Evercare at University: Sexual Assault Immediate Jeopardy - IL
The caller was right on all three counts.
Surveillance video reviewed that same morning showed a male resident, identified in inspection records as R3, wheeling himself down the hallway at 8:59 a.m. and entering the room of a woman identified as R2. She was severely cognitively impaired, dependent for mobility, and used a wheelchair. She could not walk away. She could not call for help. R3 was in her room for five minutes.
At 9:04 a.m., he wheeled himself out.
A staff member identified as V7 had entered the room during that window and called for a colleague, V18. What V18 described to inspectors was this: R3 was out of his wheelchair and lying in bed with R2. R2 was on her left side, facing the wall. She had shaving cream on her right buttock. R3, when removed, said: "You stopped me before I started."
The psychiatric note written three days later, on October 9, was blunt. The nurse practitioner documented that R3 had entered a female peer's room, gotten into her bed, removed her incontinence brief, and put shaving cream on her. When asked about it, R3 admitted to going into the room. He said he wanted to have sex.
R2's care plan contained no language addressing her risk of abuse or neglect. None.
R3's care plan, initiated September 29, six days before the assault, noted he had a history of inappropriate contact with peers and staff. A progress note from October 6 at 9:00 a.m., written by a staff member identified as V2, documented only that R3 had been found in another resident's room, removed, and moved to a different hallway. The note did not describe what had happened to R2. It did not use the word assault. It did not trigger a police call.
That call came from someone else entirely.
The local police report, printed October 16, documented that dispatch had received an anonymous call at 10:56 a.m. on October 6. The caller reported an alleged rape occurring that day at the facility. The caller said multiple incidents were happening. The caller said administrators were not reporting them to police. The caller said a resident was sexually assaulting another individual named R2, though the caller did not know the suspect's name. The caller said the facility was not doing anything about it.
The facility administrator, identified as V1, was aware of the incident. When inspectors arrived, V1 showed them the surveillance footage. V1 confirmed an incident had occurred.
CMS inspectors tagged the violation at the highest level of severity: Immediate Jeopardy to resident health or safety. The deficiency was found to have begun October 5, the day before the assault.
The facility's own abuse prevention policy, reviewed as recently as June 1, 2025, stated that every resident has the right to be free from sexual abuse, that the facility maintains zero tolerance for abuse of any kind, that staff must not permit anyone to engage in abuse, and that the administrator is personally responsible for coordinating and implementing the abuse prevention program. The same policy stated the facility promptly and thoroughly investigates all reports of resident abuse.
The anonymous caller's account suggests otherwise.
R3's diagnoses included cerebral infarction, major depressive disorder, and generalized anxiety disorder. His care plan acknowledged the history of inappropriate contact. His psychiatry note documented his admission. The facility had the information it needed to protect R2 before October 6. The care plan for R2 did not reflect any of it.
What the care plan said about R2's safety was nothing.
The immediate jeopardy finding was not removed until October 17, eleven days after the assault. To get there, the facility conducted a root cause analysis, re-trained the administrator and the staff member who wrote the October 6 progress note on abuse and neglect policy, held in-service sessions with department heads, reviewed seven days of 24-hour reports, and initiated a program of staff interviews five times a week for four weeks to confirm that employees knew who to report abuse to.
That last item is worth pausing on. Four weeks of interviews to confirm that staff knew who to report abuse to. At a facility whose own policy stated that the administrator was responsible for exactly that.
The facility's abuse policy said staff must not permit anyone to engage in sexual abuse. On the morning of October 6, a severely cognitively impaired woman was lying on her left side, facing the wall, with shaving cream on her body, while a man who had already been flagged for inappropriate contact with residents lay in her bed. The staff member who found them wrote a progress note that described it as a room-entry incident and moved R3 to another hallway.
Nobody called police. The facility did not call police. The documentation did not treat it as a sexual assault. The administrator knew.
An anonymous voice on a dispatch recording was the one who said the word rape.
R2 was admitted to Evercare at University with diagnoses including frontal lobe and executive function deficit following a cerebral infarction and unspecified psychosis. The inspection records do not describe what happened to her after October 6. They do not say whether she understood what had been done to her, whether she was told, whether anyone sat with her. They record her MDS assessment: severely cognitively impaired, dependent, wheelchair-bound.
She was facing the wall when they found her.
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.
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 24, 2026 · Our methodology
EVERCARE AT UNIVERSITY in EDWARDSVILLE, IL was cited for immediate jeopardy violations during a health inspection on October 21, 2025.
The caller was right on all three counts.
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.