Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 3 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 0580
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to notify the physician of R3's change in condition and
unresponsive episode for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3
experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently
becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of
ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized
with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life
sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of
urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment), dated 8/5/2024, documents that R3 indicated
Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident
received new med order per (V4, Nurse Practitioner) for the following: Send resident to ER (emergency
room) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA
(power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in
1 hour. Writer verbally notified pm nurse and told her after an hour to check back with ambulance company.
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director
of Nursing Services) was called to resident room per emergency response due to resident noted with rapid
condition decline. Crash cart requested and reported to resident room with Code called for assistance.
1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested
and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in
bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment.
Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to
obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with
evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased
oral/nasal secretions. [NAME] in color with thick frothy
(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 20
Event ID:
145847
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0580
Level of Harm - Actual harm
Residents Affected - Few
consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived.
Suction set up and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued
intermittent suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed
from oral cavity, no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced
but clear bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports
while care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices
(suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse
present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer
resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports
concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for
assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to
ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into
ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and
assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse
contacted POA (power of attorney) and made aware of condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted
number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as
follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival
to give resident her meds writer observed resident was foaming at the mouth writer immediately notified
staff for help and called paramedics, staff applied oxygen and suctioning to resident and elevated her head
to keep her stable till paramedics arrived, resident was still breathing and had a pulse, but it was faint and
light, paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to
stretcher, writer sent resident out to hospital, resident currently being transported to hospital by
paramedic,s writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the
correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work
ordered 11/26/2024, change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max
(assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call
from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive
and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and
continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was
agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local
hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that this [AGE] year [NAME] Female
presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04
Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest 17:03
occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS (Advanced
Cardiovascular Life Support), oxygen. Per EMS patient was found FOAMING AT THE MOUTH BY NH
(nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving CPR upon
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 2 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0580
Level of Harm - Actual harm
Residents Affected - Few
arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils: constricted,
bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild, ankle edema,
that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no spontaneous
respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state, patient being
intubated. It also documents Procedures: 12/04 Intubation: A time-out was completed verifying correct
patient, procedure, site, positioning and intubation 16:59 set-up. The patient was pre-oxygenated using an
Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC. The MAC 3 blade was
used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A 7.5
French endotracheal tube was inserted and visualized going through the vocal cords. The stylet was
removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard in both lung
fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray was
ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary, dated
12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that
documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse
failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment
skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the
care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3
received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5,
License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because
she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her
that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so
long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance
during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and
would be transported to outlying hospital. V20 stated that she is very upset and concerned because she
was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they
send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting
in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her
hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they
did not do anything.
On 12/12/2024 at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7
stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and
would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse
to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and
help with transfers, continent for the most part. V7 stated that the day before R3 went he again told the
nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and
he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right.
V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated
that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with
R3. V7 stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and
the Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 3 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0580
Level of Harm - Actual harm
Residents Affected - Few
R3's change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and
refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was
not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he
notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of
attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the
ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does
not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that
he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself
for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated
that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at
all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1
stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got there after 2:00 PM. V6 stated
that she received shift report and was informed in shift report that R3 was going to the hospital and that the
ambulance should be at the facility in 30 minutes if not call the service. V6 stated that she was not informed
of R3's condition and did not think it was an emergency. V6 stated that she went about, did her rounds, and
started prepping for her shift and getting herself ready to pass her medications. V6 stated that around 4 to
4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when she entered
the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow breathing and
foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6 stated at that
time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have
some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was
out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to
the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17
stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's
room but did not a look at her. V17 stated that she let the ambulance in and got the oxygen when told to do
so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is
normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other
CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated
that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15
stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed
in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increase
incontinence. V15 stated that the nurse was notified.
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18
stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 4 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0580
this was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have
behaviors and would refuse care. V18 stated that this was different.
Level of Harm - Actual harm
Residents Affected - Few
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to
cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have
some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3
at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed
with food tray on table next to the bed. V9 stated that she called out to R3 and no response. V9 stated that
she went to raise the head of the bed and it did not work and R3 did not respond to movement. V9 stated
that she noticed at that time that R3 was unresponsive. V9 stated that she performed a sternal rub and R3
did not respond. V9 stated that she notified the nurse and was informed that this was a behavior and not to
worry about it. V9 stated at that time she did some in servicing with the staff about feeding R3 with bed
being flat and to raise the head of the bed. V9 stated that at about an hour later she again noticed that R3
was unresponsive and notified the nurse asking for vitals. V9 stated that she was informed that the vitals
could not be taken because the battery was dead in the machine. V9 stated that at about 4 PM she entered
R3's room and it was the scariest thing she has seen. V9 stated that R3 was lying in bed unresponsive with
foam coming out of her nose. V9 stated that she told the nurse and was informed that the nurse on days
said R3 was going out but was waiting on an ambulance. V9 stated that she informed the nurse that R3
needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that
she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on
with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and
to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM
and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small
amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses
care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all.
