Evercare of Collinsville: Pressure Ulcer Care Failures - IL
Federal inspectors who visited Evercare of Collinsville on May 26, 2026, following a complaint, found that nursing staff were failing to document pressure ulcer treatments on residents' treatment administration records after completing them. Without that documentation, there was no way to confirm the treatments had happened at all.
The resident at the center of the complaint, identified in inspection records as R2, explained it plainly. After nurses administer pressure ulcer treatments, she said, she expects the nurse to document the treatment on her treatment administration record. If staff don't document it, she said, she can't say the treatment was administered. She can't say staff are following her physician's orders.
She expected all staff to follow those orders. She expected them to follow the facility's pressure ulcer policy, too.
The facility's own wound management policy, last reviewed September 5, 2025, states that nursing staff will initiate treatment per attending physician order and utilize interventions for pressure redistribution and wound management. A wound monitoring record is to be completed for each wound.
The gap between that written policy and what inspectors found during the complaint visit was the violation.
The administrator, identified as V1, spoke with inspectors at 11:45 that morning. She is a nurse herself. She acknowledged that if a resident has a pressure ulcer on their sacrum and is left sitting up for long periods, the wound could get worse due to the extended pressure. She said it plainly, without apparent dispute about the underlying medical reality.
Pressure ulcers on the sacrum, the bony base of the spine, are among the most serious wounds that develop in nursing home residents. They form when sustained pressure cuts off blood flow to the skin. Leaving a resident with a sacral wound seated upright for extended periods compounds that pressure directly on the injury. The wounds can deepen through layers of skin and tissue.
The inspection tagged the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. That classification sits near the lower end of the federal severity scale. It does not mean the underlying failure was minor.
Documentation of wound care is not a clerical formality. When a nurse treats a pressure ulcer and does not record it, the next nurse coming on shift has no way to know whether the treatment was given. A physician reviewing the resident's chart cannot tell whether their orders are being carried out. A family member asking questions gets no answer. The resident, as R2 made clear, is left unable to say what happened to her own body.
The facility's policy existed. The physician's orders existed. What inspectors found was that neither was reliably making it onto the page.
R2 had requested records from the facility before inspectors arrived, the report notes, and had received fewer documents than she initially asked for. The inspection was triggered by a complaint. She had been paying attention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Collinsville from 2026-05-26 including all violations, facility responses, and corrective action plans.
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: August 13, 2026 · Our methodology
EVERCARE OF COLLINSVILLE in COLLINSVILLE, IL was cited for violations during a health inspection on May 26, 2026.
Without that documentation, there was no way to confirm the treatments had happened at all.
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.