Evercare of Collinsville: Family Not Told of Falls - IL
The resident, identified in inspection records only as R8, had fallen nine times between June 15 and August 16, 2025. R8 has catatonic schizophrenia, major depressive disorder, anxiety, hypertension, and Type II Diabetes. A cognitive assessment documented in the inspection report gave R8 a score of 6 on the Brief Interview of Mental Status, which indicates severe cognitive impairment. R8 could not advocate for himself. His family member was his connection to the outside.
The falls came in a cluster: June 15, July 4, July 26, July 27, August 5, August 7, August 12, and twice on August 16. Nine falls in 62 days. Progress notes in R8's chart document each one. None of them document that the family was ever contacted.
On August 18, the day inspectors arrived, R8's family member told them directly what had been happening. The facility used to call him when R8 fell, he said. They had stopped doing that. The cut above the eye was how he found out about at least one of the falls. He told inspectors they hadn't been notifying him of any changes with R8 at all.
The same morning, the facility's registered nurse and assistant director of nurses told inspectors the opposite. They notify the family and physician when a resident falls, she said. The administrator, interviewed separately, said the same thing: they notify the physician and family when a resident falls.
The chart said otherwise. The family said otherwise.
The facility's own fall policy, though undated, states that staff must complete an accident and incident report and notify the physician and the responsible party. There is no documentation in R8's progress notes that the responsible party, the family member who had been coming in to visit, was ever reached after any of the nine falls.
The inspection was a complaint survey, meaning someone had contacted regulators before inspectors walked through the door. CMS rated the harm level as minimal harm or potential for actual harm, the lower end of the deficiency scale. The deficiency covered one resident out of four reviewed for falls in an eight-person sample.
What the rating doesn't capture is the position R8's family member was put in. His relative has severe cognitive impairment. R8 cannot describe pain, report an injury, or explain that something went wrong. The family member is the person who would notice a change, ask questions, push for follow-up care. Between June and August, he was making visits and finding injuries he hadn't been told about, asking nurses what happened, and piecing together a picture the facility had not given him.
He told inspectors the facility used to call. The word "used to" carries weight. At some point the calls stopped. Nine falls passed without one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Collinsville from 2025-08-18 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 22, 2026 · Our methodology
EVERCARE OF COLLINSVILLE in COLLINSVILLE, IL was cited for violations during a health inspection on August 18, 2025.
The resident, identified in inspection records only as R8, had fallen nine times between June 15 and August 16, 2025.
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.