stated, he did it because his roommate would not shut up. Administrator made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 3 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 aware of situation. Level of Harm - Minimal harm or potential for actual harm R41's Nurse's Progress Notes dated 11/29/22 at 5:00 AM documents, (R41) and his roommate had no more complications throughout the night. Both parties refused to leave the room during the initial situation. Resident noted to be lying in bed with eyes closed. Residents Affected - Few A resident -resident altercation report/investigation was requested but not received. The Care Plan did not address the behavior of R41. R41's Nurse's Progress Notes dated 11/5/23 documents R41 was pushed out of his wheelchair by another resident. Nurse's Progress Notes dated 11/6/23 documents, QA notes documents the QA committee met related to fall on 11/5/23. Staff to supervise R41 while outside on the patio. The Care Plan dated 1/4/23 documents Resident has potential for altered activity pursuit pattern/social isolation as related to -11/6/23 Resident fell from wheelchair on 11/5/23 while outside on the patio. On 11/17/23 at 9:00 AM, V9 RN stated there was bickering between R41 and the other resident, but she could not remember what the bickering was about. The other resident just dumped R41 out of the wheelchair. R41 was sent to the hospital and there have been no further problems between the two. On 11/17/23 at 9:21 AM, R41 stated, he could not remember the guys' name that hit him in the head. R41 states he does not smoke but goes outside to get some air. Someone told him to pass a cigarette to someone and the other guy got mad and gave him a head butt. R41 did not remember the altercation of 11/28/22. R41 did state he is paralyzed and cannot defend himself. R41 could not name any witnesses either. On 11/17/23 at 12:48 PM, V1 Administrator stated her expectations are that the residents be separated immediately and then she be notified. R41's Face Sheet undated documents he was admitted [DATE] with diagnosis of Altered Mental Status, Chronic Pain and Insomnia. R41's Minimum Data Set, (MDS), dated [DATE] documents R41 behavior of inattention and disorganized thinking is present. The Facility Policy & Procedure for Abuse Prevention Program undated documents the first step is choosing an Investigation Path to follow: Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation should consist of -An interview with staff members having contact with the resident and accused individual during the regular contact. -Interview with other residents to which the accused individual has regular contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 4 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Interview with other employees to determine if they have ever witnessed other incidents of mistreatments involving the accused individual -An interview with the accused individual or individuals (with a witness present) After a conclusion based on the investigation is determined, internal reports, interviews, witness statements, and identities of individuals involved shall be released only with the permission of the administrator or the facility attorney. Even if the facility investigation is not complete, the administrator will cooperate with any Department of Public Health investigation in the matter. After reviewing the final report, the administrator or designee is responsible for forwarding an approved copy of the final report to the Department of Public Health within five working days of the occurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 5 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a complete investigation of an injury of unknown origin on 2/16/23 for 1 resident (R44) in a sample of 50; Additionally, the facility failed to provide a complete investigation on 11/28/22 and 11/7/23 for one resident (R41) in a sample of 50. Residents Affected - Few Findings include: 1. R44 Nurse's Progress Notes dated 2/16/23 documents, that V14 granddaughter of R44 was combing R44's hair and observed a scar about 16 centimeters at the back of R44's head. No further documentation. R44's Face Sheet undated documents, R44 was admitted to the facility 2/19/22 with a pertinent diagnosis of Dementia. R44's Minimum Data Set, (MDS), dated [DATE] documents, R44 has severe cognitive impairment and is Totally dependent for personal grooming and dressing. On 11/15/23 at 4:00 PM, V2 Director of Nursing, (DON), stated, I was not here then I can't tell you what happened but I will try to find out for you. On 11/16/23 at 8:10 AM, V2 DON stated, the Nurse on duty at the time was interviewed and stated it was a scar, she did not know how it occurred. R44 was assessed again today and there is nothing there. On 11/16/23 at 8:40 AM, V9 RN stated, the granddaughter (V14) alerted me to the scar on her grandmother's head. There was no blood, it was above the nape of her neck and white. I had the Nurse Practitioner look at it and she said it look like a surgical scar. There was no treatment. R44 was not admitted with the scar. We did not determine the cause of the scar. We looked this morning and there is nothing. On 11/16/23 at 9:34 AM, V14 Granddaughter to R44 stated, she was initially concerned about the scar on the back of her grandmother's (R44's) head. It was scabbed over and was from ear