Health inspection·February 21, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of abnormal vital signs and a change in resident's condition for 1 of 4 residents (R1) reviewed for physician notification in a sample of 9. Findings include: R1's admission record documents an admission date of 11/16/2024 and the following diagnoses in part, unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing need for assistance with personal care. R1's Minimum data set (MDS) dated [DATE] documents a Brief Interview for Mental Status of 15, indicating that R1 was cognitively intact. R1's progress notes documents on 12/10/2024 at 12:01am, This nurse went into pt's (patient's) room and son visiting had pulse oximeter on his mother's finger and it was reading 90%. He states when it first was put on it was 80. This PT very anxious. Color natural skin w/d (warm/dry). Resp (respirations) even and slightly labored. This nurse put her pulse oximeter on her, and it read 93. Spoke with son and ask his concerns. He states she gets confused, and he think her oxygen might be going down. He also states with her swelling may be making it worse, but she is on metolazone now and should help. States he does not want her sent to hospital and to just wait and see. Placed on 2 L (liters) O2 per NC (nasal cannula) and SPO2 increased to 95. This occurred at 730pm. R1's progress notes documents on 12/10/24 at 12:22am, resting quietly in bed with eyes closed, HOB (head of bed) elevating 30 degrees to facilitate breathing. resp (respirations) even and NL (not labored) .to begin metolazone in the AM for edema to BLE's (bilateral lower extremities). Noted 2+ edema to BLE's. The following vital signs were documented, Respirations of 20, oxygen level of 95 on 2 liters of oxygen via nasal cannula, blood pressure of 134/78. R1's progress notes documents on 12/11/2024 at 12:42pm, this nurse approached resident to administrate noon meds and res is lethargic, sleepy, difficult to arouse. this nurse assessed res (resident). The following vital signs were documented temperature of 98.1, pulse 73, respirations 14, and a blood pressure of 89/53. R1's progress notes document on 12/11/2024 at 2:23pm, Res (resident) has been differing from her last known normal since yesterday morning. Res is lethargic and slow to respond to verbal commands. Res son requests that she go to the er. Dr agrees. EMS contacted and en route. Page 1 of 3 146032 146032 02/21/2025 Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832

F 0580 Level of Harm - Minimal harm or potential for actual harm On 02/18/25 at 11:14am, V5 (Physician) stated if R1's blood pressure was 89/53, and if her baseline is much higher than that, he would expected to be notified. V5 stated especially if they are more lethargic than usual. V5 stated it is his expectation that the nursing staff rely on nursing judgment and if there is any question they should contact him. V5 stated he did not believe the facility contacted him on 12/10/25 or 12/11/25 until they were requesting for R1 to be sent out to the hospital. Residents Affected - Few On 02/18/25 at 1:44pm, V2 (Director of Nurses/DON) stated they do not have a facility or corporate policy on vital signs, she stated their expectation is for vitals to be obtained for any change in condition and per doctor's orders. V2 stated anything abnormal, staff should contact the physician. On 02/20/2025 at 7:43 am, V16 (Licensed Practical Nurse/LPN) stated, she would have notified V5 if a resident had a change in behavior, vital signs of baseline, including a blood pressure of 80/50 or if she applied oxygen to a resident. On 02/20/2025 at 9:26am, V2 (DON) stated the only standing order we utilize is the bowel protocol. She stated anything else, including oxygen the physician must be contacted. V2 stated there may be standing orders in Point Click Care, but staff knows it is her expectation they contact the physician. V2 stated her expectation is that nurses use nursing judgment and if they have concerns or unsure they should contact V5. V2 stated if a resident needs oxygen, they will contact the physician for an as needed order for oxygen, usually will start residents out on 2 liters. V2 stated that the day R1's blood pressure was 89/53, the nurse decided to try to push fluids before notifying the physician. V2 stated her expectation would have been for staff to have contacted the physician right away and recheck the vital signs. On 02/20/2025 at 9:43 AM, V4 (Registered Nurse/RN) stated, R1 started to have behavior changes on 12/10/2024. V4 stated, she had assessed R1 on 12/10/2025 and R1 had been lethargic, more confused than usual and not able to communicate well with her. V4 stated, R1 had been more resistant to care and refused water. V4 stated, she encouraged fluids for R1 and did not notify V5. V4 stated on 12/11/2024 R1 continued to have a change in behavior when she arrived for her morning shift. V4 stated, she did take R1's blood pressure at 12:42pm on 12/11/2024 and documented the 89/53. V4 stated, she did not call V5 at this time, but did encourage fluids. V4 stated, at 2:43 PM on 12/11/2024, R1 had not been getting any better so she notified V5 and then V3 (family) that R1 would be going to the local hospital for evaluation. V4 stated she did not recheck R1's blood pressure after documenting the 89/53 at 12:42 PM. V4 stated she would immediately notify V5 for any resident who had a change in behavior, vital signs from baseline, declining to eat or drink, etc. V4 stated she did not contact V5 immediately with R1's change in behavior or blood pressure reading. On 02/20/2025 at 11:16am, V19 (LPN) stated she had a vague recollection of R1, she did not care for her often. V19 stated she recalled the incident on 12/10/25 that involved R1 having decreased oxygen saturation and applying oxygen via nasal cannula. V19 stated the facility has an as needed order for oxygen. V19 could not recall if she contacted the physician but stated she would have noted it if she did. V19 stated she may have sent him a text message, but she couldn't recall. V19 stated a physician should be contacted anytime they notice a change in condition or anything concerning. V19 stated if a vital sign is obtained that is abnormal from someone's baseline, the physician should be contacted right away. Facility Change in a Resident's Condition or Status (revised May 2017) under Policy Statement, our facility shall promptly notify the resident, his or her attending physician and representative of 146032 Page 2 of 3 146032 02/21/2025 Fairview Rehab & Healthcare 602 East Jackson Du Quoin, IL 62832

F 0580 Level of Harm - Minimal harm or potential for actual harm changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In this same document under Policy Interpretation and Implementation, 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): d. significant change in the resident's physical/emotional/mental condition. Residents Affected - Few 146032 Page 3 of 3