Health inspection·October 24, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement new fall interventions to aid in fall prevention for 1 (R10) of 3 residents reviewed for falls in the sample of 22. Findings include: R10's Face Sheet documented an admission date of 06/20/24 and included diagnoses of legal blindness, hallucinations, delusional disorders, major depressive disorder, restlessness and agitation, anxiety disorder, overactive bladder, and pain in thoracic spine. R10's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. This MDS also documented R10 needs substantial to maximal assistance for sit to stand. R10's Long Term Care Fall Log dated 08/26/24 documented a fall on 08/26/24 on the 2:00 PM to 10:00 PM shift. The summary of the incident documents: Certified Nurse Aide (CNA) had been in R10's room to ask about a shower and resident refused. CNA stepped out of room to notify nurse of refusal and heard alarm sounding. R10 was on the floor in front of the recliner. R10 stated, that she did not fall, but stood up and then laid down on the floor. The intervention for this fall is documented as: R10 has chair alarm and is on hourly rounds. CNA had just been in R10's room. Continue current interventions. R10's Long Term Care Fall Log dated 09/10/24 documented a fall during the 6:00 AM to 6:00 PM shift. The summary of the incident documents: resident (R10) slid out of recliner and was found sitting on the floor. The intervention for this fall is documented as: R10 has safety alarm and is on hourly rounds, checked 15 minutes prior to the incident. R10 has behaviors and no safety awareness. R10's Long Term Care Fall Log dated 09/24/24 documents a fall on 09/24/24 on the 6:00 AM - 6:00 PM shift. The summary of incident documents: CNA had just been in R10's room, no needs were voiced, three minutes later R10 was found sitting on her buttocks on the floor. R10 stated she stretched and slid to foot of recliner and slid to floor. R10's intervention for this fall is documented as: has an alarm, a low bed, soft mats and hourly rounds. R10 has behaviors, no safety awareness, no acute illness, and no environmental factors. R10 is in the safest environment possible. R10's Care Plan documents under Focus Area fall risk, had previous fall on 08/02/24 resulted in fracture to her left distal radial arm. She recently was in the hospital and returned to the Long Term Care on 08/15/24. Resident slid from her recliner to the floor on 08/17/24 with no new injuries noted. Resident is experiencing hallucinations and delusions. She is not aware of her physical limitations, with poor balance, unsteady gait. Family have declined surgery to repair the fracture. Often (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 6 Event ID: 145499 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 10/24/2024 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)