Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 thoroughly investigate an allegation of abuse for 1 of 1
resident (R26) reviewed for abuse in a sample of 43.
Residents Affected - Few
Findings include:
The Facility's Incident Investigation Form, dated 8/11/2024 at 1:30 PM documents, spoke to (R26) R/T
(related to) alleged abuse on 8/9/2024 @ (at) 2:45 AM. Stated that he was hit and scratched by NOC
(night) CNA (Certified Nursing Assistant). Asked (R26) about minimal swelling to RT (right) upper lip and
left cheek. At first, he stated that he was in his room and was attacked by NOC (night) CNA. Informed (R26)
that camera was reviewed and CNA with alleged allegations did not enter his room. (R26) then stated that
NOC CNA hit him outside on the patio with (R26) during his shift. According to nurses' documentation @
times of allegation and head to toe assessment, there were no abnormal skin findings. Provider was
notified, orders were received for labs, X-Ray to face. X-Ray results negative for fx (fracture.) Nursing staff
to monitor his behavior and use two staff members when entering (R26's) room or providing care.
V1, Administrator's typed statement dated 8/15/2024 documents, This letter will serve as a follow up to the
initial report 8/9/2024 regarding an alleged incident involving resident (R26) and (V8, Certified Nursing
Assistant, CNA.) (R26) is a [AGE] year-old long term resident of the facility with diagnosis of schizophrenia,
depression, anxiety, diabetes, sleep apnea, COPD, and morbid obesity. He is not a registered offender. On
8/9/2024, nurse reported an alleged altercation between (R26) and (V8). The nurse assessed (R26) with no
signs of injury, no swelling, no redness noted to (R26). Employee was suspended pending investigation.
Investigation was initiated per protocol. (R26) was interviewed. He reported that at around 2:00 AM, as he
was going out the patio door, V8 pushed him against a wall and began hitting R26. He stated that he was
punched in the face, shoulder, and chest. He also stated that he did not defend himself, but stood still until
(V8) was finished, and then he walked away. (V8) was interviewed. He stated that he was not assigned to
(R26's) hallway for the shift nor had any interaction with (R26). Facility cameras were reviewed by
Administrator. No interaction was seen between (R26 and V8). Local Police Officer came to the facility to
gather information. During the police interview, at times (R26) spoke so softly that the police officer could
not hear him. At other times, (R26) would not answer any questions or gave answer that did not relate to
the question. The police officer stated to Administrator that he would not start an investigation. (R26) was
interviewed again during a care plan meeting on 8/15/2024. He refused to speak about the alleged
allegation and stated to administrator, I don't know what you are talking about. Multiple residents and staff
were interviewed with no one witnessing or reporting an altercation between (R26 and V8). In conclusion,
the facility was unable to substantiate the allegation of abuse. (R26) received a telehealth visit from the
facility NP (nurse practitioner) who gave orders for a medical work up. The IDT
(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 5
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
11/14/2024
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 0610
(Interdisciplinary Team) has met, and resident's care plan has been updated to reflect current status.
Level of Harm - Minimal harm
or potential for actual harm
The Facility's Newly Acquired Skin Conditions dated 8/9/2024, documents size and location: 0.25 cm
(centimeters) left upper check and 1.0 cm left lower cheek.
Residents Affected - Few
Review of resident interviews included: R6 written statement dated 8/9/2024 documents, (R26) goes out to
smoke. Did you see any altercation? No. R20 undated written statement documents I didn't see anyone
fighting. R209 written statement dated 8/9/2024 documents, I was sleeping. R209 stated that he didn't know
what I was talking about. R30's written statement dated 8/9/2024 documents, (R30) stated that he didn't
see (R26) and staff altercation. These statements didn't address if any staff were abusive toward the
resident or address the abuse allegation.
On 11/13/2024 at 1:08 PM V1, Administrator stated she interviewed other residents after the allegation of
staff to resident abuse, but she realized she didn't ask the correct abuse questions.
The Facility's Abuse Prevention Policy & Procedure Policy revised 11/28/2016, documents investigation
procedures to conduct interviews with resident's roommate and other residents to which the accused
individual has regular contact with.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145438
If continuation sheet
Page 2 of 5
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
11/14/2024
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to address pain on one of three resident's care
plan (R3) reviewed for care plans in a sample of 43.
Findings include:
R3's Minimum Data Set (MDS) dated [DATE] documents resident is alert with occasional pain. Over last
five days and pain effect on sleep: rarely or not at all. Over the last five days, how often have you limited
your day-to-day activities because of pain? Occasionally. Numeric rating scale: 6/10. Verbal descriptor
scale: not answered.
R3's Physician's Order Sheet, POS, dated 11/2024 documents the following pain medications: Tramadol
HCL 50 mg (milligrams) PRN (whenever necessary) every 6 hours as needed for pain, Carbamazepine 200
mg BID (twice a day) for pain, Acetaminophen 500 mg 2 tablets TID (three times a day) for pain,
Gabapentin 400 mg TID for pain, Diclofenac sodium 1% gel apply topically 2 grams to ankles and knees
twice a day for pain.
