Evercare Of Calhoun

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was ok to transport him in the van.On 8/19/25 at 11:25 AM, V1 stated typically discharges are initiated by

the team/family/resident, then referrals are sent out to the facility, the facility is contacted to coordinate a date/time, the physician is contacted for orders, and the family is notified.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. The facility will provide sufficient orientation to residents to ensure safe and orderly transfer or discharge from the facility including an opportunity to participate in deciding where to go. If transferred to another health care facility upon order of a physician, a two-copy transfer form is completed. One copy is sent with the resident and the other is filed in the resident's record. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b.

The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged . Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13, Medical Director, was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the Facility failed to document notice of transfer requirement for 1 of 3 residents (Resident R2) reviewed for transfer and discharge in the sample of 3. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:Resident R2's Face Sheet documents Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's disease and diabetes mellitus.Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.Resident R2's Care Plan does not address any plan for discharge.Resident R2's 7/17/25 Progress Note by V11, LPN, documents Resident R2 will be discharging to another facility on 7/18/25.Resident R2's Progress Notes do not document Resident R2's discharge notice was given or family was contacted regarding Resident R2's discharge.On 8/19/25 at 10:39 AM, V7, Resident R2's Family, stated she is Resident R2's Power of Attorney (POA) and was never notified of Resident R2's discharge by the Facility.On 8/19/25 at 1:55 PM, V1, Administrator, stated he would expect the medical record to contain documentation that notification was made to the resident's representative and a discharge notice was given.The Facility's Discharge and Transfer Policy revised 4/2025 documents, Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Prior to resident being transferred or discharged , the facility must provide a written notice to the resident, and if known, a family member or legal representative of the resident. This must be issued at least 30 days before the resident is transferred or discharged or as soon as practicable for immediate transfers or the resident has not resided in the facility for 30 days. The written discharge/transfer notice must contain the following information: a. The reason for transfer or discharge; b. The effective date of transfer or discharge; c. The location to which the resident is transferred or discharged .Prior to the survey date of 8/19/25, the Facility had taken the following action to correct the non-compliance:On 7/21/25, V1, V2, and V4 were educated by V12 regarding discharge planning to ensure responsible parties were notified of discharges and transfers.On 7/21/25, an Ad Hoc QAPI Meeting including V13 was held to identify issue and discuss the development of a past non-compliance to address.V2 is reviewing discharges and transfers five days a week for 60 days, then three times a week for four weeks, then monthly to ensure compliance.

Event ID:

Facility ID:

If continuation sheet