Inspection·October 16, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few done. Resident assisted to bed by staff. Neuros WNL (within normal limit) at this time. VS (vital signs) -132/69, 94, 24, 97.8, pulse ox 93%. Daughter notified. Doctor on call notified.R2's Fall Investigation (Final), dated 10/7/25, documents in part On Tuesday, October 7, 2025, around 8:30 PM, (R2) was assisted to the toilet by staff. (R2) was unattended on the toilet when staff heard (R2) fall on the bathroom floor. Resident was assessed and noted to have a hematoma to left side of head about 2 inches above the ear and was complaining of pain to left hip. Swelling was noted to front of left hip area. (R2) was assisted to bed by staff. MD (medical doctor) and POA (power of attorney) notified of incident. Orders from MD received to send (R2) to ER (emergency room) for evaluation and treatment. (R2) was transferred to (local community hospital) where x-rays were taken and revealed a subcaptial femoral neck fracture. (R2) was then transferred on to (regional hospital) for further treatment including surgical repair of fracture. It continues Upon completion of investigation, (R2) was standing up from the toilet and had lost balance and fell on the floor resulting in the fracture and injury to left side of head. At this time, (R2) has not returned to the facility. Upon readmission, facility will follow all orders regarding treatment of fracture and will be reassessed to ensure proper care is received. V2, Director of Nursing (DON's) Investigation of R2's Fall, dated 10/7/25, documents in part Resident was placed on the toilet in room [ROOM NUMBER] due to resident's roommate being on the toilet in their room. Staff left resident to go and get supplies. Resident attempted to stand up unassisted and fell to the floor landing on her left side. Nurse was a couple of rooms up the hall. Nurse (V4, Registered Nurse/RN) stepped out in the hallway and heard a thud. Quickly (V4) and (V3, Certified Nursing Assistant/CNA) went to the bathroom and found the resident on the floor lying on her left side.V3's handwritten statement, dated 10/7/25, documents Resident urgently needed to use the restroom, resident requested privacy as it may take her a while. I stepped around the corner where resident could still be seen, when an alarm started to go off. I told the resident to use bathroom call light when finished as I was stepping out to answer an alarm. Resident confirmed knowing what the bathroom call light was, how to use it, and when to use it when she was finished if I wasn't back yet, answered alarm, talked with (V4, RN) regarding a resident and then heard resident fall in bathroom. All of this occurred in a matter of a few minutes from my recollection of fall incident on the night of 10/7/25. R2's (local hospital) Radiology reports, dated 10/7/25, documents X-Ray Hip 2-3 views left, fall with left hip injury. Findings: Subcapital femoral neck fracture identified. There is at least 2.2 CM (centimeter) superior and 1.5 CM lateral displacement of the fracture.R2's (Local Community Hospital) Discharge summary, dated [DATE], documents R2 was admitted to the floor from the ER for further management evaluation of left hip fracture. Cardiology was consulted due to R2's significant cardiac history and Thoracic Aortic Aneurysm (TAA). After family and medical considerations, R2 was transferred to (Regional Hospital) Trauma Service for evaluation of surgery.R2's (Regional Hospital) Progress Note, dated 10/14/25, documents in part 90 y.o. (year old) female with notable PMHx (past medical history) of dementia (A&O - alert and oriented x1 at baseline), legally blind, CAD (coronary artery disease) with PCI (Percutaneous coronary intervention) in 2013, on Plavix, diastolic HF (heart failure), COPD, mild to moderate aortic stenosis, TAA, Moderate Left ICA (internal carotid artery) stenosis, questionable seizures, who was found down following unwitnessed fall at skilled facility and transferred from OSH (outside hospital) with left femoral neck fracture and UTI (urinary tract infection). Surgery: 10/10/25 Left Hip Hemiarthroplasty.On 10/15/25 at 8:50 AM, V1, Administrator, stated We had a staff member mess up and he left R2 on the toilet for about 11 minutes, which he shouldn't have done, in which time R2 fell off the toilet and fractured her hip.On 10/15/25 at 9:25 AM, V2, Director of Nursing (DON), stated (V3, Certified Nursing Assistant (CNA)), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145910 If continuation sheet Page 2 of 3 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 10/16/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was the one working with (R2) the night she fell. (V3) left (R2) on the toilet and (R2) got up on her own and fell with no one around her. On 10/15/25 at 4:00 PM, V3, CNA, stated It all began when (R2) requested to use the restroom, and her roommate was already in their restroom, so I took her across the hall to use a different one. I assisted (R2) to the toilet and then heard an alarm going off in another room so I asked (R2) if she could use the call light when she is finished, and she said yes. I even asked R2 again, what do you do when you are done and she said she would use the call light, so I felt like she understood so I left her to check on the other alarm. After I checked one alarm, I heard another one going off, so I checked on that one too. Both of those residents were fine, so I stopped to talk to the nurse about those residents when we heard (R2) fall on the floor. When we got there, (R2) was on the floor by the toilet, and it looked like she was trying to walk towards the restroom door and collapsed to the floor. When asked what R2's transfer status was, V3 stated I believe she was a one-person assist with a gait belt. I was never told not to leave her alone until after the fall, now everyone is telling me that she should never be left alone. I was never taught in school when or when not to leave someone by themselves and that I didn't know (R2) well enough to know. On 10/15/25 at 11:48 AM, V5, CNA, stated I worked all the time with (R2) and she was a feisty one, especially when trying to redirect her to call for help. I would always stay with (R2) while in the restroom and she would even get mad at me for staying with her. (R2) always had an alarm on either in her bed or wheelchair.On 10/15/25 at 3:20 PM, V6, CNA, stated (R2) is typically an assist of one with a gait belt. Sometimes she would walk with staff using a gait belt, and sometimes she would complain of her legs hurting and refuse to walk and would have to use her wheelchair. Staff should never leave her on the toilet or anywhere else by herself because she would get up on her own. She always had an alarm on her wheelchair and on the bed and would typically hang out by the nurse's desk talking to everyone. On 10/15/25 at 3:25 PM, V7, RN, stated (R2) was always very quick and the minute you turned your back on her, she was up. You always had to keep your eye on her and know where she is and what she is doing.On 10/15/25 at 3:45 PM, V2, DON, stated I would expect the staff to follow resident fall precautions and interventions to keep them safe. I would expect the staff to monitor any resident who is a High Fall Risk and stay with them while using the restroom to prevent them from getting up on their own and falling.On 10/15/25 at 3:47 PM, V1, Administrator, stated I would expect all staff to keep residents safe at all times and to monitor those residents who are a high fall risk.On 10/16/25 at 9:46 AM, V1 stated That is the only policy we have for fall precautions or Resident safety.The Facility's Interdisciplinary Fall Reduction / Injury Prevention Protocol, dated 1/2025, documents in part Intent: An interdisciplinary approach at reducing falls, preventing injury and increasing safety awareness ultimately resulting in improved quality of care for our residents. Event ID: Facility ID: 145910 If continuation sheet Page 3 of 3