to ear right about her hair line in the back of her head. V14 did inquire about the scar, and no one could explain what happened. We were never given a definitive answer as to how the injury occurred. No staff person came to me/family and said what happened and my grandmother could not say what happened either. I have never had any concerns and that was the first time that I am aware of anything happening to her. Initially, we were the only ones combing R44's hair but the CNAs did start combing her hair also. The Facility Policy & Procedure for Injuries of Unknown Origins undated documents all injuries will be investigated to determine the potential cause of the injury. Upon identification of the cause, interventions will be established to prevent any further injury by the IDT or Administration. All Injuries of Unknown Origin will be discussed at the daily QA meeting. The following is not necessarily all inconclusive but give guidance on the most common causes of Unknown Injuries. 2. R41's Nurse's Progress Notes dated 11/28/22 at 11:30 PM documents, R41 hit his roommate with his leg brace. Resident stated, he did it because, his roommate would not shut up. Administrator made aware of situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 6 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 Level of Harm - Minimal harm or potential for actual harm R41's Nurse's Progress Notes dated 11/29/22 at 5:00 AM documents, R41 and his roommate had no more complications throughout the night. Both parties refused to leave the room during the initial situation. Resident noted to be lying in bed with eyes closed. A resident-to-resident altercation report/investigation was requested but not received. Residents Affected - Few The Care Plan did not address the behavior of R41. R41's Nurse's Progress Notes dated 11/5/23 documents, R41 was pushed out of his wheelchair by another resident. Nurse's Progress Notes dated 11/6/23 documents, QA notes documents, the QA committee met related to fall on 11/5 23. Staff to supervise R41 while outside on the patio. The Care Plan dated 1/4/23 documents, R41 has potential for altered activity pursuit pattern/social isolation as related to -11/6/23 R41 fell from wheelchair on 11/5/23 while outside on the patio. On 11/17/23 at 9:00 AM, V9 RN stated, there was bickering between R41 and the other resident, but she could not remember what the bickering was about. The other resident just dumped R41 out of the wheelchair. R41 was sent to the Hospital and there have been no further problems between the two. On 11/17/23 at 9:21 AM, R41 stated, he could not remember the guys' name that hit him in the head. R41 states he does not smoke but goes outside to get some air. Someone told him to pass a cigarette to someone and the other guy got mad and gave him a head butt. R41 did not remember the altercation of 11/28/22. R41 did state he is paralyzed and cannot defend himself. R41 could not name any witnesses either. On 11/17/23 at 12:48 PM, V1 Administrator stated her expectations are that the residents be separated immediately and then she be notified. R41's Face Sheet undated documents, he was admitted [DATE] with diagnosis of Altered Mental Status, Chronic Pain and Insomnia. R41's Minimum Data Set, (MDS), dated [DATE] documents R41 behavior of inattention and disorganized thinking is present. The Facility Policy & Procedure for Abuse Prevention Program undated documents the first step is choosing an Investigation Path to follow: Regardless of the specific nature of the allegation (physical, sexual, verbal/exploitation/mental, theft or neglect), the investigation should consist of -An interview with staff members having contact with the resident and accused individual during the regular contact. -Interview with other residents to which the accused individual has regular contact -Interview with other employees to determine if they have ever witnessed other incidents of mistreatments involving the accused individual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 7 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610 -An interview with the accused individual or individuals (with a witness present) Level of Harm - Minimal harm or potential for actual harm After a conclusion based on the investigation is determined, internal reports, interviews, witness statements, and identities of individuals involved shall be released only with the permission of the administrator or the facility attorney. Even if the facility investigation is not complete, the administrator will cooperate with any Department of Public Health investigation in the matter. Residents Affected - Few After reviewing the final report, the administrator or designee is responsible for forwarding an approved copy of the final report to the Department of Public Health within five working days of the occurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 8 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm On 11/14/23 at 10:17 AM, R23 was in her wheelchair, (w/c), in the dining room, yelling out, Come in here and help me! Take me out of here! No staff approached R23 to give reassurance or to assess needs. At 10:27 AM, R23 was still yelling out and sitting in her w/c in the dining room by herself with no staff in the room or in sight of resident. R23 stated, They took me out to smoke and then left me in here and never came