Health inspection·June 11, 2025

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 resident's representatives of a fall in 1 of 4 residents (R3) reviewed for accidents in the sample of 4. Findings include: 1.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including osteoporosis, pain and dementia. V4, R3's Family, is listed as R3's Emergency Contact and Durable Power of Attorney. R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and required partial assistance with bed mobility and transfer. R3's Fall Report dated 5/27/25 documents R3 had an unwitnessed fall. R3's Progress Note dated 5/27/25 at 10:31 AM by V5, Licensed Practical Nurse (LPN), documents R3 was found on the floor with a hematoma (bruise) on the right side of (her head). R3's Progress Note dated 5/28/25 at 4:07 PM by V6, Social Services Director, documents V4, R3's family, was not notified of R3's fall, and it was determined that the contact number for V4 was incorrect. On 6/10/25 at 11:20 AM, V1, Administrator, stated V5 tried to call V4 when R3 fell, but the voicemail box was not set up. V4 came to the Facility later and noticed R3's face was bruised and was upset that nobody had contacted her. V1 followed up with V5, and they discovered the phone number V5 used was not correct. On 6/10/25 at 1:18 PM, V5 stated she tried to contact R3's family after her fall, but the number she dialed was not the correct number. On 6/10/25 at 1:24 PM, V6, Social Services Director, stated V4's contact number was not listed correctly, so V4 was not aware of R3's fall until she came to the Facility to visit. On 6/10/25 at 2:35 PM, V4 stated when she came to visit R3, the entire side of her face and eye were black and blue. She was shocked and upset that the Facility did not contact her regarding R3's fall. (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 5 Event ID: 145985 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 145985 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare at University 1095 University Drive Edwardsville, IL 62025 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)