Health inspection·December 8, 2025

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:Based on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:R2's admission Record, print date of 12/1/25, documents R2 was admitted on [DATE] with diagnoses of Osteoarthritis and Dementia. R2's Minimum Data Set, dated [DATE], documents R2 is severely cognitively impaired, is dependent on staff for toileting, lower body dressing, chair to bed transfer, is incontinent of bowel and bladder, and has no behaviors. R2's Care Plan, Date Initiated: 05/27/2025, documents, Resident has some memory loss and impaired decision making ability. Dx (diagnosis) dementia. Resident can be resistive to cares, verbally abusive to staff d/t (due to) confusion/dementia. Interventions: dated 5/27/25 revision on 11/4/25. Staff to approach at later time if being combative as able. Inform resident what task you are helping with prior to performing. Staff may need to provide care in pairs if resident is overly stimulated. Refer to psych (psychiatry) as needed. R2's Nursing Note, dated 11/22/2025 2:54 PM, documents, Made aware by CNA (Certified Nurse Aide) staff that he heard a POP while turning and repositioning resident from wheelchair to bed. This nurse assessed resident. Resident noted to be lying in bed on back, holding left arm. resident alert and oriented per usual, verbal, c/o (complaint of) pain to L (left) elbow. No bruising noted to arm; resident stated that the CNA hurt her arm . Limited ROM (range of motion) noted to L arm. Resident noted to have acute pain to L mid-humerus and elbow area. Mild deformity observed to L mid humerus area. Resident rates the pain a 10/10, worsening when area is touched or lifted. Denies numbness or tingling. Distal pulse present, cap (capillary) refill <3 seconds and skin warm. Sensation noted to finger, and able to slowly wiggle fingers, but not able to form a fist at time of incident. Call placed to MD (Medical Doctor) to make aware of incident. New order received to send resident to ER (Emergency Room) for eval/treat (evaluation and treatment). Call placed to 911 for transport. Resident transported to (Regional Hospital). On 11/27/25 at 12:18 PM, V1, Administrator, stated, (R2) did break her arm last Sunday. She was combative with care. I did do an investigation on it and sent in the final report last night. (V4) did not mean to hurt (R2). He has since received training. On 11/27/25 at 1:12 PM, V3, Certified Nurse Aide (CNA), stated, (R2) can become combative. You have to just walk away and left her calm down and then you go back to her. You never make any resident do something they don't want to do. On 11/27/25 at 2:20 PM, V4, CNA, stated, I transferred (R2) to bed using the full mechanical lift by myself. She transferred just fine. I had her on her left side doing peri care. She was being combative. She began to lean over to the edge of the bed. I was trying to get her back into the middle of the bed. She was fighting me. As I was trying to get her back in bed, I heard a pop from her arm. She Residents Affected - Few Page 1 of 2 146075 146075 12/08/2025 Evercare of Granite City 3500 Century Drive Granite City, IL 62040

F 0744 Level of Harm - Actual harm Residents Affected - Few called out. I ran out of the room and got the nurse. The nurse (V7) examined (R2) and sent her to the hospital. On 12/1/25 at 2:00 PM, V7, Licensed Practical Nurse, stated, (V4) came and got me and told me while he was transferring (R2) he heard her arm pop. When I got into the room, she was in bed. I asked again what happened and (V4) said it happened while he was putting her pants on. I was confusing as to what happened. I assessed her arm, and it was deformed looking. I called 911 and sent her out to the hospital. I have had to tell (V4) before that he is working with older people, and he needs to think about things that he is doing with them like don't push their wheelchair so fast or don't sneak up on them from behind. I don't think he would intentionally hurt anyone. If any resident begins to get combative or refuse care you just leave them be, re-approach them later, or you can see if another staff member can work with them. You never just keep working with them. On 12/2/25 at 2:00 PM, V2, Director of Nurses, stated if a resident is agitated or combative the staff should back away, leave the resident alone, and leave and go get some help. On 12/4/25 at 10:06 AM, V13, Medical Director, stated he expects the residents to be safe. R2's Nursing Note, dated 11/23/2025 11:32 AM, documents, Admitting dx (diagnosis) from (Regional Hospital) is Left distal humerus displaced fx (fractured). R2's Nurses Notes, dated 11/27/2025 09:40 AM, documents, Resident returned from (Regional) Hospital at 7:58 am. R2's Hospital Notes, admission date of 12/22/25, documents, XR (Xray) Elbow Left 3 or more views result date of 11/22/25. Left shoulder / humerus; acute spiral fracture of the left proximal humerus with lateral displacement of approximately one shaft with. No additional fractures noted. The glenohumeral joint remains intact with moderate glenohumeral osteoarthritis. Treatment Plan Note Fracture of left humerus. Assessment & Plan. Ortho (Orthopedics) Trauma consulted. Non-operative management. [NAME] brace. NWB (non-weight bearing) LUE Left Upper Extremity. PT/OT (physical therapy / occupational therapy). The V4, CNA, written statement, undated, documents, While providing care to (R2) on her left side she began falling out of bed. While attempting to get the resident back into a safe position in bed, I heard a loud pop from her left arm, and I heard a loud pop from her left arm, and she called out in pain. I immediately ran to get the nurse. The facility's written interview from V6, CNA, undated, documents, V6 stated she entered the room with V7 LPN. (V4) was crying and saying, I think I broke her arm. V7 assessed R2 and called 911. R2 repeated, He broke my arm. The facility's written interview from V7, dated 11/22/25, documents, V7 stated that V4 pushed R2 to her room in her wheelchair at approx. (approximately) 2:45 PM. V7 stated, Then after a little bit, he came out of the room yelling for me. He was visibly very upset. He looked like he was about to cry. He said, 'I heard a pop when I was repositioning her. I went to the room and assessed (R2). Her upper left arm and elbow looked swollen. It looked like it was deformed. When I went to touch her, she yelled out. (R2) stated, ‘he hurt my arm.' I ran down the hall and called 911. The facility's written statement from R1, dated 11/24/25, documents, (V2) interviewed (R1) in her room. At approx. 1:00 PM, I asked (R1) if she was aware of any incident with her roommate on Saturday. (R1) stated, ‘yes'. I asked (R1) if she saw anything that had occurred. (R1) stated, 'No the curtain was pulled'. (R1) stated, ‘I heard that lady fussing with the man aide (V4)'. She was fussing about her foot. Then I heard her say ‘you hurt my arm.' (R1) stated, ‘(R2) fights and yells with every aide every time she gets care. The Caregiver's Guide to understanding Dementia Behaviors, undated, documents, Agitation refers to a range of behaviors associated with dementia, including irritability, sleeplessness, and verbal or physical aggression. It continues, Most often, agitation is triggered when the person experiences, control being taken from him or her. It continues, Do not try to restrain the person during a period of agitation. 146075 Page 2 of 2