back. V1, Administrator, was walking up the hall and was asked about R23 sitting in the dining room yelling out. V1 stated R23 is kept in the dining room so staff can interact with her when she is yelling out and offer her snacks. R23 did not have any snacks at the time of the observation. At 10:40 AM, R23 was sitting in the dining room again and yelling out loudly, Mom!. V2 DON was in dining room talking to R23 and assuring her she is not in the way. Residents Affected - Many R23's Face Sheet documents, her diagnoses to include Psychosis, Blindness Both Eyes, Schizophrenia, Anxiety and Bipolar Disorder. R23's Minimum Data Set, (MDS), documents she is moderately cognitively impaired. R23's Care Plan dated 9/24/23 documents, the problem: Blindness (Sensory Perceptual Deficit) with the goal, dated 12/23/21, Will function at optimal level through adaptation skills within limitation imposed by blindness x 90 days. Intervention for this problem includes Adapt activity involvement with talking books, radio reading, braille bingo cards, etc. R23's Care Plan dated 3/8/23 documents, the problem: Sad, Depressed Mood Indicators with the goal, dated 6/6/23, Resident will verbalize reason for negative feelings and verbalize one positive aspect of current situation once weekly through next 90 days. Intervention for this care plan includes, Seat in an area of activity for added stimulation and opportunity for socialization. R23's Care Plan dated 3/8/23 documents the problem: Altered Mood State (anger/easily upset) potential for altered social reaction. The goal for this care plan, dated 6/6/23 is, Resident will accept redirection/support during episodes of anger as evidenced by reduction of <> to <> over next 90 days. Intervention for this care plan includes, Encourage, invite, and praise involvement in activities, assist as necessary. The Facility's Activity Policy reviewed 9/17 documents, It is the policy of (Facility) to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial wellbeing of each resident. Activities shall be planned on a monthly basis for the following month. An activity calendar shall be posted at the beginning of each month for formal activities. The calendar will be printed in large print and displayed in the following area(s). Bulletin board in the main entry area by Nurse's station, Activity Director Office, Adapt Dining Room. The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/14/23 documents, there are 55 residents living in the Facility. Based on observation, interview, and record review, the Facility failed to provide an ongoing resident centered activities program to support residents in all their wellness domains. This has the potential to affect all 55 residents living in the Facility. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 9 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During the Resident Council Group Meeting on 11/15/23 at 10:02 AM, R24 stated the Facility used to have an Activities Director, but she left last December and has not been replaced. R24 stated, They have nothing for us to do around here. It's very boring. R34 stated V3, Social Services Director, is the social worker and has other things to do besides Activities. On 11/15/23 at 11:50 AM, R32 stated, We used to have activities, but we don't anymore. We want to play Bingo and go outside and go to the store. It would just give us something to look forward to. We're just bored. It just isn't right. They need to treat us like this is our home. It's important. On 11/16/23 at 1:15 PM, R1 stated the Facility used to tell them when they were going to have Activities, but they have not done that in a while. On 11/14/23 at 11:10 AM, V2, Director of Nursing, (DON), stated V11, Facility Van Driver, does both Transportation and Activities. She stated V11 was not in the Facility, and there was nobody doing Activities today. On 11/15/23 at 10:36 AM, V3, Social Services Director, stated V11 has been doing Activities in between Transportation for the past several months and was unsure whether V11 had any specialized training for Activities. On 11/15/23 at 10:55 AM V1, Administrator, stated the Facility has not had a full time Activities Director for about 6 months, but V11, Facility Van Driver, has been doing both Transportation and Activities. V1 stated V11 is a Certified Nurse Aide (CNA) and has no specialized training for Activities. On 11/15/23 at 1:40 PM, V11, Facility Van Driver, stated she is doing both Transportation and Activities. She usually does Activities three or four times per week, depending on the Transportation schedule, and verbally informs each resident of Activities instead of using an Activities Calendar. She said there is no staff available to do Activities on the weekends. She stated she is a CNA and has not had any formal training for Activities. On 11/17/23 at 9:02 AM, V2, DON, stated the Facility is actively looking for an Activities Director, but they have not had any applicants. She would expect the Facility to follow its Activity related policies. During the course of the survey, there were no Activities Calendars posted on bulletin boards, in the Activity Director's Office, or in the (Psychosocial Programming) Dining Room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 10 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the Facility failed to employ a qualified therapeutic