Health inspection·September 14, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct pain assessments in accordance with professional standards of practice for 1 of 1 (R27) resident reviewed for pain management in a sample of 23. This failure resulted in R27 experiencing unrelieved pain for potentially 5 days due to an unknown left hip fracture. Residents Affected - Few Findings include: R27's Face Sheet documents admission to the facility on [DATE] with diagnoses of dementia, urinary tract infection, seizures, vitamin D deficiency, and hypokalemia. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Section G, Functional Status, documents R27 requires Extensive Assistance with physical assist x (times) 2 with bed mobility, Total Dependence with dressing, toilet use, personal hygiene, and eating. Section J100 for Pain Management documents R27 receives scheduled pain medication; J200, Pain Assessment Interview should not be conducted due to R27 is rarely/never understood; J800, Indicators of Pain or Possible Pain (non-verbal sounds, vocal complaints of pain, facial expressions (grimacing, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), protective body movements or postures (bracing, guarding, rubbing or massaging a body part, clutching or holding a body part during movement); J850, Frequency of Indicator of Pain or Possible Pain documented possible pain observed 3-4 days in the last 5 days. R27's Physician's Order, dated 7/15/2023 documents Tylenol 650mg by mouth every four hours for pain as needed. The orginal start date is not listed. A facility final investigation report submitted to IDPH on 7/28/23 documented the following, in part .On 7/10/2023, R27 was sitting up in wheelchair . started having a seizure . frothy drool came from mouth and became unresponsive .sent to the emergency room and was admitted to a local hospital with a diagnosis of seizures, hypokalemia, and aspiration pneumonia .returned back to the facility on 7/15/2023. R27 experienced continual pain in her left leg/groin area from her return from the hospital and on 7/22/2023 an x-ray was obtained that resulted with a left hip fracture. On 9/13/2023 at 3:00 PM, V17 (Registered Nurse/RN) stated that he worked the evening shift on July 15, 2023, and received report from the previous nurse that R27 had returned from a hospital stay on this same date. V17 stated that he did a skin assessment on R27 that evening and noticed that she had a healing bruise on her top, left thigh. V17 stated that he did not assess range of motion or pain when R27 returned back from the hospital on 7/15/2023. A written statement as part of the facility's investigation regarding R27's hip fracture, by V16 (Certified Nurse Aide/CNA) documents Based on what I noticed since R27's return last week, she has been grabbing at her leg when we go in to change her. I noticed this on date 7/17/2023. R27 would grab at it and say ouch when rolling her to change brief. On 9/12/2023 at 12:50 PM, V10 (Certified Nurse Aide/CNA) stated that she works the day shift 6:00 AM 2:00 PM and remembers taking care of R27 when she returned from the hospital in July 2023. V10 stated that one morning, she could not recall exact date, she and V11 (CNA) were getting ready to transfer R27 from her bed to her wheelchair with the mechanical lift. R27 was moaning out while they were rolling her and before her heel got off the bed, R27 grabbed her left hip, crying out. V10 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 If continuation sheet Page 2 of 5 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 09/14/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few she reported R27's pain to her left hip to V13 (Licensed Practical Nurse/LPN). V10 stated she worked the next day and R27 still appeared to have a lot of pain while trying to transfer her. V10 stated that R27 was grabbing more to her left side/buttock area and her face showed grimacing. V10 stated that she then reported R27's pain to V9 (LPN) and V9 stated to her that she would check on R27 and do an assessment on her. V10's (CNA) written statement from the facility's investigation regarding R27's hip fracture dated 7/22/2023 documents, On Thursday, 7/20/2023, during AM care with R27, observed R27 repeatedly grabbing at her left hip/groin area when being changed. R27 does this every time when being changed but on this morning, she was grimacing and holding onto the hip, upper thigh area and when being turned to get brief on, she reached behind her to grasp her left