Evercare Of Calhoun
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was the one working with (Resident R2) the night she fell. (V3) left (Resident R2) on the toilet and (Resident 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 (Resident 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 (Resident R2) to the toilet and then heard an alarm going off in another room so I asked (Resident R2) if she could use the call light when she is finished, and she said yes. I even asked Resident 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 (Resident R2) fall on the floor. When we got there, (Resident 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 Resident 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 (Resident R2) well enough to know.
On 10/15/25 at 11:48 AM, V5, CNA, stated I worked all the time with (Resident R2) and she was a feisty one, especially when trying to redirect her to call for help. I would always stay with (Resident R2) while in the restroom and
she would even get mad at me for staying with her. (Resident R2) always had an alarm on either in her bed or wheelchair.On 10/15/25 at 3:20 PM, V6, CNA, stated (Resident 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 (Resident 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.
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If continuation sheet
Evercare of Calhoun in HARDIN, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HARDIN, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Evercare of Calhoun or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.