Evercare of Collinsville: Background Check Failures - IL
That admission, made to state inspectors in September 2025, sat at the center of a federal Immediate Jeopardy citation, the most serious classification available to inspectors, one that signals residents face a risk of serious injury, harm, or death. The citation had actually begun nearly a year earlier, on September 30, 2024. It was not removed until September 15, 2025, the day before inspectors completed their review.
The facility houses 79 residents.
The administrator, identified in inspection records as V1, told inspectors that prior to conducting Healthcare Worker Registry and background checks herself on September 9 and 10 of 2025, she had no knowledge of whether the seven employees, designated V6, V12, V16, V17, V18, V19, and V20, had any offenses on their records or whether they were even eligible to work in a licensed skilled nursing facility. She acknowledged the checks should have been completed upon hire. They were not.
"You never know who is or will harm someone."
That was the medical director, identified as V21, speaking to inspectors on September 11. He said he would expect staff to follow state guidelines on background screening. He called the residents in the facility vulnerable. He called timely background checks imperative. He said, plainly, that the checks should have been done.
They were not done. And for the residents living at Evercare of Collinsville, the gap between what the facility's own policy promised and what actually happened was not a matter of paperwork. It was a matter of who was walking into their rooms.
The facility's own Abuse Prevention and Prohibition Program, dated June 1, 2025, states that the facility does not knowingly employ anyone who has had disciplinary action taken against a professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment, or misappropriation of property, or anyone convicted of abusing, neglecting, or mistreating other people. The policy declares zero tolerance for abuse, neglect, and mistreatment. It describes a standardized methodology for prevention, identification, investigation, and reporting.
The facility wrote that policy. Then it hired workers without checking whether any of them had the exact histories the policy was designed to screen out.
Whether any of the seven employees had such histories is not stated in the inspection report. The inspectors' finding was not that the workers were known to be dangerous. It was that the facility had no idea, because it never looked.
That distinction matters, but it does not make the situation less serious. Background checks and Healthcare Worker Registry verifications exist precisely because nursing home residents cannot screen the people entering their rooms. Many cannot speak. Many cannot defend themselves. Many do not know the names of the aides who dress them in the morning or help them to the bathroom at night. The screening system is the protection they are given instead.
At Evercare of Collinsville, that protection was not in place for at least seven workers across a period that, by the timeline in the inspection report, stretched into the fall of 2024. The Immediate Jeopardy designation began September 30, 2024. The administrator ran the checks September 9 and 10, 2025. More than eleven months passed between those two dates.
The inspection report does not specify when each of the seven workers was hired, how many shifts they worked, or which residents they had contact with. It does not say whether the facility identified the lapse on its own or whether it came to light through a complaint. The inspection was complaint-driven, according to the filing.
What the report does describe is what the facility did once the Immediate Jeopardy was formally on the table. On September 15, 2025, one day before the inspection concluded, the facility submitted actions it said removed the immediacy of the threat. The administrator was in-serviced by the Vice President of Clinical Services on background checks and the requirement that they be completed before a staff member's first shift. The administrator then in-serviced department heads on the same requirement. All staff members currently on the working schedule were verified to have completed background checks and confirmed eligible to work. An initial audit of all current employees was completed. The facility's policy and procedure was reviewed and updated to reflect current practices.
Going forward, the facility said, no staff member would work before a background check was completed. An audit tool was implemented to verify new hires were screened before their first working day, with the administrator and department managers listed as responsible parties.
A root cause analysis was completed. Its finding was brief and direct: the facility failed to run background checks on new employees prior to their first shift.
There is no explanation in the report of how that failure persisted for as long as it did. There is no account of who was responsible for the oversight process before the administrator ran the checks herself in September 2025, or why the system did not catch the gap sooner. There is no description of what triggered the original Immediate Jeopardy finding in September 2024, nearly a year before inspectors arrived.
The inspection report rates the level of harm as minimal harm or potential for actual harm, and notes that few residents were affected. Those classifications reflect the regulatory framework's assessment of documented harm at the time of inspection. They do not resolve the question the medical director raised in his interview with inspectors: you never know who is or will harm someone.
That is precisely the point of the screening requirement. The checks are not run after something goes wrong. They are run so that facilities know, before a worker ever enters a resident's room, whether there is something in that person's record that disqualifies them from being there. At Evercare of Collinsville, for seven workers with direct resident access, that knowledge did not exist. The administrator said so herself.
The 79 residents living in the facility during this period had no way of knowing that. They did not know which of the aides caring for them had been checked and which had not. They could not have known. That is not a condition that resolves itself when the paperwork is finally completed. The eleven months during which the facility operated without that information cannot be recovered.
The medical director's words stay with this: the residents in the facility are vulnerable and need protection. He said it to inspectors as though it were obvious. It is obvious. It is also, by the facility's own admission, something that the people responsible for that protection had failed to act on.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Collinsville from 2025-09-16 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 September 16, 2025.
The citation had actually begun nearly a year earlier, on September 30, 2024.
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.