F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to administer ordered medications to 1 of 5 residents (R2)
reviewed for pharmacy services in the sample of 9.
Findings include:
R2's Face sheet documents an admission date of 1/11/2024 with diagnoses of Metabolic encephalopathy,
Alzheimer's, Interstitial Cystitis (chronic) with Hematuria, Dysphagia.
R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired. R2 is
dependent on staff for activities of daily living (ADL's) and requires substantial assist for mobility and
transfers.
R2's Care Plan dated 10/2/2024 documents Problem: I have potential for pain/discomfort related to
diagnosis of pain, Gastroesophageal Reflux Disease, GERD, Interstitial cystitis (chronic) with hematuria
and constipation. Interventions include: Record/report to Nurse any signs/symptoms of non-verbal pain:
Changes in breathing, vocalizations, mood/behavior changes, eyes, face, body. Observe the effectiveness
of pain interventions every shift. Review for compliance alleviating of symptoms, dosing schedules and
resident satisfaction with results, impact on functional ability and impact on cognition.
R2's order sheet dated 7/25/2024 documents oxycodone - Schedule II. Tablet; 5 mg (milligrams); amt:
(amount) 1 tablet; oral. Four Times A Day to be administered at 5:00 AM - 06:00 AM, 11:00 AM - 12:00 PM,
05:00 PM - 06:00 PM, 11:00 PM - 12:00 AM.
R2's September 2024 Medication Administrator Record (MAR) document for R2's oxycodone 9/17/2024
5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/17/2024 11:00 AM - 12:00 PM Not
Administered: Drug/Item Unavailable Comment: waiting on script. 9/17/2024 5:00 PM - 6:00 PM Not
Administered: Drug/Item Unavailable. 9/17/2024 11:00 PM - 12:00 AM Not Administered: Drug/Item
Unavailable. 9/18/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/18/2024 11:00 AM 12:00 PM Not Administered: Drug/Item Unavailable. 9/18/2024 11:00 PM - 12:00 AM Not Administered:
Drug/Item Unavailable. 9/19/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/19/2024
11:00 AM - 12:00 PM Not Administered: Drug/Item Unavailable. 9/19/2024 11:00 PM - 12:00 AM Not
Administered: Drug/Item Unavailable. 9/20/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item
Unavailable. 9/20/2024 11:00 AM - 12:00 PM Not Administered: Drug/Item Unavailable.
R2's progress notes dated 9/19/2024 at 12:13 PM Call placed to Hospice letting them know that we
(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:
145555
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
145555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Edwardsville
401 St Mary Drive
Edwardsville, IL 62025
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 0755
need R2's pain medicine sent out as soon as possible.
Level of Harm - Minimal harm
or potential for actual harm
On 10/9/2024 at 12:00PM V3, Assistant Director of Nursing (ADON), stated I am going to be honest with
you. We have been having trouble with the hospice company (R2) is enrolled in. It looks like on 9/19/2024
we ran out of oxycodone for (R2), and hospice did not refill it.
Residents Affected - Few
On 10/9/2024 at 9:30AM V11, (R2's family), stated Supposedly they were out of hydrocodone, and she was
switched to oxycodone. We have trouble getting them to give her meds in the evening. I don't know what
they give her now. The meds are just in pudding.
On 10/10/2024 at 11:07AM V2, Director of Nursing (DON), stated V20, Registered Nurse (RN), called
hospice several times about R2 needing a script for oxycodone. V20 (RN), did not chart that she had been
calling so I knew nothing about it.
On 10/9/2024 at 5:00PM V16 (RN) stated (R2's) oxycodone is not in the drawer. I will have to talk to (V2).
We will have to call pharmacy. We cannot get in the E (Emergency) kit without a prescription.
On 10/9/24, At 5:10PM V16 (RN) stated V2 already called for a script to get into the E kit. I have to wait to
get approval to get the oxycodone out of the E kit. At 5:30PM V16 (RN) was approved to get an oxycodone
out of E kit and administered oxycodone 5mg to R2. V16 (RN) stated R2's oxycodone will arrive tonight with
pharmacy.
Facility medication policy with a revision date of 4/2019 states Medications are administered in a safe and
timely manner, and as prescribed. Medications are administered in accordance with prescriber orders,
including any required time frames.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145555
If continuation sheet
Page 2 of 2
