Evercare of Collinsville: Background Check Failures - IL
A federal inspection completed September 16, 2025 found that the facility had hired certified nursing assistants and other employees with direct access to residents without first completing required Healthcare Worker Registry checks or background screenings. The violation triggered an Immediate Jeopardy citation, the most serious level of deficiency federal inspectors can assign, indicating a situation likely to cause serious harm or death. That citation had begun September 30, 2024, nearly a full year before inspectors documented the details of what went wrong.
The administrator, identified in the report as V1, told inspectors she did not have a business office person at the time and considered herself ultimately responsible. On September 9 and 10, 2025, she ran background checks herself on employees hired in June and July. Those checks had never been done. She confirmed to inspectors that prior to running them herself, she had no idea whether any of those employees had disqualifying offenses or were even eligible to work in a licensed facility.
At least seven employees with direct resident access, identified in the report as V6, V12, V16, V17, V18, V19, and V20, had been working without completed checks. Two of them, V6 and V16, were CNAs. The report does not say what the background checks ultimately revealed about any of them.
Seventy-nine people were living at the facility when inspectors arrived.
The medical director, identified as V21, told inspectors on September 11, 2025 that he would expect staff to follow the state's requirements on background screening. He did not stop there. "The residents in the facility are vulnerable and need protection," he said. "It is imperative that the background checks are done and timely because you never know who is or will harm someone."
That last phrase, offered by the facility's own medical director, is the clearest summary of what was at stake. The entire architecture of background screening in nursing homes exists because the people living in them cannot always speak for themselves, cannot always recognize when someone means them harm, and cannot always leave. A CNA with a history of abuse and a resident with dementia are not an equal match. The check is supposed to happen before the employee ever sets foot in a resident's room. At Evercare of Collinsville, it didn't.
The facility's own abuse prevention policy, dated June 1, 2025, states the facility "does not knowingly employ anyone" with a finding on the state nurse aide registry related to abuse, neglect, or mistreatment, or anyone convicted of abusing, neglecting, or mistreating other people. The policy also states background checks are to be completed upon hire. The gap between that written commitment and what the administrator described to inspectors, employees hired in June and July whose checks weren't run until September, is not a paperwork technicality. It is the policy failing at its most basic level.
The root cause analysis the facility eventually completed identified the deficiency plainly: the facility failed to run background checks on new employees prior to them working their first shift.
Immediate Jeopardy citations are not handed out for administrative inconveniences. They require inspectors to find that a facility's failure placed residents in immediate risk of serious harm. This one began September 30, 2024. The inspection report does not describe what prompted the original finding that day, or how many employees were working without completed checks at that point. What it documents is that the problem persisted long enough, and broadly enough, to still be generating findings when inspectors returned more than eleven months later.
The Immediate Jeopardy was not removed until September 15, 2025, one day before the inspection closed. The steps the facility took to remove it were logged in the report: the administrator was trained by a vice president of clinical services on background check requirements, department heads were briefed, all current scheduled staff had their background checks completed and eligibility confirmed, the policy was reviewed, and a quality assurance audit tool was put in place to catch new hires before their first shift.
Those are the right steps. They are also the steps that were supposed to be in place before any of this happened.
The administrator's account to inspectors carries a particular weight. She said she ran the checks herself in early September because she discovered, while looking into one employee's file, that the checks hadn't been done. She then looked at other recent hires and found the same gap. The picture that emerges is not of a single oversight but of a hiring process that had stopped functioning, for at least two months of documented new hires, without anyone catching it.
There is no business office person. The administrator is ultimately responsible. Those two facts, offered by the administrator herself, explain the mechanism of the failure. They do not resolve the question of what it meant for the 79 residents living there while it was happening.
The facility's prevention policy is written in the language of zero tolerance. "Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment." Zero tolerance is a standard that has to be operationalized before it means anything. It requires knowing who you have hired. Evercare of Collinsville, by its own administrator's account, did not know that about at least seven employees for somewhere between two months and potentially far longer, depending on when the original Immediate Jeopardy finding was made.
The medical director's words are worth returning to. He said the checks should have been done. He said the residents are vulnerable. He said you never know who will harm someone. He is the facility's own physician leader, and he is describing, in plain terms, the specific risk that the facility's failure created. Not a regulatory abstraction. A resident, in a room, with a staff member whose history no one had reviewed.
The inspection report does not name any resident who was harmed. It does not describe a specific incident that triggered the original September 2024 finding. What it documents is the structure of a failure, the months it persisted, and the moment an administrator sat down at a computer and started running checks on people who had already been working alongside her residents for weeks.
Seventy-nine people were living there. The checks are done now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Collinsville from 2025-09-16 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 28, 2026 · Our methodology
EVERCARE OF COLLINSVILLE in COLLINSVILLE, IL was cited for violations during a health inspection on September 16, 2025.
That citation had begun September 30, 2024, nearly a full year before inspectors documented the details of what went wrong.
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.