V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care
at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10
stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you
when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated
that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that
R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating
at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician
Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was
called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it
looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and
nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a
weak pulse. V2 stated that the foam was frothy she was almost post ictal. V2 stated that they were unable to
obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping
R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left
facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but did not
actually see R3 prior to this event.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 5 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0580
Level of Harm - Actual harm
Residents Affected - Few
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a
message that R3 was refusing medication and food, facility attempted to get a urine and was not successful
and R3 was shaking. V4 stated that at 12:30 PM she responded to send R3 to ER for eval. V4 stated that
she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated that
if she would have been notified, she would have expected them to send R3 to hospital immediately. V4
stated that they know that this would be an emergency and with nursing judgement R3 should be sent out
with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an
assessment. V4 stated that she was not aware of R3's change of condition and decline days before.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21
stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at
4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into
cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal
rub and attempts to arouse R3 had failed he would consider that an emergency and would have sent R3 to
the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and vitals.
V21 stated that these are things he would have wanted to know. V21 stated that he was not aware that R3
was having change in condition prior to the event, not eating, taking to the bed and not allow staff to care
for her for days. V21 stated that these are red flags and would have wanted to look further. V21 stated that
he would have wanted to know what the assessment was. V21 stated that a resident needing minimal help
to dependent, alert and then not is an emergency and V21 would have wanted R3 to be seen at the
emergency room. V21 stated that he would expect to be notified of the changes of condition prior to the
unresponsive episode with assessment including vitals.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team
(QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what
happened. V36 stated that they found that they did not respond timely and appropriately with R3's change
in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and
if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17, documents
PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant
change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take
prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document
in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender
notification. c. Notification of responsible party.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 6 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility neglected to provide necessary medical services including
assessing a change in resident's condition and recognizing when a resident needs emergent medical
intervention. This failure resulted in the medical neglect of R3, who did not receive needed emergency
medical treatment in a timely manner despite, over the course of five and a half hours, R3 exhibiting a
significant decline in condition and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no
medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary
Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause
unspecified and Severe Septic Shock.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life
sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of
urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated 8/5/2024, documents that R3 indicated
Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident
received new med order per (V4 Nurse Practitioner) for the following: Send resident to ER (emergency
room) for evaluation and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA
(power of attorney) notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in
1 hour. Writer verbally notified pm nurse and told her after an hour to check back with the ambulance
company.
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director
of Nursing Services) was called to resident room per emergency response due to resident noted with rapid
condition decline. Crash cart requested and reported to resident room with Code called for assistance.
1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested
and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in
bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment.
Resident tachypneic with evidence of respiratory depression. Pulse present, weak and thready. Unable to
obtain accurate reading on Pulse oximeter. Resident known to this nurse to have history of seizures with
evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic, bilateral pupil dilation, increased
oral/nasal secretions. [NAME] in color with thick frothy consistency. Resident unresponsive to verbal stimuli,
tactile stimuli notes no response. Crash cart arrived. Suction set up and this DNS initiated suctioning, O2
(oxygen) initiated 5L (liters) via mask with continued intermittent suctioning to maintain airway. No gag
reflex noted during suction, slight secretions removed from oral cavity, no evidence of food or other particles
noted to indicate aspiration. LS (lung sounds) forced but clear bilateral. Care continued until arrival of EMS
(Emergency Medical Service). This DNS gave reports while care transitioned to EMS. Facility provided
medical equipment transitioned to EMS medical devices (suctioning, oxygen) without further distress noted.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 7 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Level of Harm - Actual harm
Residents Affected - Few
Resident remains tachypneic, with weak thready pulse present. Unable to obtain BP (blood pressure). This
DNS along with facility staff assisted EMS to transfer resident to stretcher for continued care and transfer.
EMT (emergency medical technicians) reports concerns of cardiac arrest during transport. States they were
having difficulty obtaining a second rig for assistance due to shortages today. This DNS along with second
nurse assisted EMS with resident move to ambulance with no loss of pulse or decreased respiration
enroute to ambulance. 1700: Resident placed into ambulance with EMTs, and staff return to facility. 1708
EMTs now noted with second rig finally arrived and assistance being provided. Resident to be transfer to
closest hospital due to critical status. Staff nurse contacted POA (power of attorney) and made aware of
condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted
number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as
follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival
to give resident her meds writer observed resident was foaming at the mouth writer immediately notified
staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head
to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and
light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to
stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics
writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the
correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work
ordered 11/26/2024 change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max
(assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call
from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive
and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and
continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was
agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local
hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that This 63 yrs (years) old [NAME]
Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04
Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest
17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS
(Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE
MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving
CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils:
constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild,
ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no
spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state,
patient being intubated. It also documents Procedures: 12/04 Intubation: A time-out was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 8 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Level of Harm - Actual harm
Residents Affected - Few
completed verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient
was pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG
SUC. The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view
of the vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal
cords. The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were
heard in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A
chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition
Summary, dated 12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that
documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse
failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment
skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the
care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3
received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5,
License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because
she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her
that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so
long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance
during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and
would be transported to outlying hospital. V20 stated that she is very upset and concerned because she
was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they
send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting
in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her
hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they
did not do anything.
