Evercare at Stearns: Dead Resident's Morphine Given to Another - IL
Federal inspectors cited the facility on November 20, 2025, after uncovering the chain of events that led a deceased resident's controlled substance to be administered to a living one, with altered records covering the trail.
The resident who died, identified in inspection records as R3, had morphine remaining in the medication cart at the time of his death. The director of nursing, identified as V2, told inspectors she had implemented a practice of personally overseeing the destruction of controlled substances because of concerns about diversion, specifically citing past experiences with agency staff. When R3 died on a Wednesday or Thursday, V2 went to destroy the medication herself.
What she found instead was a controlled drug record with R3's name marked out and another resident's name, R5, handwritten in its place. The original medication box had been altered in the same way.
V2 asked her staff what had happened. A licensed practical nurse identified as V6 told her that when R5 was admitted, he was in pain. The morphine was already in the cart. A hospice registered nurse, identified as V5, had changed the name on the record and on the box.
V2 told inspectors directly: her staff had administered R3's medication to R5. "This is medication tampering," she said, "and is not allowed in her facility."
The hospice nurse told a different story about who did what.
V5 told inspectors she came to the facility because R5 was being admitted to hospice. His family was asking for pain relief and he was in significant pain. V6 told her R3's morphine was already in the cart. V5 said she initialed that R3 had 29.5 milliliters of morphine remaining, but she denied altering the record or the container. She said V6 was the one who altered the document and the bottle.
V5 also told inspectors she did not order the morphine for R5. She placed other medication orders for him, but held off on ordering morphine specifically because V6 had told her the facility would use what was already there, the supply belonging to the man who had just died.
That morphine was then administered.
A second LPN, identified as V9, told inspectors she gave R5 0.5 milliliters from the morphine bottle in the cart and documented it on the controlled drug record bearing R5's name. She also acknowledged that the signatures on R3's controlled medication record for September 21 at 10 a.m., 2 p.m., and 4 p.m. were hers. The medication documented on R3's record during those hours had actually gone to R5.
V9 said she did not notice the marked-out name. She said she only looked at R5's name on the record. "They don't use other residents' medication," she told inspectors, "and if she would have noticed it, she would have said something."
She had not noticed. Or she had not said something. The record does not resolve which.
What the inspection record does make clear is the sequence: a resident died, his controlled substance remained in the cart, someone physically altered both the medication container and the official controlled drug record to substitute another resident's name, and nurses then administered that medication across multiple documented doses on the same day, signing their names to records that had been falsified.
The facility's own abuse prevention policy, dated January 2025, defines misappropriation of resident property as "the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent." Morphine prescribed to a specific resident is that resident's medication. R3 did not consent to its transfer. R3 was dead.
The deficiency was cited at a level of harm described as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework inspectors apply, not necessarily the gravity of what occurred. Controlled substances in nursing homes are subject to strict tracking requirements precisely because the risks of diversion, misuse, and falsified records are well-documented. What happened at Evercare at Stearns is a version of what those requirements are designed to prevent: a medication belonging to one person, administered to another, under a record that had been physically altered to obscure the substitution.
V2, the director of nursing, had put her personal oversight system in place because she did not fully trust the existing controls. She went to destroy R3's morphine herself. She found the bottle already relabeled.
V5, the hospice nurse, knew the morphine in the cart belonged to a resident who had just died. She initialed the count. She did not order separate morphine for R5 because she had been told the facility would use what was there. She told inspectors she did not alter anything herself.
V6, the LPN identified by both V2 and V5 as the person who physically altered the record and the container, does not appear in the inspection narrative with a direct statement disputing that account.
V9 administered the medication. Three times, by the signatures on the record. She said she did not notice the crossed-out name.
R5, the resident who received the morphine, was in pain and had just been admitted to hospice. Whether the medication relieved that pain, and what the clinical consequences were of receiving a controlled substance prescribed for a different patient rather than one ordered specifically for him, the inspection report does not say.
R3 had no say in any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare At Stearns from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Evercare at Stearns in GRANITE CITY, IL was cited for violations during a health inspection on November 20, 2025.
The resident who died, identified in inspection records as R3, had morphine remaining in the medication cart at the time of his death.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.