Health inspection·October 17, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide a Medicare written notice regarding of the resident's potential liability for a non-covered stay for 2 of 3 residents (R5, R16) reviewed for Beneficiary Protection Notification in the sample of 17. Residents Affected - Few Findings include: 1. R5's Medication Review Report documents diagnoses including: displaced trimalleolar fracture of right lower leg, aphasia following cerebral infarction, and neuropathy. R5's admission/registration record documents a admission date of 02/17/24. R5's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview of mental status) score of 00 indicating severe cognition impairment. R5's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS (Center for Medicare Services) 10055) form was not provided to R5 to explain her right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days. R5's Medical record does not contain a CMS 10055 document. 2. R16's Medication Review Report documents diagnoses including: stable burst fracture of fourth lumbar vertebra, wedge compression fracture of unspecified thoracic vertebra, type II diabetes mellitus, and dementia. R16's admission/registration record documents a admission date of 04/17/24. R16's Minimum Data Set (MDS) dated [DATE] documents a BIMS score of 06 indicating severe cognitive impairment. R16's SNF Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS10055) form was not provided to R16 to explain her right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days. R16's Medical record does not contain a CMS 10055 document. On 10/17/24 at 1:45 PM, R16 stated she does not remember if she received any forms about her therapy days. Page 1 of 7 145552 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0582 Level of Harm - Minimal harm or potential for actual harm On 10/17/24 at 1:45 PM, V3 (Care plan coordinator/Minimum Data Set Coordinator) stated they do not have the form (CMS 10055) for R5 or R16, they read the instructions incorrectly and they did not give the CMS 10055 they only gave the NOMNC (Notice of Medicare Non-Coverage) form. Residents Affected - Few 145552 Page 2 of 7 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement treatment and services to prevent a decline in range of motion for 1 of 1 (R8) residents reviewed for position and mobility in the sample of 17. Findings Include: R8's Admission/Registration Record dated 12/29/23 documents R8 was admitted to the facility on [DATE]. R8's Medication Review Report dated 10/17/24 documents R8's diagnoses include Alzheimer's disease, anemia, dementia, and anxiety disorder. R8's MDS (Minimum Data Set) dated 9/19/24 documents R8 has a severe cognitive impairment. This same MDS documents under Section GG, R8 is dependent on staff for bed mobility and transfers and does not ambulate. R8's current Care Plan documents a Focus area of (R8) has limited physical mobility. (R8) has poor sitting balance and leans forward while in chair. Date Initiated: 12/29/2023 This same Focus area includes the following interventions, May have reclining wheelchair to help while positioning. Date Initiated: 10/16/2024. The resident is Weight-bearing, pivot transfer. Date Initiated: 12/29/2023. Locomotion: The resident is totally dependent on 1 staff for locomotion using wheelchair. Date Initiated: 01/09/2024 .Nursing Rehab/Restorative: Passive ROM (range of motion) Program #1 Nursing to perform passive ROM to BUE (bilateral upper extremities) BLE (bilateral lower extremities) x (times) 15 reps every day. Date Initiated 10/16/24 .Nursing Rehab/Restorative: Resident to tolerate 2 hours up in chair daily. Date Initiated: 10/16/2024 On 10/16/24 at 1:50 PM, R8 was observed in bed turning from back to side, with no assistance from staff. V6 (Caregiver) stated R8 will support her weight when they transfer her from bed to chair and will assist with pivoting to the next surface. V6 stated as far as she knows R8 is not being provided with any restorative programs or therapy services. On 10/16/24 at 1:58 PM, V3 (MDS Coordinator) stated R8 does not have a restorative program in place. V3 stated therapy usually writes the programs and she thinks it just got missed. R8's Medication Review Report dated 10/17/24 includes the following orders with a start date of 10/16/24, Restorative plan- Patient to tolerate 2 hours up in chair daily. Restorative plan- Nursing to perform passive ROM (range of motion) to BUE (bilateral upper extremities) BLE (bilateral lower extremities) x (times) 15 reps daily. R8's Medication Review Report does not document orders for restorative programs prior to 10/16/24. The facility Nursing Administration policy dated 8/2024 documents under 4. Restorative Nursing: a. Restorative nursing procedures will be carried out on all residents who require them. b. Nursing personnel will accomplish restorative nursing procedures through the following nursing measures .c. Nursing's goal is to rehabilitate each resident to his maximum capability and to maintain his highest level as long as he may live 145552 Page 3 of 7 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure equipment was maintained in a safe functional manner to ensure resident safety for one (R3) of five residents reviewed for falls in a sample of 17. This failure caused R3 to receive five staples in R3's head. Findings include: R3's Medication Review Report documents diagnoses including: chronic kidney disease, age related osteoporosis, major depressive disorder, displaced bicondylar fracture of right tibia, and heart failure. R3's admission/registration record documents a admission date of 01/07/24. R3's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief interview of mental status) score of 13 indicating R3 is cognitively intact. R3's care plan's focus area documents: R3 is a high risk for falls relating to weakness. On 10/15/24 at 9:50 AM, R3 stated she fell while she was transferring in the shower room. R3 stated , The chair moved and the girl tried to catch her but she is little, she could not hold me and I hit my head and had to get staples put in my head. R3 stated, it did hurt for a while, when her head would hit the pillow. On 10/17/24 at 10:50 AM, R3 stated she thinks there was problems with the wheels on the shower chair before but she does not completely remember. On 10/17/24 at 10:57 AM, V8 (Certified Nurse Aide/CNA) stated she assisted R3 with her shower when she fell. V8 stated R3 was in the shower chair and while she was putting a mechanical standing assistive device under her the shower chair