Edwardsville Care and Rehab

In the surveyor’s words

From the most serious findings on record at Edwardsville Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 5, 2026

  The facility identified a census of 94 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent and then identify an elopement for Resident (R) 1, who had a BIMS of 15, schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and a guardian. On 02/05/26 at 02:45 AM, R1 left the facility without staff knowledge or supervision by climbing a fence surrounding a smoking patio at the facility and using a dining room chair. […]

• Immediate jeopardy, isolatedF600Jan 30, 2026

  The facility identified a census of 93 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from verbal abuse. On 01/19/26 at approximately 03:20 PM, Dietary Staff (DS) BB verbally abused R2, and Certified Medication Aide (CMA) R had to step between DS BB and R2 in order to assist R2 out of the situation. Per the interview with Administrative Staff A and CMA R, DS BB called R2 an [expletive] during the incident. […]

• Immediate jeopardy, isolatedF689Jan 29, 2025

  The facility reported a census of 96 residents, with 31 residents assessed at risk for elopement (when a resident leaves the premises or safe area without staff knowledge), and five residents sampled. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision and appropriate interventions to prevent the elopement of cognitively impaired R1, who had poor safety awareness. On 01/23/25 at approximately 04:58 PM, R1 exited the facility, unimpeded and without staff knowledge, and R1 remained out of the facility without staff knowledge for approximately 45 minutes, with outdoor temperatures between 16 and 18 degrees Fahrenheit (F). […]

• Immediate jeopardy, isolatedF689Apr 28, 2022

  The facility identified a census of 90, with three residents reviewed for accidents. Based on record review and interviews, the facility failed to provide adequate supervision for Resident (R) 1, who was independent with ambulation, at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff), and had poor safety awareness. On 04/25/22 at 07:50 PM R1 refused his evening medications, this was the last time facility staff observed R1 in the facility. At 06:25 AM on 04/26/22, approximately 10 hours later, oncoming staff observed R1's window open. Upon investigation, facility staff were unable to locate R1 in the facility. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2026

  Based on observation, record review, and interview, the facility failed to ensure dietary staff appropriately stored, labeled, and dated foods after the original storage container was opened. Findings included:- During the initial tour of the facility kitchen on 08/03/2026 at 08:13 AM, observation revealed the stand-alone refrigerator had a gallon jug of 2% milk that was half full did not have an open date on it. A half-gallon jug of chocolate milk was opened and did not have an open date on it. In the walk-in refrigerator, there were five-pound containers of ham salad, pasta salad, and potato salad that had been opened but lacked an open date. There was a gallon container of creamy Italian dressing that had been opened but lacked an open date. […]