Health inspection·August 6, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R2), reviewed for abuse in the sample of 5. This failure resulted in R2 being hit in the face by R1, which resulted in redness and R2 feeling fearful of R1.Findings Include:On 8/6/25 at 3:35 PM, R1 was observed, when surveyor knocked on his door, R1 cracked the door, the surveyor asked if she could come into his room, he stated no, when asked if she could talk with him, he stated no and shut the door. R1 appeared paranoid.On 8/6/25 at 3:37 PM, R2 was observed in his room, in a wheelchair, calm, and pleasant. R2 stated he had an incident with R1 a while ago, he had opened R1's room door for him, to be nice, and R1 was cussing at him and hit him upside the head in the face and scratched his arms. R2 stated his head bled where R1 had hit him. Stated he feels fairly safe in the facility but doesn't feel safe around R1. R2 stated he is around R1 sometimes and staff are around so he can get them if needed. R1's Face Sheet, undated, documents R1 has the following diagnoses: Obsessive Compulsive Disorder, Alzheimer's Disease, Psychosis, Obsessive Compulsive Personality Disorder, Unspecified Mental Disorder, and Dementia with Behavioral Disturbance.R1's MDS (Minimum Data Set), dated 6/14/25, documents R1 has a BIMS (Brief Interview of Mental Status) score of 13, indicating R1 is cognitively intact and rejects care.R1's Care Plan, dated 6/14/25, documents R1 has a history of inappropriate contact with his peers and staff. R1 had an encounter with another resident. R1 was placed on 15-minute checks with no further occurrence. Social Service Director to follow up and make sure both residents remain feeling safe at the facility. Behavior tracking updated, in-service on behavior, abuse and neglect completed. R1's Care Plan, dated 12/27/24, documents R1 has the potential to be physically aggressive related to anger, depression and poor impulse control.R1's Care Plan, dated 1/15/21, documents R1 becomes easily annoyed by fellow residents and will attempt physical aggression to get his point across, such as raising his fist at them.R1's Care Plan, dated 7/17/19, documents R1 doesn't like his personal space invaded or staff looking at him related to Paranoia.R1's Progress Note, dated 6/16/2025 at 9:03 AM, documents the following: IDT (Interdisciplinary Team) met regarding resident-to-resident allegation. Interviews and investigation initiated. Care plan reviewed and updated. New intervention: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert Attention.R2's Face Sheet, undated, documents R2 has the following diagnoses: Cerebral Infarction, Major Depressive Disorder, Dementia without Behavioral Disturbance, and Alzheimer's Disease.R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact and doesn't exhibit any behaviors.R2's Care Plan, dated 11/13/24, has no documentation of R2 having any behaviors.R2's Progress Note, dated 6/16/25 at 9:51 AM, documents the following: IDT met to review resident to resident allegation. Skin and pain assessments complete. Interviews and investigation initiated. Care plan reviewed and updated. New intervention: Educate resident to ask for staff assistance when he notices that other residents (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 08/06/2025 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)