Evercare of Calhoun: Fall After CNA Left Resident Alone - IL
The resident, identified in inspection records only as R2, was a high fall risk. She had alarms on both her bed and her wheelchair. Her coworkers knew her well enough to know she would get up the moment anyone looked away. The CNA who left her alone said she didn't.
Federal inspectors cited Evercare of Calhoun, a nursing facility in Hardin, Illinois, for causing actual harm to a resident after the October fall. The citation, the most serious category short of immediate jeopardy, was based on what the CNA said happened and what other staff said should have been common knowledge about this particular woman.
The CNA, identified as V3, explained the sequence to inspectors on October 15. R2's own restroom was occupied by her roommate, so V3 took her across the hall. She helped R2 onto the toilet, then heard an alarm. She asked R2 whether she could use the call light when she was done. R2 said yes. V3 asked again, to make sure she understood. R2 said yes again. So V3 left.
"After I checked one alarm, I heard another one going off, so I checked on that one too," V3 told inspectors. "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 they reached her, R2 was on the floor near the toilet. It looked as though she had been trying to walk toward the restroom door when she collapsed.
V3 told inspectors she believed R2 required a one-person assist with a gait belt for transfers. She said she was never told not to leave R2 alone until after the fall happened. "Now everyone is telling me that she should never be left alone," V3 said. "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."
Other staff who worked regularly with R2 described a very different shared understanding of how she had to be handled.
A second CNA, V5, told inspectors she had worked with R2 often. "She was a feisty one, especially when trying to redirect her to call for help," V5 said. "I would always stay with R2 while in the restroom and she would even get mad at me for staying with her." R2, V5 said, always had an alarm on her bed or wheelchair.
A third CNA, V6, was just as direct. "Staff should never leave her on the toilet or anywhere else by herself because she would get up on her own." V6 described a woman who sometimes walked with staff using a gait belt, sometimes refused and used her wheelchair when her legs hurt, and who spent time at the nurses' station talking to everyone. The alarms, V6 said, were constant.
The unit's registered nurse, V7, told inspectors 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."
The Director of Nursing told inspectors she would expect staff to follow fall precautions and stay with any high fall risk resident while using the restroom. The administrator said she expected all staff to keep residents safe at all times.
Neither said those expectations had been clearly communicated to V3 before the fall.
The facility's fall reduction protocol, dated January 2025, describes an interdisciplinary approach to reducing falls and preventing injury. The administrator told inspectors on October 16 that it was the only fall precautions policy the facility had.
R2 got up on her own, in an unfamiliar restroom, across the hall from her own room, while the CNA assigned to her was down the corridor talking about two other residents who turned out to be fine.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Calhoun from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Evercare of Calhoun in HARDIN, IL was cited for violations during a health inspection on October 16, 2025.
The resident, identified in inspection records only as R2, was a high fall risk.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.