Evercare At University
EVERCARE AT UNIVERSITY in EDWARDSVILLE, IL — inspection on October 21, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
peers and staff.R3's Progress Note by V2 dated 10/6/25 at 9:00 AM documents, Resident was found
jeopardy to resident health or hallway.R3's Psychiatry Note by V24, Nurse Practitioner (NP) note dated 10/9/25 documents, Per safety staff patient entered into female peer room, got into her bed remove(d) her (incontinent brief) and put shaving cream on her.
Admits to going into peer room states he wanted to have sex.Local Police
regarding an alleged rape occurring today at (Facility).
The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police.
The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name.
The caller stated the facility administrators were not doing anything about the incidents. V1 had been made aware of the alleged occurrence and stated than an incident had occurred. V1 showed surveillance video which showed R3 moving his wheelchair down the hallway and entering R2's room at 8:59 AM on 10/6/25. V7 was seen entering R2's room and calling for V18. At 9:04 AM on 10/6/25, R3 was seen wheeling himself out of the room. V18 stated V7 entered the room to find R3 out of his chair and lying in bed with R2. V18 said R3 had shaving cream on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found lying on her left side, facing the facility wall, and had shaving cream on her right butt cheek.
The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.
Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse., neglect, mistreatment.
The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.
The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems.
The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.The Immediate Jeopardy and deficiency practice that began on 10/5/25 was corrected/removed on 10/17/25 after the Facility took the following actions to correct the noncompliance: V1 and V2 were in-serviced on abuse and neglect by V41, department heads were in-serviced on abuse and neglect policy and procedure by V1, 24 hour reports for the last seven days were reviewed, 24 hour report audits were initiated, interviews with 5 staff members 5x/week x 4 weeks were initiated to ensure staff know who to report abuse and neglect to, and root cause analysis was completed for abuse and neglect.
The abatement was validated by review of abuse policy, review of root cause analysis and interviews from V3, V22, V25, V29, V32, V33, V35, V36, V37, V38, V39, V40.
145985 10/21/2025
Evercare at University 1095 University Drive Edwardsville, IL 62025
on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found
Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents Each resident has
property.
The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.
Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse., neglect, mistreatment.
The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.
The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems.
The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.
145985 10/21/2025
Evercare at University 1095 University Drive Edwardsville, IL 62025
authorities.
interview and record review, the Facility failed to report allegation of sexual abuse for 1 of 3
was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff.On 10/15/25 at 2:10 PM, V7, Certified Nursing Assistant (CNA), stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to and facing toward R2 moving his arm back and forth repeatedly. V7 walked closer and saw R2's lower buttocks exposed with R3's hand in her diaper. R3 stated he was checking her diaper. V7 told V20, Licensed Practical Nurse (LPN), who notified V1, Administrator. On 10/16/25 at 2:54 PM, V20 stated when she arrived at work on 10/5/25 she was informed by V7 that R3 was observed with his hands in R2's incontinent brief. V20 notified V1 who stated she would take care of it. On 10/16/25 at 11:09 AM, V1 stated she was notified about V7's allegation on 10/5/25, but did not report the allegation because nothing had happened.
Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility).
The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police.The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.
Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment.
The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.
The Administrator is responsible for coordinating and implementing the facility abuse prevention policies, procedures, training programs, and systems.
The Facility promptly and thoroughly investigates reports or resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.
145985 10/21/2025
Evercare at University 1095 University Drive Edwardsville, IL 62025
unknown source, or criminal acts.
145985 10/21/2025
Evercare at University 1095 University Drive Edwardsville, IL 62025
We wanted to find a (different) Facility for R3, because usually if they do it once they are going to do it again.
Allegations of abuse should be reported immediately and residents should be separated to make sure they are safe.
Local Police Report printed 10/16/25 documents on 10/6/25 at 10:56 AM, dispatch forwarded an anonymous caller regarding an alleged rape occurring today at (Facility).
The caller stated multiple incidents were happening at the facility, but the administrators were not reporting them to the police.
The caller stated a resident staying at the facility was sexually assaulting another individual by the name of (R2) but did not know the suspect's name.
The caller stated the facility administrators were not doing anything about the incidents. V1 had been made aware of the alleged occurrence and stated than an incident had occurred. V1 showed surveillance video which showed R3 moving his wheelchair down the hallway and entering R2's room at 8:59 AM on 10/6/25. V7 was seen entering R2's and calling for V18. At 9:04 AM on 10/6/25, R3 was seen wheeling himself out of the room. V18 stated V7 entered the room to find R3 out of his chair and lying in bed with R2. V18 said R3 had shaving cream on R2's right butt check and heard him say, You stopped me before I started. V18 said R2 was found lying on her left side, facing the facility wall, and had shaving cream on her right butt cheek.
The Facility's Abuse Prevention and Prohibition Program Reviewed 6/1/25 documents Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.
Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment.
The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.