recreational specialist or activities professional to provide a resident centered activities program. This has the potential to affect all 55 residents living in the Facility. Residents Affected - Many Findings include: During the Resident Council Group Meeting on 11/15/23 at 10:02 AM, R24 stated the Facility used to have an Activities Director, but she left last December and has not been replaced. R24 stated, They have nothing for us to do around here. It's very boring. On 11/15/23 at 11:50 AM, R32 stated, We used to have activities, but we don't anymore. We want to play Bingo and go outside and go to the store. It would just give us something to look forward to. We're just bored. It just isn't right. They need to treat us like this is our home. It's important. On 11/15/23 at 10:55 AM, V1, Administrator, stated they have been without a full time Activities Director for about 6 months, but V11, Facility Van Driver, has been doing Activities along with Transportation. V1 stated V11 is a Certified Nurse Aide, (CNA), and has no training specific to activities. On 11/14/23 at 11:10 AM, V2, Director of Nursing, (DON), stated, (V11) is the Activities person, but she is not here and may be running residents to appointments. She also does transportation. There is nobody doing activities today. On 11/15/23 at 10:36 AM, V3, Social Services Director, stated V11 has been doing Activities in between resident transportation since June or July of this year. V3 was unsure whether V11 had any certifications in order to provide the activities. On 11/15/23 at 1:40 PM, V11, Facility Van Driver, stated she does both Transportation and Activities. She stated activities are usually three to four times per week, depending on transportation schedule, and there are no activities on the weekends. She stated she has worked here as a CNA for years but, has no specialized training for activities. On 11/17/23 at 9:02 AM, V2, DON, stated the Facility is actively looking for an Activity Director, but have not had any applications. She stated, she would expect the Facility to follow its Activity related policies. The Facility's Policy For Activity Director reviewed 9/17 documents, It is the policy of (Facility) to provide an activities program that is directed by a qualified professional who is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. An activities program must be directed by a qualified professional who: 1. Is a qualified therapeutic recreation specialist or an activities professional who: A. Is licensed or registered, if applicable, by the State in which practicing. B. Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990. 2. Has 2 years of experience in a social or recreational program within the last 5 years, 1 of which was full-time in a patient activities program in a health care setting. 3. Is a qualified occupational therapist or occupational therapy assistant. 4. Has a training course approved by the State. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 11 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0680 The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/14/23 documents there are 55 residents living in the Facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 12 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide adequate supervision and progressive devices to prevent falls for one of thirteen residents (R2) reviewed for falls in the sample of 50. This failure resulted in R2 falling from the toilet when left unsupervised and sustained multiple rib fractures and laceration to his head. Findings include: R2's Cumulative Diagnosis Log undated documents diagnoses Paranoid Schizophrenia, anemia, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, vitamin D deficiency, anxiety, repeated falls, and major depressive disorder. R2's Fall Risk assessment dated [DATE] documents, a score of 20. 10 or more points = High Risk Score. R2's MDS, (Minimum Data Set), dated 09/13/23 documents, a BIMS, (Brief Interview of Mental Status), score of 15 out of 15. The MDS documents, that R2 requires limited assistance of one person for bed mobility, transfer, locomotion on unit, locomotion off unit, and personal hygiene. The MDS documents, that R2 requires extensive assistance of one person for toilet use. The MDS documents, that R2 is not steady, only able to stabilize with staff assistance. R2's Care Plan dated 03/07/19 documents, Has risk factors for falls: balance, assistive devices, needs assist for transfer, vision problems, medical conditions, meds, poor safety awareness, and behaviors put resident at risk. R2's Interventions: 02/26/23 r/t, (related to), fall, staff to check on frequently when in bed. 03/06/23 r/t fall, staff to utilize pressure alarm for bed and wheelchair. 08/17/23 r/t fall, educated resident and staff to ensure that w/c, (wheelchair) is locked during all transfers. 09/06/23 r/t fall, instructed to use call light and wait for assistance. R2's Nurses Note dated 11/06/22 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P, (blood pressure), 120/58, P (pulse) 88, R, (respiration), 21, T, (temperature), 97.1. He stated that he was trying to put his tablet in his drawer. R2's Quality Improvement Review Note dated 11/07/22 at 9:00 AM documents, QA, (quality assurance), committee met to review fall on 11/07/22, resident attempting to put item in drawer, encourage to ask for assistance. No note written for fall on 11/22/22. On 11/16/23 at 3:00 PM, V2, DON, (Director of Nursing), stated that she could find a nurses note about any fall on 11/22/22. R2's Quality Improvement Review Note dated 11/22/22 at 9:15 AM documents, QA committee met to review fall with no injury noted. Resident was attempting to sit in w/c and missed, resulting in him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 13 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 sitting on floor in front of wheelchair. Encouraged resident to use call light and wait on staff assistance. Medical workup obtained. Level of Harm - Actual harm Residents Affected - Few R2's Nurses Note dated 02/26/23 at 8:40 AM documents, This nurse passing HS meds when resident reported to nurse having severe pain 8/10 to left rib area. This nurse asked what happen to area, he reports he had a fall at 3a (SIC) while attempting to go to restroom in bedroom. Resident was able to recall event and states prior to falling he felt dizzy. Resident states he fell on the toilet landing on his left side and hitting head on the wall. Resident states he did not report incident sooner because he was scared and thought Jesus would heal him sooner. This nurse does not see any visible injuries. VS, (vital signs), WNL, (within normal limits). ROM, (range of motion), WNL. Lying in bed currently. Schedule PP, (pain pill), given. Call light in reach. Will follow up with NP, (Nurse Practitioner), for orders to send to ER, (Emergency Room). R2's Nurses Note dated 02/27/23 at 2:00 AM documents, Nurse from (local hospital) called states resident is being d/c, (discharge), with multiple rib fracture and sternum mass on liver, no transportation to get resident back to facility, phone call to (V1) administrator to make her aware of situation, states (psychosocial program) can pick him up from hospital @ 7a (SIC) when they arrive. R2's Quality Improvement Review Note dated 02/27/23 at 10:30 AM documents, QA committee met r/t fall reported on 02/26/23. Resident reported to staff nurse that he fell overnight trying to go to bathroom w/o, (without), assistance, stated he felt dizzy and fell over toilet, he was sent to ER for eval, resident sustained multiple rib fractures from unwitnessed fall, he returned back to facility, staff to check more frequently when in bed. R2's Nurses Note dated 03/06/23 at 8:45 AM documents Resident was ambulating to bathroom on his way back out of bathroom he lost his balance, fell to floor landing on his left side. States he hit his head. Assessment by nurse. Moves all extremities WNL for this resident neuro checks started. V/S 120/77 - 66 18 - 97.8 96% RA, (room air), O2 sats, (oxygen saturation). C/o, (complaint of), pain to left ribs area. R2's Quality Improvement Review Note dated 03/07/23 at 10:15 AM documents QA committee met r/t fall on 03/06/23, resident attempted to go to bathroom without assistance. Resident lost balance and fell, staff to utilize pressure alarm for bed. R2's Nurses Note dated 05/19/23 at 11:35 AM documents, resident chair alarm going off. CNA went to room and resident noted to be on knees on the floor. this nurse came to room and resident was getting up from floor by himself. Resident states he has no pain to knees. Resident states he also hit his left shoulder on his roommate's bed. denies pain to shoulder and ROM WNL. Redness/abrasions noted post-fall. Attempted to call emergency contact (POA) but the number is incorrect. Attempted to call NP x 2 but went voicemail and voicemail is full. Will try again. neuro checks WNL - ROM WNL. VS 126/74, 72, 18, 97.5, 96% RA. Resident denies hitting head. Will monitor. Spoke with NP - 0 new orders. monitor for bruising/pain. No Quality Improvement Review Noted for fall on 05/19/23. No intervention noted for fall on 05/19/23. R2's Nurses Note dated 08/17/23 2:10 AM documents, Resident had a fall in bedroom. Staff was in room with resident. No injury noted. NP was notified. Administrator was notified. Resident emergency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 14 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 contact notified. Level of Harm - Actual harm R2's Quality Improvement Review Note dated 08/12/23 9:30 AM documents QA committee met r/t fall with zero injury noted on 08/17/23. Resident attempted to sit back in w/c after incontinent care with CNA, (Certified Nurse Aide), and w/c moved causing him to land on buttocks. Educated resident and staff to ensure that w/c is locked during all transfers. Residents Affected - Few R2's Nurses Note dated 09/06/23 at 6:25 AM documents, Resident had a fall in his room. Writer went to resident room. Found him on the floor sitting on his buttocks. Resident stated, that he was trying to go to his closet to shut the door and went in the opposite direction and slipped and felled (SIC). No injury noted. Vitals are B/P 130/80, P - 113, R 22, T 97.4. Notified emergency contact, notified NP, notified Administrator, notified DON. Will follow facility protocol related to falls. R2's Quality Improvement Review Note dated 09/07/23 at 9:15 AM documents QA committee met r/t fall on 09/06/23 with no injury noted. Resident stated he was closing his closet door and walking backwards and fell, instructed to utilize call light and wait for assistance. R2's Nurses Note dated 11/06/23 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P 