Evercare of Jerseyville

In the surveyor’s words

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

• Immediate jeopardy, widespreadF607Dec 14, 2025

  Based on interview and record review, the facility failed to implement its abuse and resident background check policies by failing to screen for potentially abusive residents during the admission process, failing to report and track residents qualifying criminal offenses, failing to ensure a risk assessment was completed, and failing to implement protective measures to prevent abuse for 1 of 3 (R54) residents reviewed for abuse in the sample of 35. This failure resulted an Immediate Jeopardy when R62 was admitted to the facility on [DATE] without appropriate screening, referrals and interventions for criminal convictions and proceeded to sexually abuse R54. This has the potential to affect all 55 residents who reside in the facility. […]

• Actual harm, isolatedF558Dec 14, 2025

  Based on observation, record review, and interview, the facility failed to ensure 1 of 3 (R24) resident's call light in reach in a sample of 35. This failure resulted in R24 unable to call for help for over 2 hours. This also resulted in R24 sitting in urine, feeling angry, embarrassed, unwanted, depressed and a burden.Findings include:R24's Care Plan, dated 3/25/2025, documents R24 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke with left sided weakness. Interventions Encourage the resident to use bell to call for assistance. R24 is at risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs. […]

• Actual harm, isolatedF600Dec 14, 2025

  Based on interview and record review, the facility failed to prevent physical abuse of a resident from another resident with a known criminal history for 1 of 4 residents (R54) reviewed for abuse in the sample of 35. This failure resulted in R62 exposing his genitals to R54 and R62 then grabbed R54's breast. A reasonable person would expect to be safe in their home and would experience fear/anxiety, humiliation, and anger if physically and sexually abused. Findings Include:R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. […]

• Actual harm, isolatedF690Dec 14, 2025

  Based on observation, interview and record review the facility failed to provide timely and complete incontinent care for 4 of 4 (R7, R8, R22, R24,) residents in a sample of 35. This failure resulted in R24 feeling angry, embarrassed, unwanted, depressed and a burden. Findings include:1. R24's Care Plan, dated 3/25/2025, documents that the resident has bladder incontinence r/t (related to) Confusion, Dementia, Impaired Mobility, Poor toileting habits total assist with transfers per Hoyer lift. It also documents interventions: Brief Use: The resident uses disposable briefs. Change every 2 hours and prn (as needed). Clean peri-area with each incontinence episode. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. […]

• Actual harm, isolatedF689Sep 28, 2023

  Based on interview, observation, and record review, the facility failed to provide and implement interventions to prevent resident falls for 4 of 4 residents (R11, R19, R29, R32) reviewed for resident safety in the sample of 27. This failure resulted in R32 transported to the hospital for a facial laceration with sutures and a fractured humerus on one incident, and a fractured hip with surgery on another incident. The Findings Include: 1. R32's Face Sheet, undated, documents R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. […]