Evercare at Edwardsville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 30, 2025

  Deficiencies at this level require two deficient practice statements.A. Based on interview and record review the Facility failed to ensure residents were free of neglect for 1 of 3 residents (R2) reviewed for neglect in the sample of 16. This failure occurred when (R2) was transferred from another nursing home to the facility on [DATE], with no dialysis services set up and/or scheduled prior to her acceptance to the facility. No alternate dialysis treatment was put into place while the facility was waiting for the new provider to perform treatment. […]

• Immediate jeopardy, isolatedF698Oct 30, 2025

  Based on interview and record review the Facility failed to ensure coordination of care for a resident to receive medically necessary hemodialysis for 1 of 3 residents (R2) reviewed for dialysis services in the sample of 16. This failure occurred when (R2) was admitted to the facility on [DATE] and did not receive dialysis services for 12 days. R2 was sent to the hospital per family request where she was found with critical lab values, shortness of breath and had a 5 day hospital stay.Findings include:The IJ (Immediate Jeopardy) was presented and called on 10/29/2025 at 1:12 PM, with V1, Administrator, V22, [NAME] President of Clinical Operations and V23 Regional Director of Operations. The Immediate Jeopardy began on 10/8/2025 at 1:20 PM when R2 arrived at the facility. […]

• Immediate jeopardy, isolatedF684Sep 6, 2023

  Based on interview and record review the facility failed to monitor, assess, and notify the physician of an acute change in condition to ensure timely medical treatment for 1 of 3 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in an Immediate Jeopardy when R3 began having ongoing respiratory distress with no medical monitoring resulting in death from pneumonia and acute respiratory failure. The Immediate Jeopardy began on [DATE] at 9:51 AM, when staff identified that R3 was having respiratory distress, failed to provide ongoing assessment/monitoring to address respiratory distressed caused by pneumonia. At 7:10 PM, R3 was found unresponsive, and the facility called 911. R3 expired at the hospital. […]

• Actual harm, isolatedF689Mar 20, 2026

  Based on interview and record review, the facility failed to use the required equipment (gait belt) during transfer and appropriately use the full mechanical lift to prevent falls in 2 of 3 residents (R3, R29) reviewed for accidents and hazards in the sample of 38. These failures resulted in R3 sustaining a left femur fracture and R29 sustaining a hematoma to her head and requiring emergency care. Findings include: 1. R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, and abnormalities of gait and mobility. R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired and was dependent with transfers from chair to bed or bed to chair. […]

• Actual harm, isolatedF600Aug 6, 2025

  Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R2), reviewed for abuse in the sample of 5. This failure resulted in R2 being hit in the face by R1, which resulted in redness and R2 feeling fearful of R1.Findings Include:On 8/6/25 at 3:35 PM, R1 was observed, when surveyor knocked on his door, R1 cracked the door, the surveyor asked if she could come into his room, he stated no, when asked if she could talk with him, he stated no and shut the door. R1 appeared paranoid.On 8/6/25 at 3:37 PM, R2 was observed in his room, in a wheelchair, calm, and pleasant. […]