Evercare At Edwardsville
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
day and her labs were good considering she was on dialysis. He can say he was not informed of her situation. If he would have known (R2) did not get her dialysis treatment he would have sent her to the hospital for treatment.R2's Hospital records dated 10/20/2025 document R2 had not had dialysis in about two weeks since coming to the new facility, and had elevated potassium levels (6.2 mEq/L milliequivalents/Liter) (normal 3.4-5.0); BUN (blood urea nitrogen (74) (normal 7-25 <=23.0) , and elevated serum creatinine levels 9.17 (normal 0.55-1.02 mg/dl - milligrams/deciliter).
Patient states she had not underwent hemodialysis and the nursing facility was spoken with this nurse who informed them that they were not able to set up outpatient hemodialysis sessions prior to patient's transfer to their facility unfortunately, patient is asymptomatic but needs 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Edwardsville
401 St Mary Drive Edwardsville, IL 62025
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
in this alleged interaction, and both wish to remain at (Facility).
Final Interventions: 1) Care plans reviewed and updated for both residents. 2) Staff in-serviced on facility abuse prevention and policy. 3) Psychosocial follow ups completed, no changes.
Both residents wish to remain at (Facility). 4) Both residents' care plans reviewed and updated accordingly. 5) Final sent to IDPH.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare at Edwardsville
401 St Mary Drive Edwardsville, IL 62025
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
she had any of those symptoms from not having dialysis. I know when she just came back from the hospital, she is on dialysis now and it is all set up.On 10/29/2025 at 9:22 AM, V21, Nephrologist (Kidney Specialist) stated, It is critical that if a resident who is receiving dialysis and goes to another facility that dialysis is set up ahead of time and no treatments are missed. No treatments should be missed. ESRD (End stage renal disease) depends in dialysis. A resident may not even be having symptoms because a lot of these things are silent killers can affect the heart and cause death. If a resident does not have dialysis set up, I would expect them to be sent the ER to get treatments until they are able to get treatments from the new facility.
Any resident missing 10 treatments I would absolutely consider that neglect.
This could cause serious harm and death the body is depending on the dialysis treatment.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.
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.
Facility ID: