Inspection·July 18, 2023

F 0689 the toilet and walking. R2's MDS documents R2 was frequently incontinent of bowel and bladder. Level of Harm - Actual harm R2's Nurse's Note, dated 7/8/23 at 7:18AM, documented, Writer called residents room and observed (R2) lying on the bathroom floor on his left side with his head resting against door frame. The commode riser twisted on toilet, water on floor around toilet when asked (R2), what happened, (R2) states, 'I was trying to get up off the toilet so I could get ready for the day and fell.' Residents Affected - Few R2's, Facility Reported Occurrence Report, documented on 7/8/23 at 7:18 AM, R2 was found on floor in bathroom. The Report documented R2 had attempted to transfer self from toilet, did not use call light for assistance. The Report documented areas of injury, scalp, hematoma to head and left hip pain during range of motion assessment. The Report documented there was a wet floor, and alarm not activated at time off fall along with Care Plan interventions to be completed upon resident return to facility after assessment of current status completed. R2's entitled, Fall Details Report, dated 7/8/23 at 7:18 AM, documented visually observed on floor by V6, Certified Nurse's Aide (CNA), call light off, care prior to fall was 7/8/23 at 6:15AM, last documentation. Residents state of motion at time of fall was transferring with no staff assistance. R2's Hospital Imaging Services report, dated 7/8/23 at 8:36 AM, documented R2's final result report study of anterior (front) and posterior (back) of left hip with two radiology views taken, Exam is positive for mildly displaced left intertrochanteric fracture. On 7/12/23 at 2:30 PM, V2, Director of Nursing, DON, stated it was reported that a fluid substance was found on the floor around the toilet base at the time of R2's fall; however, when V2 went to address R2's incident, there were towels wrapped around the toilet basin. V2 stated that R2 is a one nursing assist with walker to the bathroom. V2 stated V5, CNA from night shift, had gotten R2 up and transferred him to the toilet at 5:45 AM and at 6:00 AM, V5 went to re-check on R2, where he continued to remain on the toilet and that R2 had stated he was not ready to get off the toilet. V2 stated that V5 left her work shift at 6:00 AM and gave report to the on-coming CNA, V6, that R2 remained on the toilet. V2 stated that at 6:15 AM, V6 went to check on R2 and R2 stated I still need more time. V2 stated V6 continued to care for her residents as she was assigned too. V2 stated I returned to check on R2 at 7:15AM and found him on the bathroom floor lying on his left side. V2 stated prior to this incident, R2 had complained of left knee pain and was recently ordered for a cortisone (steroid) injection) to his left knee. V2 stated R2 has always used his call light, but R2's call light was not activated on 7/8/23 when R2 fell. On 7/17/23 at 9:02 AM, V2 stated that V3, Licensed Practical Nurse (LPN) went to R2's room around 6:27 AM on 7/8/23 to get R2's oxygen saturation and R2 was still on the toilet. V2 stated V3 had observed towels around the toilet basin and based on V6 fall incident interview that a liquid was observed around the toilet basin V2 stated she notified maintenance. V2 stated maintenance observed no water coming out around the toilet basin, but V2 stated the maintenance man stated, if a person is to sit too far back on the toilet seat it can cause the toilet base to separate from the toilet tank and could cause water to come out around either the tank, the maintenance man found no evidence the toilet seals were broken to cause a leak but ordered for a new toilet parts replacement anyway. V2 continues to state, she feels the facility did no wrong for R2's fall incident, he is known to use his call light. On 7/17/23 at 9:30 AM, V3 stated on 7/8/23 at 6:29 AM she went into R2's room to get his oxygen saturation monitored while R2 was on the toilet and observed no liquid substance on the floor around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145271 If continuation sheet Page 2 of 3 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 145271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Litchfield Health & Rehab Center 628 S Illinois Ave Litchfield, IL 62056 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 0689 Level of Harm - Actual harm Residents Affected - Few the toilet. V3 stated she remained on the same hall across from R2's room attending to resident medication needs and heard no call light activated from R2's room at 7:18A M, V6 found R2 lying on the bathroom floor, performed an assessment on R2 and found towels wrapped around the toilet basin. V3 states, I feel he (R2) should not have been left alone, his legs are weak and especially, after receiving a cortisone injection in his left knee, due to his complaint of pain. On 7/17/23 at 3:40 PM, V7, CNA stated R2 was a tall guy at least 6 feet and then some and V7 took care of him a lot. V7 states, (R2) was quick to get up on his own but knew he needed assistance, and when he was taken to the toilet, he was told to use the call light and he would, when he wanted, but would be quick to the draw to get up on his own, so since (R2) got up off the toilet without listening, I (V7) started staying right at his bathroom door, until he was finished, because no one is going to fall on my shift. The Facility's CNA Report for Falls, dated 7/8/23 and written by V6, documents, the last time V6 repositioned R2 was 6:15 AM, and the last time fluids were offered was 6:00 AM. The report documented there was water on the floor. R2's CNA Statement of Care Provided During Shift, written by V6, dated 7/8/23, documents Offered fluids at 6:00 AM. Came on shift and at 6:15 AM and at 6:15 AM checked on resident. He stated he was not ready, and he needed more time, so when I came back, and he was on the floor 7:18 AM. Resident did not use his call light R2 usually rings light when done, he has gotten up by (V5). Facility's, untitled sheet, dated 7/14/23, documents, Per interview with (V3) regarding (R2) 7/8/23, documented, during this interview form, V3 was asked was R2 prior to the fall did you remind him to use the call light when he was finished, answer from V3, Yes, I always tell the residents to use their call light if they need anything before, I leave the room. Interviewer asked, what was his response.? V3 documented I don't remember. On 7/18/23 at 9:30 AM, V1, Administrator with V2 present, states, Yes, I see that (R2's) fall resulted in a fracture would be considered harm. But I can't see in the future if the fracture was due to his fall or a weakness in his hip already. V1 stated she reached out to a physician, unknown name, that informed V1 of the possible causes of R2's fracture. The Facility's policy and procedure, entitled, Accidents & Incidents, date initiated: 7/1/23, documents, An accident/incident is any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145271 If continuation sheet Page 3 of 3