On 12/12/2024 at 1:50 PM V7, CNA, stated that he was not here when R3 went out to the hospital. V7
stated that he had worked with R3 the days and nights before. V7 stated that R3 had taken to the bed and
would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated that R3 would refuse
to allow care but this was different from the norm. V7 stated that R3 was alert and verbal, able to stand and
help with transfers, continent for the most part. V7 stated that the day before R3 went, he again told the
nurse that R3 was different and that something was not right. V7 stated that R3 was not able to stand, and
he had to use a full mechanical lift. V7 stated that she was taken to the dining room, and she was not right.
V7 stated that he informed the nurse passing pills that R3 was shaking like she had Parkinson's. V7 stated
that R3 was different. V7 stated that he told the nurses and V2, DON, that there was something wrong with
R3. V7 stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and
the Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's
change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and
refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was
not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he
notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of
attorney and called the ambulance. V5 stated that he was informed that it would
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 9 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Level of Harm - Actual harm
Residents Affected - Few
be an hour before the ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if
the ambulance does not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork
ready. V5 stated that he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself
for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated
that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at
all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1
stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM.
V6 stated that she received shift report, was informed in shift report that R3 was going to the hospital and
that the ambulance should be at the facility in 30 minutes and if not, call the service. V6 stated that she was
not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her
rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that
around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when
she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow
breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6
stated at that time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have
some changes. V14 stated that R3 was not herself. She would not talk and was spaced out. She (R3) was
out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to
the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17
stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's
room but V17 did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to
do so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17
is normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the
other CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated
that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15
stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed
in the bed, went from standing and verbalizing her needs to dependent on staff, not eating and increased
incontinence. V15 stated that the nurse was notified.
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18
stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this
was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have
behaviors and would refuse care. V18 stated that this was different.
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to
cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 10 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Level of Harm - Actual harm
Residents Affected - Few
have some changes in her ADLs within the last week or so. V9 stated that because of this she went in to
see R3 at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in
the bed with food tray on table next to the bed. V9 stated that she called out to R3 and there was no
response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not respond
to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she
performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed
that this was a behavior and not to worry about it. V9 stated at that time she did some in servicing with the
staff about feeding R3 with bed being flat and to raise the head of the bed. V9 stated that about an hour
later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she
was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated
that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3
was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was
informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that
she informed the nurse that R3 needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that
she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on
with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and
to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM
and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small
amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses
care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all.
V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care
at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10
stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you
when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated
that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that
R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating
at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician
Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was
called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it
looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and
nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow shallow breathing and a
weak pulse. V2 stated that the foam was frothy, she was almost post ictal. V2 stated that they were unable
to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2 stated that they were keeping
R3's airway safe. V2 stated that EMTs came and took over and R3 was transferred to the stretcher and left
facility. V2 stated that she had not seen R3 that day. V2 stated that she passed R3's room but had not
actually seen R3 prior to this event.
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a
message that R3 was refusing medication and food, facility attempted to get a urine and was not successful
and R3 was shaking. V4 stated that at 12:30 PM she responded to send to ER for eval. V4 stated that she
was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 11 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0600
Level of Harm - Actual harm
Residents Affected - Few
V4 stated that if she would have been notified, she would have expected them to send R3 to hospital
immediately. V4 stated that they know that this would be an emergency and with nursing judgement R3
should be sent out with 911 called. V4 stated if the nurse thought this was a behavior, then there still should
have been an assessment. V4 stated that she was not aware of R3's change of condition and decline days
before.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21
stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at
4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into
cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal
rub andd attempts to arouse R3 had failed. He would have consideresd that an emergency and would have
sent R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done
and vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not
aware that R3 was having change in condition prior to the event, not eating, taking to the bed and not
allowing staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to
look further. V21 stated that he would have wanted to know what the assessment was. V21 stated that a
resident needing minimal help to dependent, alert and then not is an emergency and V21 would have
wanted R3 to be seen at the emergency room. V21 stated that he would expect to be notified of the
changes of condition prior to and the unresponsive episode with assessment including vitals.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality Assurance team
(QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what
happened. V36 stated that they found that they did not respond timely and appropriately with R3's change
in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and
if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17, documents
PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a. Significant
change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals to take
prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2. Document
in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician extender
notification. c. Notification of responsible party.
The facility's Abuse Prevention Policy, revised 10/22/24, documented Neglect: A failure of the facility, its
employees, or service providers to price goods and services necessary to avoid physical harm, mental
anguish, emotional distress or pain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 12 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3)
residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of
Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00
AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary
Resuscitation performed, and intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause
unspecified and Severe Septic Shock.
Residents Affected - Few
This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/30/24 when the
facility failed to: 1. assess, monitor, and provide timely treatment for a change in R3's condition. 2. Notify the
physician of R3's decline in ADLs from 11/30 through 12/4 and being unresponsive on 12/4/24 at 9:00 AM.
