Evercare of Collinsville: Family Left in Dark About Falls - IL
The resident at Evercare of Collinsville had fallen nine times between June and August, including twice in a single day, but the facility failed to notify family members about any of these incidents, according to a federal inspection completed August 18.
The resident, identified in records as having severe cognitive impairment from catatonic schizophrenia and a documented history of repeated falls, sustained injuries that family members learned about by chance during visits.
"The facility used to notify him when R8 had fallen but they have not been doing that recently," the family member told inspectors. When he came to see the resident during his last visit, "R8 had a cut above his eye, and he asked the nurse what happened and that was how he found out R8 had fallen."
Progress notes document the resident fell on June 15, July 4, July 26, July 27, August 5, August 7, August 12, and twice on August 16. None of these records show that family members were notified about the falls or any resulting injuries.
The family member told inspectors the facility "haven't been notifying him of any changes" with the resident.
Federal regulations require nursing homes to immediately inform residents' families and doctors about situations affecting the resident, including injuries and changes in condition.
The resident's medical records show diagnoses including catatonic schizophrenia, anxiety disorder, repeated falls, hypertension, major depressive disorder, and Type II diabetes. A mental status assessment scored the resident at 6 points, indicating severe cognitive impairment.
When confronted by inspectors, facility leadership insisted they follow proper notification procedures.
The registered nurse and assistant director of nurses told inspectors "they notify the family and physician when a resident falls." The administrator made the same claim, stating "they notify the physician family when a resident falls."
The facility's own fall policy requires staff to "complete the Accident/Incident report and notify the physician and responsible party" after any fall incident.
Yet documentation shows this policy wasn't followed for any of the nine documented falls over the two-month period.
The pattern of non-notification meant family members couldn't make informed decisions about their loved one's care or safety. They remained unaware of the resident's declining stability and increasing fall risk, which escalated from single incidents to two falls in one day by mid-August.
The discovery came during a complaint investigation, suggesting family members or others had raised concerns about the facility's communication practices.
The resident's vulnerability was particularly acute given their severe cognitive impairment and inability to communicate effectively about injuries or changes in condition. Family notification becomes critical for residents who cannot advocate for themselves or report problems to loved ones.
This communication breakdown left a family member in the position of conducting their own informal investigations during visits, having to ask staff directly about visible injuries rather than receiving timely notification as required by federal law.
The inspection found the facility failed in its basic obligation to keep families informed about significant events affecting their loved ones' health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Collinsville from 2025-08-18 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 21, 2026 · Our methodology
EVERCARE OF COLLINSVILLE in COLLINSVILLE, IL was cited for violations during a health inspection on August 18, 2025.
"The facility used to notify him when R8 had fallen but they have not been doing that recently," the family member told inspectors.
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.