120/58, P 88, R 21, T 97.1. He stated that he was trying to put his tablet in his drawer. No Quality Improvement Review Noted for fall on 11/06/23. No intervention noted for fall on 11/06/23. On 11/17/23 at 10:59 AM, R2 observed sitting in dining area in wheelchair unsupervised. Chair alarm noted attached to resident. On 11/17/23 at 10:55 AM, V16, CNA stated that they use bed and alarms to prevent (R2) from falling. She stated that he started ambulating with a walker under supervision with a wheelchair following. On 11/17/23 at 11:30 AM, V12, LPN, (Licensed Practical Nurse), stated that to prevent (R2) from falling they use bed alarm and chair alarm. (R2) is a one assist from staff. She stated that they re-educate him on using the call light. On 11/17/23 at 12:45 PM, V2, DON stated that she would expect there to progressive interventions added to a resident's care plan following a fall. Facility's Fall Prevention policy dated 11/10/18 documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 15 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications are controlled for 4 of 4 residents (R23, R27, R43, and R52) reviewed for medication storage in the sample of 50. Findings include: On 8/15/23 at 8:10 AM, V9 Registered Nurse (RN) opened the top drawer of the 300-hall medication cart to administer medications for R40. While drawer was opened, 4 clear medication cups were observed in the top drawer, with each cup containing multiple pills and capsules. There were last names on these cups, but no date or time of when they were set up or when they were to be administered. There was also an insulin syringe lying next to the cups in the drawer containing 7 units of cloudy liquid. The insulin syringe was not labeled with a name or date. V9 identified the medications she had pre-set up in the four cups as R43's, R23's, R27's, and R52's morning medications. She also identified the syringe as R43's morning dose of 7 units of Humalog insulin. V9 stated she had them ready for when the residents come up to the dining room. She stated she does not always pre-set up medications. She stated if any of the medication cups got spilled, she would re-pour the medications. She stated if she got called away in the case of an emergency whatever nurse replaced her could get the residents' medications off their cards if they did not want to administer what she had in the cups. On 11/16/23 at 11:45 AM, V2 Director of Nursing (DON), stated no nurse should be pre-setting up medications before starting medication pass. She stated the nurse should set up one resident's medication at a time and administer those medications before starting the next resident. The facility's policy, Medication Administration, revised 10/07 documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 16 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the Facility failed to properly store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 55 residents living in the Facility. Findings include: On 11/14/23 at 8:15 AM, in the dry storage room there were two 12-quart containers of dry cereal that were not labeled or dated. There was a package of fried onion straws that had been opened, but was not resealed, leaving the contents open to air. There was a cabinet containing chemicals that also had a case of soda inside. V4, Dietary Manager, stated that was not intended for resident consumption and would get rid of it. On 11/14/23 at 8:19 AM, in the kitchen next to the ice machine there was a bottle of unopened soap next to the meat slicer. The meat slicer was not covered. On 11/14/23 at 8:20 AM, the walk-in refrigerator had a cart with two trays of chicken strips and two trays of chicken patties. The trays were labeled with stickers, but were not covered, leaving the chicken open to air. There was a bag of white shredded cheese on a shelf that had been opened, but was not resealed, leaving the cheese open to air. There were two stainless steel containers of food that were not labeled or dated. The containers were covered with wax paper which did not form a tight seal on the items inside. V4, Dietary Manager, stated they were lasagna roll ups. There was a quart of skim milk with a Use By date of 11/11/23. There were four gallons of whole milk with Use By dates of 11/12/23. There were two vacuum sealed packages with unknown contents stored above the milk cartons that were not labeled or dated. V4 stated they were pork, and he did not know they were still in there. V4 placed the packages of pork and outdated milk on a cart and stated he would discard it. There was a large bowl of fruit on the bottom shelf that was not covered, labeled or dated. V4 stated they were pears. There were nine individual Styrofoam containers that were not labeled or dated. V4 stated those are puddings the nurses use for medication pass. There was a bowl covered with aluminum foil that was dated 11/14/23, but was not labeled. V4 lifted the lid and stated that was salad mix. On 11/14/23 at 8:25 AM, the walk in freezer had ice crystals on the ceiling pipes and an icicle measuring approximately two inches hanging from the pipe. V4 stated the temperatures have been fine, but that always just happens after they remove the ice. There was a box of donuts stored directly on the floor. There were two boxes of uncooked beef patties stored on a shelf above a box of corn dogs. The box of beef