kept moving. V8 stated she had already locked the brakes on the shower chair but it moved anyway. V8 stated she tried to catch R3 the best she could. V8 stated she turned the call light on and tried to hold R3 until someone else came to help. She stated she did not use that shower chair often, she preferred the other chair but the other chair was in use. V8 stated the standing assist device moved also because when R3 fell she had her feet on it and she pushed it when she fell. R3's post fall evaluation dated 07/22/2024 at 2:16 PM documents: fall details: date/time of fall: 07/22/2024 at 2:00 PM fall was witnessed; who witnessed fall: (V8); fall occurred elsewhere; fall location: shower, activity at the time of fall; transferring from the shower chair to the mechanical stand assist, reason for the fall was evident, reason for the fall; both pieces of equipment moved and the floor was very wet, the pre-fall: fall risk score was 8, post-fall; the fall risk score is 8. Did an injury occur as a result of the fall: yes, injury details; the resident hit her head on the frame of the door as she was lowered to the floor, she turned her head to the right side, the back of her head causing a quarter size goose egg to her head with a minor scrape and bleeding. Did the fall result in an ER (emergency room) visit/hospitalization; no. (R3's) provider is (V11 (physician)), time notified: 07/22/2024 and she was notified of the fall and the resident hitting the back right side of her head. The fall details note; (V8) was transferring the resident from the shower chair to the mechanical standing assist chair when both chairs went out from under the resident. CNA (V8) lowered the resident to the floor. The resident hit the right side of the back of the head on door the frame causing a quarter size goose egg with scraped skin with minor bleeding. 145552 Page 4 of 7 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0689 R3's Progress note dated 7/22/24 at 4:07 PM documents R3 was sent to ER via wheelchair and two staff members. Level of Harm - Actual harm Residents Affected - Few R3's Health status note dated 07/22/2024 at 5:40 PM documents: (R3) returned to the unit via a WC (wheelchair) and was accompanied by staff from ER. Sm (small) laceration to the back of the head, right parietal area with 5 staples in place. Sm (small) mt (amount) of oozing blood was noted. Staples are to be removed in 5 days. R3 had Tylenol and clonidine in ER for the pain and elevated BP (blood pressure). R3's Progress note dated 07/23/24 documents: pain: indicators of pain: vocal complaints of pain, location: parietal region (top of back of skull), pain score is documented as a 6, cool compresses applied, non-medication interventions provided relief. R3's Progress note dated 07/24/24 at 10:08 PM documents: day 2 post fall with an injury to the head, 5 staples remain in place with no sign of infection is noted, there is moderate pain and occasional headaches but (R3) states Tylenol helps. On 10/17/24 at 11:14 AM, V10 (CNA) stated she did not typically use the pink shower chair, she would typically use the other chair. R3 fit better in the pink chair but she just liked the other chair better. V10 stated she believes they have put new wheels on the chair before but she does not remember it not working before the day R3 fell. They have removed the chair from use now. On 10/17/24 at 11:43 AM, V7 (Maintenance) stated it was reported to him on 07/22/24 there was a broken shower chair, on 07/26/24 they were informed there were no parts available so the chair was removed from inventory, on 07/31/24 the new shower chair arrived and was put together, on 08/01/24 the new chair was delivered to the 3rd floor. V7 stated, when they received the original chair, one brake worked and one brake didn't, that is why it would slide on a wet floor. 145552 Page 5 of 7 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer pneumococcal vaccinations for 2 of 5 residents (R7, R6) reviewed for immunizations in a sample of 17. Residents Affected - Few Findings include: 1. R7's Admission/Registration Record documents an admission date of 09/03/24 and a date of birth (DOB) indicating R7 is [AGE] years of age. R7's Medication Review Report documents diagnoses including: chronic kidney disease, epilepsy and type I diabetes mellitus. R7's Immunization Record in the medical record documents: Prevnar 13 was administered on 11/28/17 and Prevnar 23 was administered on 02/06/2019 under immunization record section. A document titled Immunization Status and Vaccine Consent with dates for Influenza consent of 09/03/24, refusal for Covid vaccination dated 09/04/24 and a refusal for RSV(respiratory syncytial virus) immunization dated 09/03/24 contains a blank section for the pneumonia vaccine refusal or consent. The Centers for Disease Control (CDC) Immunization Schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. There is no documentation in R7's medical record any pneumococcal vaccination was offered or administered. 2. R6's Admission/Registration Record documents an admission date of 10/25/17 and a date of birth (DOB) indicating R6 is [AGE] years of age. R6's Medication Review Report documents diagnoses including: Gastro esophageal reflux disease without esophagitis, essential hypertension, seasonal allergic rhinitis, and dementia. R6's Immunization Record in the medical record documents: Prevnar 13 was administered on 11/04/17 and Prevnar 23 was administered on 11/14/2018 under immunization record section. The Centers for Disease Control (CDC) Immunization Schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo) documents for adults age 65 or older who have: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. There is no documentation in R6's medical record any pneumococcal vaccination was offered or administered. On 10/16/24 at 1:10 PM, V3 (Care plan coordinator/Minimum Data Set Coordinator) stated she was under the impression if a resident previously had the Prevnar 13 and Prevnar 23 their pneumococcal vaccination series was complete. The facility policy dated 01/24 titled, Nursing Administration with the subject listed as: Pneumococcal Pneumonia Immunization documents: Purpose: To reduce the overall incidents pneumococcal 145552 Page 6 of 7 145552 10/17/2024 Fairfield Memorial Hospital North West 11th Street Fairfield, IL 62837

F 0883 pneumonia by providing the pneumococcal pneumonia vaccine to all residents [AGE] years of age and older and to others at high risk. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145552 Page 7 of 7