Inspection·May 20, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to properly transfer and use appropriate assistive devices for transfers for 1 of 3 (R2) resident investigated for falls. This failure resulted in R2 sustaining a left knee periprosthetic fracture of the tibial component. Findings include: R2's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility on [DATE]. R2's EMR dated 2/9/22 documents a diagnosis of other abnormalities of gait and mobility. R2's EMR dated 11/5/24 documents a diagnosis of difficulty in walking, not elsewhere classified. R2's EMR dated 8/14/24 documents a diagnosis of unspecified fracture of left fibula, subsequent encounter for closed fracture with routine healing. R2's MDS (Minimum Data Set) dated 7/26/24 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident was independent for roll left and right. The MDS documents that the resident required substantial/maximal assistance for sit to lying. The MDS documents that the resident required partial/moderate assistance for lying to sitting on side of bed. The MDS documents that the resident was dependent for sit to stand, chair/bed to chair transfer, and toilet transfer. R2's Care Plan dated 4/30/25 documents (R2) is at risk for falls. She had a L knee replacement and is unstable ambulating and transferring herself. R2's Care Plan dated 4/30 /25 documents The resident has had an actual fall with serious injury. R2's Nursing Note dated 8/3/24 at 1:15 PM documents cna (Certified Nursing Assistant) came to this nurse to let this nurse know that resident was lowered to the ground. CNA stated resident stated that her left leg gave out and then she was lowered her to the ground. States her left knee hurts. ROM (Range of Motion) WNL (Within Normal Limits). Transferred back to wheelchair. V/S (Vital Signs)-97.2-102-22-102/64-spo2 (oxygen saturation)-97%. On call NP (Nurse Practitioner)-for (V6) notified. No number to contact for her husband. Will monitor. Tylenol given for pain. R2's Nursing Note dated 8/14/24 at 5:30 AM documents X-ray results of tib/fib back- results showed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145410 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Breese 1155 North First Street Breese, IL 62230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)