patties on top had been opened and was not resealed, leaving the beef open to air. There were an additional two boxes of uncooked beef patties that were stored on top of potatoes on a shelf above cheese soup. On 11/15/23 at 3:50 PM, V1, Administrator, stated she expects staff to follow their Facility food storage policies. The Facility's Refrigerator and Freezer Storage Policy revised 10/14 documents, It is the policy of (Corporation) that any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. Cover all containers. Mark container with name of item. [NAME] the date that the original container is opened or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 17 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many date of preparation. Store cooked meats above raw meats in the refrigerator or freezer. Use or discard food according to the manufacturer's use-by-date. The Facility's Storage Policy revised 10/20 documents, It is the policy of (Corporation) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for the appropriate length of time to protect quality of food and food cost. All items will be dated upon receipt. Individual cans or bags shall each be dated to ensure that stock is rotated properly. Store chemical and poisonous materials in a separate area that can be locked. Store leftovers in covered, labeled and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/14/23 documents there are 55 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 18 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly sanitize and store a residents BiPAP device for 1 of 12 residents (R14) reviewed for infection control in the sample of 50. Residents Affected - Few Findings include: On 11/14/23 at 3:13 PM R14 stated nobody has cleaned the tubing for his BiPAP machine since he got it a few months ago. His mask for his BiPAP mask was laying on a fly swatter on his bedside table, not in a bag. R14 stated he had not used the fly swatter for a while, but he has used it to kill flies when it was hot. On 11/15/23 at 10:00 AM R14's BiPAP mask continued to lay on top of the fly swatter on his bedside table, not in a plastic bag. On 11/16/23 at 10:10 AM R14's BiPAP mask was still laying on top of a fly swatter on his bedside table, not contained in a bag. R14's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating he is alert and oriented. R14's Care Plan, Physician Order Sheet dated 11/1/23 to 11/30/23, Treatment Administration Record, and Medication Administration Record were reviewed and did not include documentation of R14's BiPAP use or directions on when to clean or change tubing. On 11/16/23 at 10:00 AM V9, Registered Nurse (RN) stated the midnight shift are responsible for changing the tubing on R14's BiPAP machine. On 11/17/23 at 10:00 AM V2, Director of Nursing (DON) stated they do not clean the tubing on R14's BiPAP machine because it would be impossible to dry it on the inside. She stated the tubing is changed once a month. On 11/17/23 at 12:25 PM V9, stated she just went down today and changed R14's BiPAP tubing and put his mask in a bag. She stated she does not know where the other nurses document when they change his tubing but she is going to put it in his nurses notes. On 11/17/23 at 12:27 PM V2 stated any oxygen, BiPAP or CPAP masks or tubing should be stored in a bag when not in use. She stated R14's BiPAP mask should not have been laying on a fly swatter on his bedside table. The facility's policy, Policy for CPAP BiPAP revised 3/8/13 documents, E. Circuits are to be cleaned every week and prn. The facility's policy, Cleaning of Respiratory Suction, Oxygen, and Humidification Equipment revised 01/02 documents, The purpose of disinfecting of respiratory equipment is to prevent equipment-associated pulmonary infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 19 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to develop and implement protocol to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotics for 1 of 3 (R36) residents reviewed for antibiotic stewardship in a sample of 50. Residents Affected - Few Findings include: R36's Physician Order undated documents diagnoses of schizoaffective disorder, depression episodic with catatonic features, hypertension, asthma, hyperlipidemia, history of cerebrovascular accident, and Gastroesophageal reflux disease. R36's Physician Order dated 11/07/23 documents Macrobid (antibiotic) 100 mg twice daily for 7 days. DX, (diagnosis): UTI, (Urinary tract Infection). UA, (urinalysis), today nitrite positive. Sending urine for CX, (culture). Start Macrobid BID for 7 days. Follow-up in 2 weeks to ensure resolution of UTI & reassess urinary symptoms. R36's Nurses Note dated 11/07/23 at 12:00 PM documents Resident came back to facility from urologist appt. Resident starting Macrobid 100 mg PO, (by mouth), twice a day r/t, (related to), UTI. UA today nitrite positive. Sending urine for culture. F/U, (follow up), in 2 weeks to ensure resolution of UTI & reassess urinary symptoms. No urine culture noted in the chart. R36's MDS, (Minimum Data Set), dated 08/18/23 documents a BIMS, (Brief Interview for Mental Status), score of 15 out of 15. The MDS documents that R36 requires limited assistance of one person for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene. The MDS documents that R36 is not steady, but able to stabilize without staff assistance. The MDS documents that R36 is always continent of bladder and bowel. R36's Care Plan 08/18/23 documents Self-care deficit - needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs (activities of daily living). On 11/17/23 at 12:45 PM, V2, DON (Director of Nursing) stated that she expect the facility to urine culture before starting antibiotics for a UTI. Facility's Antibiotic Stewardship Program policy dated 12/10/21 documents To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished utilizing the Core Elements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 20 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the Facility failed to utilize the services of an Infection Preventionist (IP) at a minimum part time basis to track Facility infections and staff and resident vaccinations in order to prevent the spread of infectious disease. This has the potential to affect all 55 residents living in the Facility. Findings include: On 11/17/23 at 9:50 AM, V2, Director of Nursing (DON), stated she is acting as the IP, but has not completed the training. She just started working here about two months ago and has not yet had the time. She thinks V20, Assistant Director of Nursing (ADON) has the certification, but she is in charge of the Facility's Infection Control. On 11/17/23 at 10:25 AM, V9, Registered Nurse (RN), stated, (V2) does Infection Control for the Facility. I notify (V2) of any resident infections, diagnoses, medications, dose, and organism, if available, but (V2) does the tracking and trending. On 11/17/23 at 12:46 PM, V1, Administrator, stated they do not have a policy specific to the Infection Preventionist, but would expect the IP to have the required training. The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/14/23 documents there are 55 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 21 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Collinsville 614 North Summit Collinsville, IL 62234 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide 80 square feet of floor space per resident bed for 25 of 55 residents (R2, R5, R6, R9, R11, R12, R13, R17, R18, R24, R29, R30, R32, R37, R38, R39, R40, R43, R44, R46, R49, R50, R103, R104 and R105) reviewed for room size in the sample of 55. Findings include: The Facility has 30 two-bed resident rooms which provide only 75 square feet per resident bed. According to historical data and current room measurements, these rooms measure 12 feet by 12 feet six inches. All these rooms are certified for Medicare and Medicaid. These rooms are as follows: room [ROOM NUMBER], 105, 106, 107, 108, 111, 116, 120, 201, 202, 203, 204, 303, 305, 306, 308, 309, 310, 311, 313, 314, 316, 317, 318, 319, 320, 321, 322 and 323. room [ROOM NUMBER] is now a family visiting room and a telephone room for residents. room [ROOM NUMBER] is now a storage room. The facility has 8 two bed resident rooms which provide only 77.5 square feet per resident bed. According to historical data and current room measurements, these rooms, measure 12 feet one inch by 12 feet six inches with an additional 10 inch by 72-inch offset. These rooms are as follows: Rooms 207, room [ROOM NUMBER], 209, 214, 216 and room [ROOM NUMBER]. The Facility has 3 two-bed resident rooms which provide only 76.5 square feet per resident bed. According to historical data and current room measurements, these rooms measure 12 feet by 12 feet six inches with an additional 10 inch by 48-inch offset, These Rooms are as follows: room [ROOM NUMBER] which is now the Break Room, 119 which is now the Activity Room. The facility has 2 two bedrooms which provide only 78.5 square feet per resident bed. According to historical data and current room measurements, these rooms measure 15 feet by 10 feet six inches. There rooms are as follows: rooms [ROOM NUMBERS]. During observation from 11/14/2023 through 11/17/2023, the following residents were in the above rooms which do not have 80 square feet per resident bed: (R2, R5, R6, R9, R11, R12, R13, R17, R18, R24, R29, R30, R32, R37, R38, R39, R40, R43, R44, R46, R49, R50, R103, R104 and R105) Form CMS 671 dated 11/14/23 documents the facility's census is 55. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145438 If continuation sheet Page 22 of 22

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Citations

12 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0881GeneralS&S Dpotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0882GeneralS&S Fpotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0679GeneralS&S Fpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0680GeneralS&S Fpotential for harm

    F680 - The activities program must be directed by a qualified professional

    Ensure the activities program is directed by a qualified professional.

  • 0689SeriousS&S Gactual harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0912GeneralS&S Bno actual harm

    F912 - Measure at least 80 square feet per resident in multiple resident

    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

FAQ · About this visit

Common questions about this visit

What happened during the November 17, 2023 survey of EVERCARE OF COLLINSVILLE?

This was a inspection survey of EVERCARE OF COLLINSVILLE on November 17, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EVERCARE OF COLLINSVILLE on November 17, 2023?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.