Evercare at Stearns: Morphine Diverted Between Residents - IL
That is what inspectors found at Evercare at Stearns after a complaint investigation completed in November 2025. What they documented was not a paperwork error. It was a controlled substance, prescribed and dispensed for one resident, used, or nearly used, for another, with records and the bottle itself altered in the process.
The visiting nurse, identified in inspection records as V5, said she came to the facility because a resident, R5, was being admitted to hospice. The family was asking for pain medication. R5 was in a lot of pain. V5 said she was told by another nurse, V6, that morphine belonging to a different resident, R3, was available in the cart. V5 said she initialed a record showing R3 had 29.5 milliliters of morphine. She said she did not change the record or the container. She placed orders for R5's medications. She did not order the morphine, she said, because she had been told they would use R3's supply instead.
V5 said V6 was the one who altered the document and the bottle.
The facility's pharmacist, identified as V10, spelled out exactly why this matters. Medications leave the pharmacy labeled with a specific resident's name. That label does not change once the medication is in the building. If a resident dies, or if the medication expires, it is destroyed. It is not reassigned. It is not shared. Each medication belongs to one person.
"Once the medication leaves the pharmacy," V10 said, "the label remains the same and is not to be changed in the facility."
The facility's own medication administration policy requires that the label and the medication administration record match, and that staff check them against each other at least three times during preparation and administration. If they don't match, the physician's orders are checked before anything is given. If a medication is discontinued or unusable, it is pulled for disposal.
None of that happened here. Instead, a bottle was relabeled. A record was initialed to show the morphine still belonged to R3. And a hospice patient in pain waited while staff worked out how to use someone else's controlled substance to treat her.
Inspectors noted the facility had 99 occupied resident beds at the time of the inspection.
The violation was cited at a level of harm described as minimal harm or potential for actual harm, affecting many residents. That language is the inspection framework's way of flagging systemic risk, not just a single incident. When a facility's medication handling breaks down this completely for one controlled substance, the question inspectors are required to ask is what else has been handled the same way, for how long, and for how many people.
What the record shows is that when a family was desperate for pain relief for someone dying in that building, the response from at least one staff member was to reach for medication that did not belong to her patient, change the label, and initial paperwork to cover it. The pharmacist's instructions, the facility's own written policies, and the most basic principle of medication safety, that drugs prescribed for one person are not given to another, were set aside.
R5's family had come to the facility asking for help. What they got was morphine pulled from another resident's supply, a bottle that had been altered, and a record that had been changed to make it look like nothing had moved.
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.
That is what inspectors found at Evercare at Stearns after a complaint investigation completed in November 2025.
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.