3. Obtain medical treatment for R3's change of condition from 9:00 AM to 4:00 PM at the time of ambulance
transfer with R3 experiencing cardiac arrest with Cardiac Pulmonary Resuscitation performed, intubation
and hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock.
V2, Director of Nursing, and V3, Regional Clinical Consultant, were notified of the Immediate Jeopardy on
12/19/24 at 1:17 PM. The surveyor confirmed by observations, interview, and record review, the Immediate
Jeopardy was removed on 12/23/2024, but the noncompliance remains at Level Two due to additional time
needed to evaluate implementation and effectiveness of training.
Findings include:
R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life
sustaining measures.
R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of
urine and always continent of bowel and requires assistance with activities of daily living (ADL).
R3's POLST (Physician Orders for Life-Sustaining Treatment,) dated 8/5/2024, documents that R3 indicated
Yes to attempt CPR if in cardiac arrest and if not in cardiac arrest: Full treatment.
R3's Progress Notes, dated 12/4/2024 at 2:23 PM, documents Nurses Note Late Entry: Note Text: Resident
received new med order per (V4) for the following: Send resident to ER (emergency room) for evaluation
and treatment R/T (related to) refusal of meds and refusal of meals. Resident POA (power of attorney)
notified. Writer contacted (Local) ambulance rep who stated that a unit would be sent in 1 hour. Writer
verbally notified pm nurse and told her after an hour to check back with (local ambulance company).
R3's Progress Notes, dated 12/4/2024 at 5:23 PM, documents Nurses Note Text: 1632: This DNS (Director
of Nursing Services) was called to resident room per emergency response due to resident noted with rapid
condition decline. Crash cart requested and reported to resident room with Code called for assistance.
1634: Upon entering resident noted with 2 nurses at bedside. Crash cart and oxygen had been requested
and enroute. 911 call already placed by staff nurse. This DNS took over lead duties. 1635: Resident noted in
bed with HOB (head of bed) elevated, staff providing airway safety as able awaiting further equipment.
Resident tachypneic with evidence of respiratory depression. Pulse present,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 13 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
weak and thready. Unable to obtain accurate reading on Pulse oximeter. Resident known to this nurse to
have history of seizures with evidence of postictal s/s (signs/symptoms) noted. Resident diaphoretic,
bilateral pupil dilation, increased oral/nasal secretions. [NAME] in color with thick frothy consistency.
Resident unresponsive to verbal stimuli, tactile stimuli notes no response. Crash cart arrived. Suction set up
and this DNS initiated suctioning, O2 (oxygen) initiated 5L (liters) via mask with continued intermittent
suctioning to maintain airway. No gag reflex noted during suction, slight secretions removed from oral cavity,
no evidence of food or other particles noted to indicate aspiration. LS (lung sounds) forced but clear
bilateral. Care continued until arrival of EMS (Emergency Medical Service). This DNS gave reports while
care transitioned to EMS. Facility provided medical equipment transitioned to EMS medical devices
(suctioning, oxygen) without further distress noted. Resident remains tachypneic, with weak thready pulse
present. Unable to obtain BP (blood pressure). This DNS along with facility staff assisted EMS to transfer
resident to stretcher for continued care and transfer. EMT (emergency medical technicians) reports
concerns of cardiac arrest during transport. States they were having difficulty obtaining a second rig for
assistance due to shortages today. This DNS along with second nurse assisted EMS with resident move to
ambulance with no loss of pulse or decreased respiration enroute to ambulance. 1700: Resident placed into
ambulance with EMTs, and staff return to facility. 1708: EMTs now noted with second rig finally arrived and
assistance being provided. Resident to be transfer to closest hospital due to critical status. Staff nurse
contacted POA (power of attorney) and made aware of condition rapid decline and transfer status.
R3's Progress Note, dated 12/4/2024 at 5:57 PM, documents Nurses Note, Note Text: Time error inverted
number 1632 should read 1623. Error in consecutive times caused by initial inversion: should read as
follows, 1624, 1625, 1630, 1637.
R3's Progress Note, dated 12/4/2024 at 6:59 PM, documents Nurses Note, Note Text: upon writer's arrival
to give resident her meds writer observed resident was foaming at the mouth writer immediately notified
staff for help and called paramedics staff applied oxygen and suctioning to resident and elevated her head
to keep her stable till paramedics arrived resident was still breathing and had a pulse, but it was faint and
light paramedics arrived and suctioned resident and applied oxygen and removed resident from bed to
stretcher writer sent resident out to hospital resident currently being transported to hospital by paramedics
writer will continue to follow up.
R3's Progress Note, dated 12/4/2024 at 9:33 PM, documents Nurses Note, Note Text: error in time the
correct time of incident was 16:23.
R3's Therapy Communication Form, documents 11/25/2024 report of change of status to NP, blood work
ordered 11/26/2024 change diet to puree, 12/4/2024 educate staff re: not to feed in bed laying flat. Max
(assist) without any response from patient.
