Evercare At Stearns

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

of using agency staff and past experiences she put this in place to prevent diversion. V2 stated that Resident R3 passed away on a Wednesday or Thursday. V2 stated that when she went to destroy the medication, she noted that the Controlled Drug Record was altered with Resident R3's name marked out and Resident R5's name handwritten

on the record. V2 stated that she checked the medication and noted that the medication and noted that the original box was altered in the same way. V2 stated that she then checked with her staff and was informed by V6, LPN , that when Resident R5 was admitted he was experiencing pain. It was noted that the morphine was in

the cart and V5, Hospice RN, changed the name on the record and the box. V2 stated that she notified hospice of what she was made aware. V2 stated that her staff did administer Resident R3's medication to Resident R5. V2 stated that this is medication tampering and is not allowed in her facility. On [DATE REDACTED] at 3:07 PM V5 stated that she came to the facility because Resident R5 was being admitted to hospice. V5 stated that Resident R5 was in a lot of pain and family was requesting pain relief. V5 stated that she was informed by V6 that Resident R3's Morphine was

in the cart. V5 stated that she initialed that Resident R3 had 29.5 mls of Morphine. V5 stated that she did not alter the

record or the container and did not administer the medication. V5 stated that V6 altered the document and

the bottle. V5 stated that she did place orders for Resident R5's medication but did not order the morphine because

she was informed by V6 that that the facility would use Resident R3's medication.On [DATE REDACTED] at 10:22 AM V9, LPN, stated that she administered Resident R5's 0.5ml from the morphine bottle labeled in the cart and documented on

the Controlled Drug Record labeled with Resident R5's name. V9 stated that the signature on Resident R3's Controlled Medication Record dated 9/21 at 10 am, 2pm and 4pm were her signature. V9 stated that the medication was administered to Resident R5. V9 stated that she did not pay attention to the marked-out name she only looked at Resident R5's name. V9 stated that they don't use other residents' medication and if she would have noticed it, she would have said something.The facility's Abuse Prevention policy, dated 1/25, documents POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteer and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions g) Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Event ID:

Facility ID:

If continuation sheet

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare at Stearns

3900 Stearns Avenue Granite City, IL 62040

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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria, as outlined below, are met. It continues Procedure: 2. Documentation will be entered into the resident's medical record regarding the transfer/discharge reason(s) and the appropriate transfer/discharge information will be communicated to the receiving healthcare center, provider, resident and/or Resident Representative. a.

Documentation includes: 1. The basis for the transfers/discharges for reasons listed (a) through (g) above.

1. 2. The specific need(s) that cannot be met, the attempts to meet the needs, and the service available at the

receiving facility to meet the need(s) for (a) above. 3. The resident's physician will provide documentation for

a transfer due to (a) and (b) above. 4. A physician will provide documentation for a transfer/discharge due to (c) and (d). 8. Before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and the resident representative or legal representative that specifies the duration of the bed-hold policy and the facility's policies regarding bed-hold policies. 13. Involuntary discharge will be effected after the minimum notice requirements prescribed by applicable state law and regulation, or thirty (30) days notice if no state law or regulation is applicable (unless the health or safety of others in the facility is jeopardized), subject to any legal rights of appeal or challenge prescribed by law.

Event ID:

Facility ID:

If continuation sheet

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare at Stearns

3900 Stearns Avenue Granite City, IL 62040

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

V5 stated that she came to the facility because Resident R5 was being admitted to hospice. V5 stated that Resident R5 was in

a lot of pain and family was requesting pain relief. V5 stated that she was informed by V6 that Resident R3's Morphine was in the cart. V5 stated that she initialed that Resident R3 had 29.5 mls of Morphine. V5 stated that she did not alter the record or the container and did not administer the medication. V5 stated that V6 altered the document and the bottle. V5 stated that she did place orders for Resident R5's medication but did not order the morphine because she was informed that that they would use Resident R3's medication.On [DATE REDACTED] at Approximately 10:00 AM V2 provided Midnight Census report, dated [DATE REDACTED], that documents 99 occupied resident beds in

the facility.On [DATE REDACTED] at 2:12 PM V10, Pharmacist, stated that the medications are labeled, with a specific resident's name and sent from the pharmacy with that label. V10 stated that once the medication leaves the pharmacy the label remains the same and is not to be changed in the facility. If the medication is expired or

the person dies the medication is to be destroyed. V10 stated that each medication is specific to a particular resident and not to be shared or used for another.The facility's Medication Storage policy, dated 1/15, documents that POLICY: All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy.The facility's Medication Administration General Guidelines, dated 1/15, documents that POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices. Procedure; 18. Prior to administration, the medication and dosage schedule on the resident's MAR I TAR is compared with the medication label.

Information on the medication should be checked against the MAR / TAR at least three times during the med preparation and administration process. If the label and MAR I TAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule prior to administering. If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal.

Event ID:

Facility ID:

If continuation sheet