F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the Facility failed to maintain an effective pest control
program so that the facility was free of roaches. This has the potential to affect all 56 residents living in the
facility.
Residents Affected - Many
Finding include:
On 6/12/2024 at 6:05 PM, V6 Licensed Practical Nurse (LPN) stated We do have roaches here. The
maintenance man was supposed to be spraying but he got fired because he was never working. The
roaches are really bad on the 300-hall. When I turn the light on, the roaches just scatter.
On 6/12/2024 at 6:38 PM, R6 stated, I have roaches in my room. When you turn the light on they run away.
I don't like bugs and or roaches.
On 6/12/2024 at 7:19 PM, V1, Administrator stated, I just had to terminate (V10) our maintenance man. He
was basically not working when he was supposed to be working. My company (Facility) had to file
bankruptcy and (V10) was supposed to be keeping up on spraying the facility, landscaping, mowing. He
was not doing it. I was finally able to get a contract for a pest control company to come in.
On 6/18/2024 at 4:14 PM, V11, Pest Control Technician stated, pest/roaches were found back in February,
and we recommended to the facility that they have monthly services, but we were not asked to come back
into the facility until yesterday 6/17/2024. We treated the exterior and kitchen and pulled out the equipment
and there was roach activity present. We treated the facility and recommended that they do not miss next
month's visit.
On 6/18/2024 at 4:44 PM, V12, Pest Control [NAME] stated, We were coming monthly to the facility, but it
looks like the account was put on hold for 'financial issues back in February and we did service the area
back up again starting yesterday.
On 06/25/24 at 8:26 AM, R1 stated that he had some roaches in his room last night.
On 06/25/24 at 10:30 AM, R2 stated that she has seen roaches in her room, but it has not been lately. She
stated that she had just seen some roaches in the bathroom two doors down the hall.
On 6/12/2024 at 5:40 PM, dead large roach in dining room and when moved chair live roach scattered
across the floor.
On 6/12/2024 at 5:59 PM, on the 100-hall was in the telephone room when the light was turned on there
were at least four roaches that ran across the room.
(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 2
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
06/26/2024
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 0925
On 06/25/24 at 10:35 AM, one live roach was noted running along the wall in the 300-hall bathroom.
Level of Harm - Minimal harm
or potential for actual harm
All Pest Control Records provided by the facility were reviewed. The last Pest Control Service provided was
dated 2/22/2024 and documents During our last visit, we treated and inspected all areas. Today I serviced
all interior and exterior equipment and treated all cracks and crevices. There was a German roach in one of
the rooms at the time of the service.
Residents Affected - Many
Pest Control Company Invoice dated 06/17/24 documents During our visit in February, we treated and
inspected all areas. Today, I treated the whole exterior, including all courtyards. I treated the kitchen. The
kitchen manager and I pulled out all heavy equipment and treated all cracks and crevices and areas of
concern. I informed him and the regional manager what to expect over the next few days. Treatment can
cause roaches to flee their normal breeding areas, resulting in what may look like an uptake. I informed
them that this is normal and that they should see a decrease in activity around after four days of treatment.
I baited individual rooms as needed and placed glue boards accordingly. I spot treated individual utility
rooms and made recommendations accordingly. During our next visit, we will continue to treat and inspect
all areas as directed. Thank you for your continued business.
Facility's policy Insect and Pest Control Policy undated documents It is the policy of this Health Care Center
to contract with a duly licensed exterminating service and/or control against infestations of insects and
rodents. A preventative treatment, both interior and exterior, shall be applied at least monthly. Treatments
will be applied more often if required. Chemicals, materials and equipment used to control insects and
rodents will be provided by the Vendor, and will be in accordance with current Federal and State
specifications for use in nursing homes. Methods of applications shall be in accordance with current Federal
and State regulations and manufacturer's recommendations.
CMS form 671 dated 06/25/24 documents a census of 56.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145438
If continuation sheet
Page 2 of 2