R3's Local Fire Department Patient Care Records, dated 12/4/2024, documents that they received a call
from local facility due to patient being unresponsive and foaming. Upon arrival patient was unresponsive
and clammy surrounded by nursing staff. Nursing staff suctioning patient. Fire department took over and
continued suctioning with contents of vomit. Staff not sure how long-ago patient had aspirated. Patient was
agonal breathing. Faint Pulse, unable to obtain oxygen level and blood pressure. During transport to local
hospital pulse was not palpable and CPR initiated.
R3's Local Hospital History and Physical, dated 12/4/2024, documents that This [AGE] year [NAME]
Female presents to, ED (emergency department) via Unassigned with complaints of Cardiac Arrest. 12/04
Preceding the arrest, the patient was choking, was found down by nursing home staff. The arrest
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 14 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
17:03 occurred at nursing home. Pre-hospital course: EMS care prior to arrival: initiation of ACLS
(Advanced Cardiovascular Life Support), oxygen. Per [NAME] patient was found FOAMING AT THE
MOUTH BY NH (nursing home) Staff. Patient arrested upon EMS intervention en route. Patient receiving
CPR upon arrival and had an IG EL (airway device) in place. It continues Exam: 12/04 17:08 Eyes: Pupils:
constricted, bilaterally. Cardiovascular: Rate: tachycardic, Rhythm: Edema: pedal edema, that is very mild,
ankle edema, that is very mild. Respiratory: no spontaneous respirations are appreciated, Respirations: no
spontaneous respirations appreciated, Breath sounds: Unable to obtain exam due to obtunded state,
patient being intubated. It also documents Procedures: 12/04 Intubation: A time-out was completed
verifying correct patient, procedure, site, positioning, and intubation 16:59 set-up. The patient was
pre-oxygenated using an Ambu bag and placed in a supine position. Sedation was obtained 100MG SUC.
The MAC 3 blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the
vocal cords. A 7.5 French endotracheal tube was inserted and visualized going through the vocal cords.
The stylet was removed. Colorimetric change was visualized on the CO2 meter. Breath sounds were heard
in both lung fields equally. The endotracheal tube was placed at 23cm, measured at the teeth. A chest x-ray
was ordered to assess for pneumothorax and verify endotracheal tube placement. Disposition Summary,
dated 12/4/2024, documents diagnosis: Cardiac Arrest and Severe Septic Shock.
On 12/19/2024 the facility provided a 5 ways Root Cause Analysis Template, dated 12/19/2024, that
documents: Clearly state the problem: Facility failed to Assess, monitor, and provide timely treatment. Nurse
failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment
skills by nurse.
On 12/12/2024 at 8:46 AM V20, R3's Power of Attorney (POA), stated that she was very concerned with the
care that R3 received at the facility. V20 stated she spoke with R3's roommate and was notified that R3
received CPR at the facility when being transported from the facility. V20 stated that she was notified by V5,
License Practical Nurse (LPN), around 1:30 -2:00 PM that R3 was being sent out to the hospital because
she was not doing well. V20 stated that she received a phone call from the facility 3 hours later telling her
that the ambulance is here and R3 is being sent out. V20 stated that she didn't understand why it took so
long. V20 stated that the (local) hospital called and told her that CPR had to be performed in the ambulance
during transport and in the emergency room. V20 stated that she was informed that R3 was on a vent and
would be transported to outlying hospital. V20 stated that she is very upset and concerned because she
was told that R3 was not doing well and needed to go to the hospital 3 hours before R3 did. Why didn't they
send her? V20 stated that for 2 weeks R3 refused to get up and laid in urine for long periods of time sitting
in her own waste. V20 stated that she was informed by the hospital that R3 had an impaction the size of her
hip socket. V20 stated that it's clear that R3 was having changes before the day she was sent out and they
did not do anything.
On 12/12/2024 at 1:50 PM V7, Certified Nurse's Assistant, CNA, stated that he was not here when R3 went
out to the hospital. V7 stated that he had worked with R3 the days and nights before. V7 stated that R3 had
taken to the bed and would not get out. V7 stated that R3 was totally incontinent and did not eat. V7 stated
that R3 would refuse to allow care but this was different from the norm. V7 stated that R3 was alert and
verbal, able to stand and help with transfers, continent for the most part. V7 stated that the day before R3
went he again told the nurse that R3 was different and that something was not right. V7 stated that R3 was
not able to stand, and he had to use a full mechanical lift. V7 stated that she was taken to the dining room,
and she was not right. V7 stated that he informed the nurse passing pills that R3 was shaking like she had
Parkinson's. V7 stated that R3 was different. V7 stated that he told the nurses and V2, DON, that there was
something wrong with R3. V7
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 15 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
stated that the changes in R3 started 12/1/2024 and this is when he started notifying the nurses and the
Director of Nursing.