R3's Pain assessment dated [DATE], 7/23/2024 and 10/23/2024 documents resident no complaint of pain
or discomfort.
R3's Care Plan, dated 6/4/2024 does not address resident's pain.
On 11/13/2024 at 1:25 PM R3 stated she has chronic pain in her legs, knees, and ankles. R3's pain at that
time was 6/10. R3 sat in a wheelchair and lifted her left leg at the time of the interview and facial grimaced.
On 11/13/2024 at 2:30 PM V9, MDS/Care Plan Coordinator stated R3 has ankle and knee pain, and it
should be care planned with pharmacological and non-pharmacological interventions should be addressed
and documented on her care plan. V9 stated she didn't know why pain wasn't addressed on R3's care plan
other than that she had been discharged to the hospital multiple times over the last 6 months.
The Facility's Comprehensive Care Planning Policy, revised 7/20/2022, documents the care plan describes
a need/problem, and indicating approaches/interventions to be instituted to assist the resident in
maintaining/receiving care in relation to the need/problem. A care plan may or may not specify a goal for
the resident. The comprehensive care plan shall strive to describe the resident's preferences, choices, and
goals to the extent possible to assist in attaining or maintaining the resident's highest practicable quality of
life. The resident's medical, nursing, physical, mental, and psychosocial needs, and preferences. Person
centered measurable objectives and timeframes for ease of evaluating resident progress toward achieving
goals. A structured program designed to change need/problem: statement of the targeted problem/need,
goal stating the expected outcome of the reduction of the targeted problem, intervention/approaches aimed
at reducing the causative factors of the targeted problem. Communication of the care plan is paramount to
the success of consistent care delivery. Problems, goals, and interventions should include the date initiated
for ease of reference. All intervention entries should include the date of the care intervention was initiated
by the staff as well as the date the intervention was added to the care plan if added after the original care
plan date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145438
If continuation sheet
Page 3 of 5
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
11/14/2024
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 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 ensure dishes were properly
cleaned and food was stored in a manner to prevent foodborne illness. This has the potential to affect all 55
residents living in the Facility.
Findings include:
On 11/12/24 at 8:10 AM, V6, Cook, washed food residue from a dish in the far-right compartment of the
three-compartment sink, dipped the dish directly into the far-left compartment of the sink containing
sanitizing solution, then placed the dish on a rack to dry. V6 did not rinse the dish in between the two sinks,
and the middle sink compartment was empty.
On 11/13/24 at 8:15 AM, V6 stated the process is usually to wash, rinse and sanitize dishes, but they do
not have a stopper for the middle sink, so she just washed and sanitized.
On 11/12/24 at 8:15 AM, in the walk-in refrigerator, there was a container labeled Super Cereal that was
dated 11/3/24 with no Use By date. There was a container labeled Meat Salad that was dated 11/5/24 with
no Use By date.
On 11/12/24 at 8:17 AM, in the walk-in freezer, there was a plastic bag with biscuit dough and a plastic bag
with breadsticks. Both bags were previously opened and resealed but were not labeled or dated upon
opening.
On 11/12/24 at 2:00 PM, V4, Dietary Manager, stated food should always be discarded after seven days.
The Facility's Refrigerator and Freezer Storage Policy revised 10/2014 documents, It is the policy of
(Facility Company) 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. Mark container with
name of item. [NAME] the date that the original container is opened or date of preparation. Label
refrigerated, potentially hazardous food prepared and held for more than 24 hours with the day/date by
which the food shall be consumed or discarded (maximum of 7 days from time of preparation).
The Facility's Undated Dishwashing: Manual Policy documents, All pots and pans shall be cleaned by
washing, rinsing, and sanitizing, according to the following guidelines. The pots and pans will be washed in
a hot detergent solution in the first compartment, rinsed in clean warm water in the second compartment,
and sanitized by either heat or chemicals in the third compartment.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 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 4 of 5
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
11/14/2024
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 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
26 of 55 residents (R4, R8, R10, R11, R12, R16, R17, R22, R29, R28, R31, R34, R38, R40, R41, R42,
R45, R46, R48, R49, R51, R53, R54, R55, R56, R57) 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 11/12/2024 through 11/15/2024, the following residents were in the above rooms
which do not have 80 square feet per resident bed: R4, R8, R10, R11, R12, R16, R17, R22, R29, R28,
R31, R34, R38, R40, R41, R42, R45, R46, R48, R49, R51, R53, R54, R55, R56, R57.
The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 11/12/2024
documents the facility's census is 55.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145438
If continuation sheet
Page 5 of 5
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Back to topCitations
4 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.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 14, 2024 survey of EVERCARE OF COLLINSVILLE?
This was a inspection survey of EVERCARE OF COLLINSVILLE on November 14, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EVERCARE OF COLLINSVILLE on November 14, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
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
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.