buttock. Reported this to my nurse, V13 (LPN). Same behavior occurred when laying her back down and changing her after lunch. Reported again to V13 that R27 was continuing this behavior and yelling out. At the end of shift, report was given to oncoming shift, and they said they had noticed R27 doing that as well. On Friday 7/21/2023, during AM report from V20 (CNA) about R27, there was no discomfort of R27 reported. When doing AM care on this date, I noticed R27 doing the same as the day before and reported her discomfort to V9 (LPN), informing V9 that she had been doing this the day before and that I had reported it to (V13). On 9/12/2023 at 1:05 PM, V11 (CNA) stated she worked 6:00 AM - 2:00 PM on July 20, 21, & 22, 2023. V11 stated that on July 20, 2023, she noticed R27 grimacing hard and grabbing her left hip/leg area while she was being rolled and during transfers. V11 stated that she reported R27's left hip/leg pain to V13 (LPN) on Thursday, July 20, 2023. V11 stated that she worked the following two days and R27 was still experiencing pain while being rolled and during transfers. V11 stated that she then reported R27's pain to V9 (LPN). V11 stated that V9 went down to assess R27. V11 stated that she did not notice any bruising to R27's left leg and there was no report that R27 had fallen. V11 stated that she noticed that R27 was a lot more tearful more frequently since she returned from the hospital. V11's (CNA) written statement dated 7/24/2023 documents On Thursday, 7/20/2023, I had noticed R27 being in a lot of pain during care. R27 would grab her left hip area and holler out. During transfers, R27 would cry out as well. Reported to nurse of what I had observed. On Friday, 7/21/2023, R27 was having same reactions during care and transfers. Reported to nurse again and also put it on our CNA communication papers and informed the 2:00 PM - 10:00 PM shift about her being in pain and to be careful with her left hip area. Saturday, 7/22/2023, R27 was still having very obvious pain. Still grabbing her hip area and yelling out and crying. Reported to nurse again, put it on our CNA communication papers and passed to the 2:00 PM - 10:00 PM shift during report. On 9/12/2023, at 1:25 PM, V9 (LPN) stated that when R27's pain was reported to her on 7/21/23, she went down to assess R27 and there were no complaints of pain to R27's left hip/leg. V9 stated that R27 pointed to her right thigh when asked if she was in pain but there were no abnormalities noted to either leg. V9 stated that she did not perform range of motion and did not ask V10 (CNA) & V11 (CNA) to perform range of motion. V9 stated that R27 was getting pain medication routinely twice a day. V9 stated that when a resident is experiencing pain, it is documented in the progress notes and reported to the following nurse on our report sheet. V9 stated that there was no fall reported on R27. V9 stated that she did not document R27's pain in the progress notes. V9 stated that she forgot to add her assessment to the progress notes on 7/21/2023. V9 (LPN's) written statement from the facility's investigation regarding R27's hip fracture documents I had taken care of R27 on 7/21/2023 and V11 (CNA) told me she thought R27 was hurting. On assessment, noted that R27 was holding her right thigh and grimaced. Pain medication was given as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 If continuation sheet Page 3 of 5 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 09/14/2023 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 0697 R27 had not fallen or any other incident. No further signs of pain or discomfort after giving pain medication. Level of Harm - Actual harm On 9/13/2023 at 11:45 AM, V13 (LPN) stated that she remembers working one day and taking care of R27 after she had returned from the hospital, later that week. V13 stated V10 (CNA) had reported to her that R27 was experiencing pain in her left groin area. V13 stated that she went down to assess R27 and noticed that her peri-area was reddened. V13 stated that she did not perform any range of motion on R27's extremities at that time and did not ask V10 (CNA) to help perform range of motion. V13 stated she contacted the primary physician to notify the physician that R27 had redness in her peri-area and an antifungal powder was ordered. V13 stated that she did not document R27's pain in the progress notes. Residents Affected - Few V13 (LPN's) written statement from the facility's investigation regarding R27's hip fracture dated 