On 12/12/2024 at 12:27 PM V5, Licensed Practical Nurse (LPN), stated that he was here the day that R3's
change in condition occurred. V5 stated that R3 has a history of behaviors as far as refusing care and
refusing to perform self-care but this was different. V5 stated that between 10:30 AM and 12:00 PM R3 was
not herself and not responding to verbal stimuli and would not take her medication. V5 stated that he
notified the Nurse Practitioner and got an order to send R3 out. V5 stated that he notified the power of
attorney and called the ambulance. V5 stated that he was informed that it would be an hour before the
ambulance would arrive. V5 stated that he told the oncoming nurse of this and that if the ambulance does
not show after 30 to 45 minutes to call them back. V5 stated that he got the paperwork ready. V5 stated that
he was not at the facility when R3 went out as he had left after completion of his shift.
On 12/12/2024 at 12:30 PM R1 stated that she and R3 were roommates. R1 stated that R3 was not herself
for most of the week. R1 stated that R3 did not eat and stayed in the bed and did not eat or drink. R1 stated
that the day before R3 went out to the hospital, V7, CNA, got R3 up. R1 stated that R3 didn't help much at
all. R1 stated that when they put R3 to bed she was talking and that was the last time she was ok. R1
stated that R3 yells when they clean R3 but nothing during the night or following day.
On 12/17/2024 at 8:30 AM V6, LPN, stated that she was running late and got to the facility after 2:00 PM.
V6 stated that she received shift report and was informed in shift report that R3 was going to the hospital
and that the ambulance should be at the facility in 30 minutes, if not call the service. V6 stated that she was
not informed of R3's condition and did not think it was an emergency. V6 stated that she went about, did her
rounds, and started prepping for her shift and getting herself ready to pass her medications. V6 stated that
around 4 to 4:30 PM the therapist (V9) reported to her that R3 needed a nurse now. V6 stated that when
she entered the room R3 was in a state of distress. V6 stated that R3 was pale, not responding, shallow
breathing and foam coming from R3's nose and mouth. V6 stated that she called 911 and called a code. V6
stated at that time she received help from other staff while she was on the phone with 911.
On 12/17/2024 at 10:21 AM V14, CNA, stated that she was not assigned to R3. V14 stated that R3 did have
some changes. V14 stated that R3 was not herself. She would not talk and was spaced out, she (R3) was
out of it. V14 stated that R3 does have behaviors but this was different. V14 stated that she reported it to
the nurse. V14 stated that she wasn't right. V14 stated this was days before she went out.
On 12/17/2024 at 10:28 AM V17, CNA, stated that she got to the facility between 3:30 to 4:00 PM. V17
stated that she was not assigned to R3 that day and maybe saw her in passing as V17 walked past R3's
room but did not look at her. V17 stated that she let the ambulance in and got the oxygen when told to do
so. V17 stated that R3 has been having some changes and requiring more assistance than normal. V17 is
normally alert and able to make her needs known. V17 stated that R3 hadn't been doing that and the other
CNAs were needing help with her which is unusual.
On 12/17/2024 at 10:32 AM V15, CNA, stated that she did not have R3 the day she went out. V15 stated
that she helped transfer R3 onto the gurney and got the oxygen tanks and things to help R3 breathe. V15
stated that R3 has behaviors and refuses care. V15 stated that prior to this R3 was not herself and stayed
in the bed, went from standing and verbalizing her needs to dependent on staff, not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 16 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
eating and increase incontinence. V15 stated that the nurse was notified.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 12/17/2024 at 10:39 AM V18, CNA, stated R3 was having changes days before she went out. V18
stated that R3 was crying a lot and not eating. V18 stated that R3 wouldn't stand up. V18 stated that this
was different for R3 and that R3 was alert and able to stand and help. V18 stated that R3 did have
behaviors and would refuse care. V18 stated that this was different.
Residents Affected - Few
On 12/17/2024 at 10:50 AM V9, Speech Therapist, stated that Speech Therapy was seeing R3 due to
cognitive changes and eating. V9 stated that R3 did not have any difficulty with swallowing but did have
some changes in her ADLs within the last week or so. V9 stated that because of this she went in to see R3
at 9:00 AM to see if she had eaten. V9 stated that she entered R3's room and R3 was lying flat in the bed
with food tray on table next to the bed. V9 stated that she called out to R3 and there was
no response. V9 stated that she went to raise the head of the bed and it did not work and R3 did not
respond to movement. V9 stated that she noticed at that time that R3 was unresponsive. V9 stated that she
performed a sternal rub and R3 did not respond. V9 stated that she notified the nurse and was informed
that this was a behavior and no to worry about it. V9 stated at that time she did some in servicing with the
staff about feeding R3 with bed being flat and raise the head of the bed. V9 stated that at about an hour
later she again noticed that R3 was unresponsive and notified the nurse asking for vitals. V9 stated that she
was informed that the vitals could not be taken because the battery was dead in the machine. V9 stated
that at about 4 PM she entered R3's room and it was the scariest thing she has seen. V9 stated that R3
was lying in bed unresponsive with foam coming out of her nose. V9 stated that she told the nurse and was
informed that the nurse on days said R3 was going out but was waiting on an ambulance. V9 stated that
she informed the nurse that R3 needed help now.
