Evercare Of Collinsville

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

from the facility on 8/21/2025 for safety reasons.On 9/9/2025 at 11:25 AM V10's background checks were requestedOn 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed.On 9/11/2025 at approximately 1:30 PM V1 stated that she is responsible for the background checks. V1 stated that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that the background checks are to be completed upon hire and should have been completed.The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.

Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A.

The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Collinsville

614 North Summit Collinsville, IL 62234

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that after finding that V10's background checks were not completed V1 then checked other hires. V1 stated that on 9/9/2025 and 9/10/2025 she ran background checks for employees hired in June and July as they were not done. V1 stated that V6's, CNA, and V16's, CNA, Healthcare worker registry checks and background checks were not completed. V1 stated that V6, V12, V16, V17, V18, V19 and V20 all have direct access to the resident and checks should have been done. V1 stated that prior to performing the Healthcare Worker Registry and Background checks herself on 9/9/2025 and 9/10/2025 she was not aware of any offenses that each employee had or if they were eligible to work in the facility. V1 stated that the background checks are to be completed upon hire and should have been completed.On 9/11/2025 at 2:44 PM V21, Medical Director, stated that he would expect the staff to follow the policy and guidelines set forth by the state regarding Healthcare Worker Registry and Background checks. V21 stated that the residents in

the facility are vulnerable and need protection. V21 stated that it is imperative that the background checks are done and timely because you never know who is or will harm someone. V21 stated that the background checks should have been done. The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements.

Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A.

The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.On 9/9/2025 the facility provided a facility matrix and room roster identifying 79 people residing in the facility. The Immediate Jeopardy that began on 9/30/2024 was removed 9/15/2025, when the facility took the following actions to remove the immediacy:A) Administrator was in-serviced by the VP (Vice President) of clinical services on background checks & the need to run prior to staff member working on 9/15/2025.B) Administrator will in-service department heads on ensuring that staff will not work without background check being completed

on 9/15/2025.2. A) All staff members that are currently on the working schedule have had a background check completed & are eligible to work in a skilled facility. Completed 9/15/2025.B) Initial audit completed for all current employees, that a background check has been completed. Completed 9/15/2025.C) Review of current policy and procedure to reflect current practices. Completed 9/15/2025.1. No staff will work

before having a background check. On-going2. A quality assurance tool was implemented: Audit will be completed for new hires to ensure that background check was completed prior to 1st working day.

Administrator and department manager. On going. 3. Root Cause Analysis Completed for background checks. Deficiency: Failed to run background checks on new employees prior to them working their 1st shift.

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If continuation sheet