Evercare of Collinsville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 4, 2025

  Based on interview, observation, and record review, the facility failed to ensure a resident was free from neglect when they failed to monitor, assess, and put forth interventions for resident safety with a disregard for resident care, comfort or safety for 1 of 6 residents (R2) reviewed for Resident Neglect in the sample of 9. This failure resulted in physical harm of R2, being sent to the emergency room multiple times for his injuries from falls, and R2 being left saturated in urine and feces with no staff checking on him. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/8/25 when the facility failed to put fall interventions in place after R2 experienced a fall. […]

• Immediate jeopardy, isolatedF689Dec 4, 2025

  Based on interview, observation, and record review, the facility failed to provide effective fall prevention and supervision for 1 of 3 residents (R2) reviewed for falls in the sample of 9. R2 is documented as experiencing 50 falls in the facility from 4/8/25 through 12/1/25. This failure resulted in R2 experiencing an injury on 4/11/25, 5/29/25, 6/15/25, 6/23/25, 7/4/25, 8/7/25, 8/13/25, 9/13/25, 10/14/25, 10/29/25, 11/7/25, 11/13/25, and 12/1/25 with R2 being sent to the emergency room on 8/7/25 with fall/contusion, 8/13/25 with fall/head injury with laceration, 10/14/25 with questionable fall/laceration of finger, 10/29/25 with fall/abrasion to face, and 11/7/25 with fall/closed head injury.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 4/8/25 when… […]

• Immediate jeopardy, isolatedF607Sep 16, 2025

  Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. The Immediate Jeopardy began on 9/30/2024. The survey team validated the abatement on 9/15/2025 at 10:46 AM. […]

• Actual harm, isolatedF689Dec 23, 2025

  Based on interview and record review the facility failed to ensure R8's batteries in alarm working, as identified as an intervention for falls for R8, for 1 of 5 residents (R8) reviewed for accidents in the sample of 67. This failure resulted in R8 falling and fracturing humerus. Prior to the survey date of 12/15/2025, the facility had taken the following action to correct the noncompliance:1 On December 2, 2025, the facility [NAME] President of Clinical Services reviewed the Fall evaluation and Prevention policy.2. On December 2, 2025, the Regional Nurse Consultant in-serviced the Facility Administrator, DON, ADON, MDS Coordinator were in-serviced on Fall Prevention Policy.3. […]

• Actual harm, isolatedF697Dec 23, 2025

  Based on interview and record review the facility failed to provide pain medication according to physician's order and effectively treat pain for 1 of 4 residents reviewed for pain management is a sample of 67. This failure resulted in R2 experiencing days of increase excruciating pain and feeling like no one cares.Findings include:1 R2's Electronic Health Record, not dated, documents admission date of 3/24/2025 and lists the following diagnosis: Peripheral Vascular Disease, Occlusion and Stenosis of bilateral Carotid arteries, Anxiety, Polyneuropathy, Dorsalgia, Weakness, Disease of the Spinal Cord, Chronic Pain, Spinal Stenosis, Cervical region, and Spondylolysis Lumbar Region.R2's Care Plan, dated 9/23/2025, documents that R1 has Acute Pain / Chronic Pain. […]