On 12/18/2024 at 10:46 AM V10, CNA, stated that she took care of R3 on 12/4/2024. V10, CNA, stated that
she came in and went to R3's room and she didn't look herself. V10 stated that she asked what's going on
with R3, she doesn't look right. V10 stated that she was informed that R3 was having some problems and
to leave her in for breakfast and so she did. V10 stated that she went back in R3's room around 10:00 AM
and provided incontinent care. V10 stated that R3 was not responding and was incontinent of a small
amount of liquid stool but not wet with urine. V10 stated that R3 does have behaviors when she refuses
care and not wanting to get up. V10 stated that this was different. V10 stated that this was not like R3 at all.
V10 stated that she left the room and let V5 the nurse know. V10 stated that she provided incontinent care
at 1:30 PM and R3 was unresponsive. V10 stated that R3 again had a small amount of liquid stool. V10
stated that this was different, this was a big change for R3. V10 stated that R3 was alert and able to tell you
when she needed to toilet. V10 stated that R3 was continent in the day and incontinent at night. V10 stated
that R3's change in condition started about 3 to 4 days prior to the unresponsive episode. V10 stated that
R3 went from standing and taking steps to using a sit to stand and then not transferring at all and not eating
at all. V10 stated that she let the nurse know.
On 12/18/2024 at 4:00 PM V3, Regional Clinical Nurse, stated that the Change in Condition and Physician
Notification Policy was all in one and had been provided.
On 12/18/2024 at 9:26 AM V2, Director of Nursing, stated that she was up in front of the building and was
called to R3's room. V2 stated that she ran down to R3's room. V2 stated that when she entered the room it
looked like R3 had a seizure. V2 stated that R3's pupils were dilated and R3 was foaming at mouth and
nose. V2 stated that there were nurses at the bedside. V2 stated that R3 had slow
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 17 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
shallow breathing and a weak pulse. V2 stated that the foam was frothy, and she was almost post ictal. V2
stated that they were unable to obtain a pulse ox and O2 applied. V2 stated that 911 had been called. V2
stated that they were keeping R3's airway safe. V2 stated that EMTs came and took over and R3 was
transferred to the stretcher and left facility. V2 stated that she had not seen R3 that day. V2 stated that she
passed R3's room but did not actually see R3 prior to this event.
On 12/18/2024 at 1:35 PM V4, Nurse Practitioner, stated that on 12/4/2024 at 10:30 AM she received a
message that R3 was refusing medication and food, facility attempted to get a urine and was not successful
and R3 was shaking. V4 stated that at 12:30 PM she responded to send to R3 to the ER for eval. V4 stated
that she was not notified of R3 being unresponsive with sternal rub being performed at 9:00 AM. V4 stated
that if she would have been notified, she would have expected them to send R3 to hospital immediately. V4
stated that they know that this would be an emergency and with nursing judgement R3 should be sent out
with 911 called. V4 stated if the nurse thought this was a behavior, then there still should have been an
assessment. V4 stated that she was not aware of R3's change of condition and decline days before.
On 12/19/2024 at approximately 11:15 AM V5 stated that he was notified of R3's change of conditions prior
to R3 being unresponsive and thought it was behavioral. V5 stated that R3 would refuse care and have
behaviors in dining room.
On 12/19/2024 at 3:10 PM V21, Physician, stated that he was not notified of R3's change of condition. V21
stated that he was not aware that R3 was found unresponsive at 9:00 AM and then foaming from nose at
4:23 PM and went out to hospital in an ambulance. V21 stated that he was not aware that R3 went into
cardiac arrest and received CPR. V21 stated that if he was notified that R3 was unresponsive to a sternal
rub, attempts to arouse R3 had failed; he would have considered that an emergency and would have sent
R3 to the hospital with lights and sirens. V21 stated that he would expect an assessment to be done and
vitals. V21 stated that these are things he would have wanted to know. V21 stated that he was not aware
that R3 was having change in condition prior to the event, not eating, taking to the bed and not allowing
staff to care for her for days. V21 stated that these are red flags and V21 would have wanted to look further.
V21 stated that he would have wanted to know what the assessment was. V21 stated that a resident
needing minimal help to dependent, alert and then not is an emergency and V21 would have wanted R3 to
be seen at the emergency room. V21 stated that he would expect to be notified of the changes of condition
prior to the unresponsive episode with assessment including vitals.
On 12/23/2024 at approximately 11:30 AM V2 stated that they had a QA meeting on 12/19/2024
concerning the change of condition to try to find out what was the cause of the delay in treatment. V2 stated
this was transcribed to the 5 ways Root Cause Analysis Template. V2 stated that their findings were
transcribed to the form. V2 stated that the Facility failed to Assess, monitor, and provide timely treatment,
Nurse failed to follow up, assess resident and call MD, Nurse thought this was resident behavior and Poor
assessment skills by nurse was the root cause of the delay in treatment.
On 12/23/2024 at 1:19 PM V36, Restorative Nurse, stated that she is a part of Quality assurance team
(QA). V36 stated that there was QA meeting, and they went over the deficiency and tried to figure out what
happened. V36 stated that they found that they did not respond timely and appropriately with R3's change
in condition. V36 stated that they have been in servicing staff related to the Change in Condition policy and
if they feel the nurse is not responding then to go above them.