7/23/2023, documents On 7/20/2023, V11 (CNA) reported that R27 acted like she was hurting in her hips or legs. Pain medication given as needed. Received new order for antifungal powder and was applied to groin area. I thought maybe that is what was hurting. No further complaints after pain medication given. V18's (former CNA) written statement from the facility's investigation regarding R27's hip fracture dated 7/24/2023, documents in part . On 7/21/2023, 8:00 PM, rolled R27 towards the closet and that is when R27 started to cry and grimace .asked R27 if she was having any pain .R27 did not respond .repositioned R27 onto her back and went down the hall to report R27's pain to V17 (RN). On 9/13/2023, at 3:00 PM, V17 (RN) stated that he worked that week after R27 returned from the hospital and took care of R27 and there was nothing reported to him of R27 experiencing any signs of pain until Friday, [DATE]. V17 stated that V18 (CNA) reported to him that R27 was holding her left hip when being turned and repositioned. V17 stated that he went down and assessed R27 on 7/21/2023, in the evening time around 8:00 p.m. V17 stated that he performed range of motion on R27, and she did not grimace or moan out in pain. V17 stated that he asked R27 if she was any pain and he stated R27 said, No. V17 stated that he did not fill out a pain assessment at this time because R27 did not complain of any pain at this time. On 9/13/2023 at 3:15 PM, V2 (Director of Nursing/DON) stated that she worked on the evening of July 22, 2023, and received in report that R27 had been uncooperative with her care and was experiencing pain in left hip. V2 stated that she went down to assess R27 and was unable to perform range of motion to R27's left leg. V2 stated that R27 kept her left leg stiff and moaned out when palpated. V2 stated that she told the nursing staff to not move R27 and she sent a concern sheet over to the emergency room and received an order to get an x-ray of R27's left side. V2 stated that R27's x-ray results showed a fracture to her left hip. V2 stated that during the week of July 15-July 22, 2023, she did not receive any reports of R27 experiencing any pain. R27's Xray report dated 7/22/2023 documents under findings: There is an acute subcapital fracture of the left femoral neck with varus angulation. On 9/13/2023 at 2:00 PM, V3 (Infection Preventionist/Risk Manager) stated that the facility does not have a pain policy. R27's Medication Administration Record dated 7/01/2023 - 7/31/2023 documents Tylenol 650mg by mouth twice a day for pain. No diagnosis given was documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 If continuation sheet Page 4 of 5 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 09/14/2023 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 0697 R27's Medication Administration Record nor the Treatment Administration Record dated 07/01/2023 7/31/2023 has any pain monitoring for either document. Level of Harm - Actual harm Residents Affected - Few On 9/13/2023 at 3:15 PM, V2 (DON) stated that the facility does not have a pain policy and the only time that nurses complete a pain assessment is when an as needed pain medication is given. V2 stated in the electronic medication administration record, a pain assessment sheet will trigger when an as needed pain medication is given. V2 stated that the only pain assessment that was filled out for R27 in the month of July 2023 is dated for 7/16/2023 by V9 (LPN). V2 stated that there is a section on the pain assessment that can be completed for non-verbal residents or residents that are unable to answer. V2 stated that she would expect the nurses to fill this out when they give a PRN pain medication or document their pain assessment in the progress notes. The only pain assessment that was completed on R27 was dated 7/16/2023 by V9 (LPN) when Tylenol was given as a PRN. This was after R27 came back from the hospital. R27's pain assessment dated [DATE] documents under Pain Pain Intensity (non-verbal), (grimacing/wincing) checked, under Res pain interview: frequency, (unable to answer) checked, under Exacerbating Factors, (movement) checked, under Alleviating Factors, (lying down) checked, under Currently on scheduled pain med, (Yes, effective scheduled pain treatment in place) checked, under Currently on PRN pain med, (Yes, PRN treatment is effective) checked, under Pain Med Type, (non narcotic analgesic) checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145499 If continuation sheet Page 5 of 5