Inspection·July 12, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few walker and assist of one (staff member). She has a safety alarm because she gets up at night and ambulates to the bathroom without assist. As the CNA (Certified Nursing Assistant) who was assisting her turned to shut off the alarm, (R1) lost her balance and fell, hitting the back of her head against the wall and pulling her walker down and hitting the front of her head with the walker. (R1) was noted to have a small bump on the back of her head, and a small bump to the right forehead with a small abrasion across it. She was able to move all extremities and had no complaints of pain except where she had bumped her head The Physician acknowledged the fall report and no new orders were received. A Fall Investigation Report dated 6/11/23 documented, (V3), Certified Nursing Assistant, (CNA) was helping (R1) up to the bathroom, (V3) thought (R1) had her balance and went to shut off alarm, (R1) lost her balance and fell beside her bed against the wall. Did bump back of head on wall and her right forehead on her walker, (causing a) small bump and scrape. This Fall Investigation did not document a root cause analysis of the fall. On 7/11/23 at 8:20am,V3, Certified Nursing Assistant, stated that on 6/11/23 around midnight, V3 was assisting R1 to the bathroom. V3 stated she had been employed at the facility about three weeks at that time. V3 stated V3 was under the impression that R1, who was alert and oriented and utilized a walker for ambulation, required stand by assistance for transfers. V3 stated she had never used a gait belt to transfer R1 and she did not utilize one on this occasion either. V3 stated she assisted R1 in sitting up to the side of the bed, putting on her house slippers and placing her walker in front of her. V3 stated R1's slippers were in good condition and not slippery. V3 stated if the slippers had been slick on the bottom, she would have put different footwear on R1. V3 stated she assisted R1 to a standing position and R1 appeared to be steady. V3 stated R1's bed pressure pad alarm was sounding, and the control box was sitting on top of the sharps container on the wall. V3 stated she turned her body away from R1 to retrieve the box, and at that moment R1 lost her balance and fell backward, with her head hitting the wall and the walker falling onto her right forehead. V3 stated V4, Licensed Practical Nurse (LPN) was immediately notified of the fall. V3 stated after the incident she found out that R1 required the assistance of at least one staff and a gait belt for transfers. V3 stated she should not have turned away from R1 and that she should have used a gait belt. V3 stated she has since been re-educated on the appropriate usage of gait belts. On 7/11/23 at 9:05am, V7, (R1's Physician) stated he was notified of R1's 6/11/23 fall. V7 stated he was aware that a gait belt had not been utilized during the transfer and that it should have been. On 7/11/23 at 10:05am, V4 stated she assessed R1 immediately after the fall. V4 stated R1's vital signs and neurological checks on 6/11/23 from the time of the fall around midnight until 6:00am at the end of her shift were within normal limits. V4 stated R1 had small bumps to the right forehead and the back of the head. V4 stated she noted R1's house slippers seemed to be slick, so she put V1's tennis shoes on her and ambulated R1 to the bathroom. V4 stated R1 had no complaints of pain, and when V4 staffed R1 with the emergency room (ER) physician he did not believe R1 needed to be seen in the ER. V4 stated V3 told V4 that V3 had turned away from R1 for a few seconds to turn off her pad alarm, and that V3 had not used a gait belt during the transfer. On 7/11/23 at 2:50pm, V2, Director of Nurses, stated the root cause analysis of the fall was that V3 should not have turned away from R1 and that V3 should have used a gait belt. V2 stated that if R1's house slippers were slick on the bottom, they should have been replaced. V2 stated CNAs will now be required to document on each shift that resident's personal alarm boxes are sitting on the residents dresser, not on the wall mounted sharps container. V2 confirmed that R1 should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 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 145499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fayette County Hospital 650 W Taylor St Vandalia, IL 62471 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 - Minimal harm or potential for actual harm Residents Affected - Few transferred using a gait belt. V2 stated she is in process of re-educating all nursing staff on the proper use of gait belts. An undated Gait Belt Policy documented in part, Employees will be educated in the use of gait belts and gait belts will be used to ensure the safety and well being of all long term care residents with an assessed need. An undated Fall Prevention Program Policy documented in part, .Ambulatory residents shall wear proper foot gear; nonskid shoes or well-fitting nonskid slippers .Encourage use of ambulation aids at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 If continuation sheet Page 3 of 3