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Complaint Investigation

Evercare At Edwardsville

October 30, 2025 · Edwardsville, IL · 401 St Mary Drive
Citations 3
CMS Rating 1/5
Beds 120
Provider ID 145555
Healthcare Facility
Evercare At Edwardsville
Edwardsville, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

EVERCARE AT EDWARDSVILLE in EDWARDSVILLE, IL — inspection on October 30, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0580
Resident Rights Deficiencies

levels (6.2 mEq/L - milliequivalents/Liter) (normal 3.4-5.0); BUN (blood urea nitrogen (74) (normal

spoken with this nurse who informed them that they were not able to set up outpatient hemodialysis

dialysis. (R2) states she has not received dialysis since being there.

She is unsure why. R2 received dialysis services at the hospital. R2's Hospital Records dated 10/25/2025 at 1:17 PM, Medical Problems: Hyperkalemia, End-stage renal disease needing dialysis, Hypertension, Insulin dependent diabetes mellitus and document R2 was discharged back to the facility on [DATE]. R2 was admitted to the hospital for five days.

The Facility Change of Condition Policy undated documents, To ensure that medical care problems are communicated to the attending physician or authorized designee and family/ responsible party in a timely, efficient, and effective manner.

The facility will inform the resident, consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: An accident involving the resident which results in injury and has the potential for requiring physician intervention. A significant change in the residents' physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life- threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke.

Clinical complications are such things as development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent urinary tract infection, or onset of depression. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).A decision to transfer or discharge the resident from the facility.

145555 10/30/2025

Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

changes.

Both residents wish to remain at (Facility). 4) Both residents' care plans reviewed and

jeopardy to resident health or safety R7's Weekly Skin assessment dated [DATE] documents quarter size bruise noted to residents left upper back area bluish in color.

On 10/28/25 at 12:22 PM, R7 stated that she does not recall exactly what happened during the altercation in September, she just remembers that (R8) hit her.

She stated that the week ago altercation, (R8) hit her twice and pulled her hair.

On 10/28/25 at 12:45 PM, R13 stated he witnessed (R8) hit (R7) in the stomach in September. He stated that (R7) did not hit her back and told him to get a CNA (Certified Nursing Aid).

On 10/28/25 at 12:59 PM, R12 stated that she witnessed (R8) hit (R7) in the dining room last week.

On 10/28/25 at 1:00pm, R10 stated she witnessed (R8) hit (R7) but she does not remember when and where.

Facility policy Abuse Prevention and Prohibition Program undated documents To ensure that 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.

145555 10/30/2025

Evercare at Edwardsville 401 St Mary Drive Edwardsville, IL 62025

member when there is: An accident involving the resident which results in injury and has the potential

jeopardy to resident health or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life- safety threatening conditions or clinical complications); Life-threatening conditions are such things as a heart attack or stroke.

Clinical complications are such things as development of a stage 2 pressure

need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g., the use of any medical procedure, or therapy that has not been used on that resident before).A decision to transfer or discharge the resident from the facility.

The Immediate Jeopardy and deficiency practice that began on 10/8/2025 when R2 was admitted without any hemodialysis treatment scheduled and or given for 12 days while she was in the facility was removed on 10/30/2025 after the facility took the following actions to remove the Immediacy:1.

The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on dialysis care r/t (related to) coordination of care by not setting up dialysis treatments.2.

All department heads on dialysis and procedure and no staff was allowed to work until they were in-serviced on dialysis.3. 24-hour report sheet was made up starting 11/1/2025. It was made to ensure that there were no dialysis residents that missed/ needed set up for treatment. 4. A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed daily x 4 weeks to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect r/t coordination of care for all new residents and dialysis needs are addressed.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EDWARDSVILLE, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERCARE AT EDWARDSVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.