Evercare at Edwardsville: No Dialysis for 12 Days - IL
Federal inspectors who reviewed what happened at Evercare at Edwardsville found the situation serious enough to declare immediate jeopardy, the most severe finding available under the inspection system, reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death.
The resident, identified in inspection records only as R2, requires hemodialysis, a procedure that filters waste, salt, and excess fluid from the blood when the kidneys can no longer do it on their own. For patients who depend on it, dialysis is not optional and it is not something that can be paused for nearly two weeks without consequence. Missing dialysis treatments allows toxins and fluid to accumulate in the body. The risks include dangerously elevated potassium levels, which can cause cardiac arrest, fluid overload in the lungs, and progressive neurological deterioration.
She arrived at the facility. No treatment was set up. Twelve days passed.
The immediate jeopardy finding was tied specifically to October 8, 2025, the date of her admission, and it remained in place until October 30, when inspectors determined the facility had taken sufficient steps to address the underlying problem. The deficiency, inspectors wrote, stemmed from a failure in coordination of care. Someone was supposed to arrange for her dialysis treatments to continue after she entered the facility. Nobody did.
What the inspection record does not say is whether R2 was hospitalized as a result, whether she suffered organ damage, a cardiac event, or any other measurable harm during those 12 days. The report is silent on her condition when the failure was discovered. What it does say is that the facility's own corrective actions acknowledged the failure as neglect, a word that appears in the root cause analysis the facility completed as part of its remediation plan.
The facility's response, once the problem was identified, was sweeping. The administrator and the assistant director of nursing were pulled aside and trained by the company's vice president of clinical services specifically on dialysis care and what coordination of care requires. That two of the facility's top leaders needed that training, after a patient had already gone nearly two weeks without treatment, is its own kind of finding.
Beyond the leadership retraining, no staff member was permitted to work until they had been put through an in-service on dialysis and the procedures surrounding it. Department heads were trained as well. The facility built a 24-hour report sheet, set to begin November 1, designed to flag any dialysis resident who had missed a treatment or needed one arranged. Daily audits of that report were scheduled for four consecutive weeks. A root cause analysis was completed examining how a new resident's dialysis needs could go unaddressed from the moment of admission.
The corrective plan was thorough enough that inspectors lifted the immediate jeopardy designation on October 30. The deficiency itself, the underlying failure in coordination of care, remained cited.
Immediate jeopardy is a designation inspectors do not apply lightly. The criteria require that a facility's failure has caused or is likely to cause serious injury, harm, impairment, or death. The standard for what qualifies is specific: accidents requiring physician intervention, life-threatening conditions, the onset of clinical complications, a need to significantly alter a resident's treatment, or a decision to transfer or discharge a resident. A patient going 12 days without hemodialysis fits within that framework without much difficulty.
What is striking about this case is not the complexity of the failure. This was not a medication interaction that required specialized clinical knowledge to detect, or a wound care protocol that demanded advanced training to execute. Hemodialysis for a patient who requires it is scheduled, recurring, and known at admission. The question of whether her treatments had been arranged had a yes-or-no answer that could have been checked on the day she arrived. For 12 days, apparently, nobody checked.
The inspection covered a complaint, meaning someone contacted regulators about what was happening at the facility before inspectors arrived. The report does not identify who made the complaint or what they reported, but the investigation that followed confirmed the immediate jeopardy finding and the 12-day gap in treatment.
The facility is in Edwardsville, a city in Madison County in southwestern Illinois, roughly 20 miles east of St. Louis. The inspection was conducted on October 30, 2025.
Nursing home admissions are supposed to include a review of every ongoing treatment a resident requires. When someone moves from a hospital or another care setting into a skilled nursing facility, the expectation is that nothing falls through. Dialysis, by its nature, cannot fall through. It runs on a schedule. Patients who receive hemodialysis typically go three times per week. A gap of 12 days represents, at minimum, four or five missed sessions for a patient on a standard schedule.
The facility's corrective documents use the word neglect in describing what the root cause analysis examined. That framing matters. Neglect, in the regulatory context of nursing home care, means a failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility, in conducting its own analysis, apparently concluded that what R2 experienced met that definition.
She came in needing dialysis. She did not receive it for 12 days. The machines that could have helped her were somewhere. The appointments were never made.
The 24-hour report sheet, the daily audits, the retraining of every staff member, the vice president of clinical services flying in to work with the administrator and assistant director of nursing, the root cause analysis, the new quality assurance tool — all of it exists because one woman was admitted to a nursing home and spent nearly two weeks without the treatment keeping her alive.
The inspection record does not say what happened to her after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare At Edwardsville from 2025-10-30 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 23, 2026 · Our methodology
EVERCARE AT EDWARDSVILLE in EDWARDSVILLE, IL was cited for violations during a health inspection on October 30, 2025.
For patients who depend on it, dialysis is not optional and it is not something that can be paused for nearly two weeks without consequence.
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.