The facility's Notification of a Change in a Status Change in Condition policy, dated 11/17,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 18 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
documents PROCEDURE: 1. Guideline for notification of physician/ responsible party (not all inclusive): a.
Significant change in /or unstable vital signs (Temperature, B/P, Pu Ise, Respiration) . h. Repeated refusals
to take prescribed medication (for two days). i. Change in level of consciousness. k. Unusual behavior. 2.
Document in the Interdisciplinary Team (IDT) notes: a. Resident change in condition. b. Physician/physician
extender notification. c. Notification of responsible party.
The facility presented an Abatement plan to remove the immediacy on 12/19/24. The survey team reviewed
the Abatement plan and was unable to accept the plan to remove the immediacy. The Abatement plan was
returned to the facility on [DATE] and 12/20/24 for revisions. The facility presented a revised Abatement
plan on 12/20/24 and the survey team accepted the Abatement plan on 12/20/24.
On 12/23/24, during the validation of the abatement plan by the survey team, it was noted that several staff
members had not been in serviced prior to working their shift, and vital sign equipment was not operational
at the time of observation. On 12/23/24, at 11:30 AM, V1, V2, and V3 were notified the abatement was not
validated as multiple staff persons working had not received the in-service prior to their shift and vital sign
equipment was not functioning. All staff who had not previously received in serviced were completed and
vital sign equipment was in working order by end of day on 12/23/24.
The Immediate Jeopardy that began on 11/30/24 was removed on 12/23/2024 when the facility took the
following actions to remove the immediacy.
1. Emergency QA held 12/19/24 at 2:45pm with interdisciplinary team which consisted of the Medical
Director, [NAME] President/Governing body (V51), Executive Director (V1), Director of Nursing Services
(V2), Regional Nurse (V3), Memory Care Manager (V52), Wound Care Nurse ( V35), and Social Service
Director (V53), to establish a system that addresses any resident in distress and or unresponsive will be
treated timely and without delay. Charge nurse will notify the MD (The resident MD), DNS (V2) and or
Administrator (V1) to ensure immediate action is taken to ensure the health and wellbeing of the resident. A
Root Cause analysis completed on 12/19/24 related to staff failure to immediately notify and transfer
resident to hospital when change in condition arose. Due to the fact of this occurrence, there was also a
failure to report R3's non-responsiveness status and seriousness of R3's current status to the oncoming
shift. This will be addressed to ensure compliance. The DNS (V2) and or Designee performed Inservice to
Licensed Nurses to ensure that shift to shift report is done. This was performed on 12-19-24.
2. Facility immediately suspended on 12/19/2024 V5 (LPN) and V9 Speech Therapist, for not responding or
making any effort to assist R3 when unresponsive. This suspension will be on-going until a complete
investigation of all actions taken by V5 LPN and V9 Speech Therapist on 12/4/24 is thoroughly investigated
by the Administrator, V1.
3. DNS (V2) and Regional Clinical Operations Nurse (V3) will immediately begin in-servicing All Staff in
person or by phone. This in-service to include notification of any change in condition to charge nurse and
Director of Nursing. Then licensed nurses will notify physician immediately. If resident is unresponsive or
acute distress to call 911 immediately and notify physician, DNS (V2) and or Administrator (V1) and
resident's responsible party. This in-service completed 12/19/24 by 11pm. Staff will not be allowed to work
unit until in-service completed.
4. DNS (V2) and or designee will do 100% visual assessment to ensure all current residents are in stable
condition and not in acute distress. Completed 12/19/24 at 3:30pm.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 19 of 20
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
145847
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/26/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Stearns
3900 Stearns Avenue
Granite City, IL 62040
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 0684
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
5. DNS (V2) and or designee will do 100% audit of vital sign equipment (Blood pressure cuff, pulse
oximetry, and thermometer) to ensure each unit has a working vital sign equipment readily available. These
will be accounted for daily and stored in the med cart.
Monitoring:
-DNS (V2) and Unit Managers (V2, Memory Care, V27 LPN - SDC, V37 LPN - MDS, V36 LPN - Restorative
and V35 LPN- Wound Care) will visually monitor every resident daily to ensure residents are not in distress
and in stable condition.
-DNS and Unit Managers will monitor daily that each unit has vital sign equipment, and it is in working
condition.
-Policy (Change in Condition) regarding this IJ related to F684 was reviewed at the Emergency QA meeting
on 12-19-24 at 3:30pm. There was no change in the Policy. There were system changes related to
assessing, monitoring, and providing timely treatment for R3's change in condition. The discussion will
continue to occur monthly, and any trends and concerns will be address immediately to ensure compliance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145847
If continuation sheet
Page 20 of 20
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Back to topCitations
3 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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the December 26, 2024 survey of Evercare at Stearns?
This was a inspection survey of Evercare at Stearns on December 26, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Evercare at Stearns on December 26, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.