Evercare at University: Sexual Assault, No Police Report - IL
The facility's administrators did.
Surveillance footage reviewed by police showed a male resident, identified in inspection records as Resident 3, wheeling himself down a hallway and entering a female resident's room at 8:59 AM. A staff member entered the room five minutes later and called for help. At 9:04 AM, Resident 3 wheeled himself out.
What the staff member found inside the room is documented in the police report, printed October 16, 2025, and in the facility's own clinical records. Resident 3 was out of his wheelchair and lying in bed with the female resident, identified as Resident 2. She was on her left side, facing the wall. She had shaving cream on her right buttock. Her incontinent brief had been removed.
A staff member, identified in inspection records as V18, said Resident 3 had shaving cream on Resident 2's right buttock when they found him. V18 said Resident 3 spoke when he was pulled from the bed. "You stopped me before I started," he said.
A psychiatry note written by a nurse practitioner on October 9, 2025, three days after the incident, documents what Resident 3 told clinical staff directly: he had entered the female resident's room, he admitted to going in, and he stated he wanted to have sex.
The facility's own abuse prevention policy, reviewed as recently as June 1, 2025, states that the administrator is responsible for coordinating and implementing abuse prevention procedures and that the facility "promptly and thoroughly investigates reports of resident abuse." The policy lists residents, staff, consultants, volunteers, family members, and visitors as people the facility is committed to protecting residents from. It describes a zero-tolerance standard. It was in place on October 6.
Police were not called by the facility. They were called by someone else.
The local police report, dated October 16, documents that dispatch received an anonymous call on October 6 at 10:56 AM, roughly two hours after the incident. The caller said multiple incidents were happening at the facility. The caller said administrators were not reporting them. The caller said a resident was sexually assaulting another resident by the name of Resident 2 and that the facility was not doing anything about it.
Federal inspectors arrived and reviewed the surveillance footage alongside the administrator, identified as V1. The administrator confirmed an incident had occurred. The footage confirmed the timeline. The clinical records confirmed what was found in the room. The psychiatry note confirmed what Resident 3 said he intended to do.
Inspectors cited the facility at the highest level of severity available under federal nursing home oversight: Immediate Jeopardy, meaning the deficient practice had placed residents in a situation likely to cause serious injury, harm, impairment, or death. The citation covered the period beginning October 5, 2025, the day before the assault occurred, suggesting inspectors determined the conditions that allowed it had been present before the morning Resident 3 wheeled himself into Resident 2's room.
The finding was not limited to the assault itself. The anonymous caller told police that multiple incidents had been happening and that administrators were not reporting them. That claim, documented in the police report inspectors reviewed, points to a pattern the inspection record does not fully resolve. What the record does establish is that on October 6, 2025, a female resident was sexually assaulted in her bed, staff witnessed the immediate aftermath, the man who assaulted her told a nurse practitioner three days later that he had wanted to have sex with her, and the facility did not contact police.
Immediate Jeopardy was not removed until October 17, 2025, eleven days after the assault. The facility's corrective actions, as documented in inspection records, included in-servicing the administrator and a staff member on abuse and neglect policy, in-servicing department heads on the same, reviewing 24-hour reports for the prior seven days, initiating weekly staff interviews to confirm employees knew who to report abuse to, and completing a root cause analysis.
The corrective plan describes a facility relearning, eleven days after a sexual assault, that staff should know who to report abuse to.
A progress note written by a staff member identified as V2 on October 6 at 9:00 AM, the same morning as the assault, documents that Resident 3 was found in another resident's room and was removed and moved to a hallway. The note is brief. It does not describe what was found in the room. It does not describe the condition of Resident 2. It does not use the word assault or abuse. It records a location and a movement.
The psychiatry note from October 9 is more direct. It records that Resident 3 entered a female peer's room, got into her bed, removed her incontinent brief, and put shaving cream on her. It records his admission. It records his stated intent.
Three days passed between those two clinical documents. The police report was printed ten days after the incident. Inspectors arrived October 21, fifteen days after the assault took place.
What Resident 2 experienced in those fifteen days is not documented in the inspection record. Her condition, her awareness of what happened, whether she was told, whether she received any support, whether she remained in the same facility as the man who assaulted her, none of that appears in the records inspectors reviewed or disclosed. The inspection record identifies her by a number. It records where the shaving cream was on her body. It records the time her attacker wheeled himself out of her room.
The anonymous caller who contacted police knew her name.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare At University from 2025-10-21 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
EVERCARE AT UNIVERSITY in EDWARDSVILLE, IL was cited for violations during a health inspection on October 21, 2025.
The facility's administrators did.
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.