Health inspection·January 3, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's family/emergency contact of a change in condition and transfer to the hospital for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 5. Findings include: R2's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses to include adjustment disorder with Mixed Anxiety and Depressed Mood, Hyperlipidemia, Gastro-esophageal Reflux Disease Without Esophagitis, Peripheral Vascular Disease, Nicotine Dependence, Hypothyroidism, Pain and Pneumonia. R2's Face Sheet documents V10 is R2's Responsible Party. R2's Progress Note dated 12/13/23 at 3:25 AM document, 12/12/23 at 7:20 PM EMTs (Emergency Medical Technicians) arrived at the facility after resident called 911 from his cell phone to say he was having chest pain. This nurse accompanied the emergency response team to the resident's room. He told them he called from his cell phone after having chest pain for 2 days. Resident did not report chest pain to the nursing staff anytime throughout the day. Resident answers questions appropriately and per his request was taken to (local hospital) for further evaluation. (Local hospital) called the facility at 10:20 PM to inform the facility that they would be discharging the resident back to the facility. Dx (diagnosis): Noncardiac Chest pain with a recommendation to follow up with his healthcare provider on 12/13/23 for further eval and treatment if needed. Resident arrived back at the facility at 11:27 PM. He denied pain/discomfort. He is resting comfortably with his call light within reach. Will continue to monitor throughout shift. On 12/29/23 at 12:33 PM, (V10) R2's Emergency Contact, stated, Nobody called and let me know when (R2) had to call 911 himself to go to the hospital for chest pains. That was a few weeks before I came to take him home for Christmas. On 1/3/24 at 8:14 AM during phone interview, V1, Administrator stated he cannot find any documentation that R2's emergency contact, V10, was contacted when he went to the hospital on [DATE]. He stated he would expect resident's family, responsible party and/or emergency contact to be notified when they are sent to the hospital. The facility's policy, Notification of a Change in Condition in Resident's Status, revised 11/17 documents, Policy: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident ' s condition, per standards of practice and Federal and /or State regulations. Procedure: 1. (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: 145910 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 145910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Calhoun #1 Myrtle Lane Hardin, IL 62047 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)