Inspection·April 12, 2024

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a timely x-ray for 1 of 4 residents (R3) reviewed for diagnostic services in the sample of 4. Residents Affected - Few Findings include: R3's Minimum Data Set, MDS, dated [DATE] documents R3 has a BIMS (Brief Interview for Mental Status) of 10, which is moderate cognitive impairment. R3's Progress Note, dated 4/8/24 at 7:30 AM, documents the following: Writer called to resident room, noted right knee deformity and resident complained of inability to move leg. No redness or swelling noted. Resident denies bumping or twisting leg at any time. CNA (Certified Nursing Assistant) reports resident ambulated to bathroom approximately 5 AM with gait belt and 1 assist with walker. No difficulty noted by caregiver or complaints of pain voiced by resident. Spoke with son who stated resident has had both knees replaced in the past. Further stated, 'she doesn't even move around that much.' Informed son we would be requesting X-ray and would update when results received. R3's Progress Note, dated 4/8/24 at 8:30 AM, documents MD (medical doctor) notified of resident c/o (complaining of) right knee pain with deformity noted. New order received for x-ray of right knee stat. POA (Power of Attorney) aware. R3's Progress Note, dated 4/8/24 at 8:44 AM, documents Upon current assessment, resident resting in bed with eyes closed. Noted discoloration evolving to right lower thigh above knee. Awaiting x-ray at this time. Resident in no apparent distress. R3's Progress Note, dated 4/8/24 at 7:45 PM, documents the following: x-Ray company in facility at this time to complete x-ray to right knee. R3's Progress Note, dated 4/8/24 at 8:08 PM, documents the following: On call physician returned call to facility at this time. He was updated on resident increased pain. New order received to send resident to emergency room for evaluation. R3's Progress Note, dated 4/9/224 01:08 AM, documents the following: Resident admitted to hospital. R3's x-ray Report with a date of service 4/8/24, no time, documents the following: right knee x-ray, impression - knee arthroplasty, proximal to which is an acute fracture. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145271 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 04/12/2024 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)