FAYETTE COUNTY HOSPITAL
Non profit - Corporation
63 Beds
Independent
Data: November 2025
Trust Grade
68/100
#142 of 665 in IL
Photo by SBL Fayette County Hospital
Photo by B Tippets
Photo by Steve Wasser
1 / 10 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fayette County Hospital has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #142 out of 665 facilities in Illinois, placing it in the top half, and is the best option among the three nursing homes in Fayette County. However, the facility is experiencing a worsening trend, with the number of reported issues increasing from 2 in 2023 to 3 in 2024. Staffing is a strong point, with a 5 out of 5-star rating and a turnover rate of 39%, which is below the state average. Despite this, the facility has faced some serious shortcomings, including failing to assess pain properly for a resident, leading to unrelieved pain for five days, and not securing a foot strap during a lift that resulted in another resident needing stitches. Additionally, there have been concerns about insufficient Registered Nurse coverage, which did not meet the required hours on multiple occasions. Overall, while there are strengths in staffing and overall ratings, families should be aware of the serious incidents and staffing challenges reported.
- Trust Score
- C+
- In Illinois
- #142/665
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near Illinois's 48% average. Typical for the industry.
- Penalties ✓ Good
- $18,233 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 71 minutes of Registered Nurse (RN) attention daily — more than 97% of Illinois nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ○ Average
- 6 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
68/100
Top 21%
Needs review
2 → 3 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 2 issues
2024: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Illinois average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 39%
Near Illinois avg (46%)
Typical for the industry
Federal Fines: $18,233
Below median ($33,413)
Minor penalties assessed
The Ugly 6 deficiencies on record
2 actual harm
Oct 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**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 (R...
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**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 tries to remove splint from left arm. She has pain to her left arm at times. She had another fall on 08/26/24, but she stated, she did not fall, she got on the floor to rest. No injury noted. 09/13/24 found on the floor. (The two open areas on the left thumb are healed on 09/23/24.) 10/21/24 resident has been picking at a reddened area on her mid forehead. The care plan's revision date is documented as 10/21/2024. There were no new fall interventions documented on R10's Care Plan following the falls on 8/26/24 and 9/24/24.
On 10/24/24 at 12:45 PM, V2 (Director of Nursing) stated they do not have a new intervention for the fall on 8/26/24 or the other fall on 9/24/24, it is just to continue the interventions that are currently in place.
On 10/24/24 at 12:50 PM, V1 (Administrator) stated it is hard to come up with new interventions for her, but they will talk to her son and see if they can figure some out.
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 tries to remove splint from left arm. She has pain to her left arm at times. She had another fall on 08/26/24, but she stated, she did not fall, she got on the floor to rest. No injury noted. 09/13/24 found on the floor. (The two open areas on the left thumb are healed on 09/23/24.) 10/21/24 resident has been picking at a reddened area on her mid forehead. The care plan's revision date is documented as 10/21/2024. There were no new fall interventions documented on R10's Care Plan following the falls on 8/26/24 and 9/24/24.
The undated facility policy titled, Fall Prevention Program documents in part: Post-fall management: Post fall assessment includes, but not limited to: what happened, how it happened, why did it happened, (vital signs, blood glucose level, neuro checks at the time of the fall), were appropriate interventions in place Specific considerations as to why the fall might have occurred, including, but not limited to: .How similar outcomes can be avoided. How the care plan will change.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the findings of monthly Medication Regimen Review's (MRR) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the findings of monthly Medication Regimen Review's (MRR) for 5 (R6, R17, R18, R22, R26) of 5 residents reviewed for unnecessary medications in a sample of 22.
Findings include:
1. R6's admission Record documented an admission date of 3/4/24 with diagnoses that included major depressive disorder, adjustment disorder with mixed anxiety and depressed mood.
R6's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating that R6 was cognitively intact.
R6's Order Summary sheet documented an active order for twenty-two oral medications.
R6's Progress Notes documented that Medication Regimen Reviews (MRR's) were completed for R6 on 3/20/24, 4/22/24 and 5/22/24.
A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R6 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024.
2. R17's admission Record documented an admission date of 4/1/22 with diagnoses that included Alzheimer's, major depressive disorder, delusional disorders, anxiety and insomnia.
R17's MDS dated [DATE] documented a BIMS score of 13, indicating R17 was cognitively intact.
R17's Order Summary sheet documented an active order for seventeen oral medications.
R17's Progress Notes documented that MRR's were completed for R17 on 4/22/24, 5/22/24 and 6/5/24.
A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R17 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024.
3. R18's admission Record documented an admission date of 10/17/22 with diagnoses that included dementia with mild anxiety, major depression disorder, generalized anxiety disorder, and post-traumatic stress disorder.
R18's MDS dated [DATE] documented a BIMS score of 7, indicating R18 was severely cognitively impaired.
R18's Order Summary sheet documented an active order for seventeen oral medications.
R18's Progress Notes documented MRR's were completed for R18 on 3/20/24, 4/22/24, 5/22/24 and 6/5/24.
A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R18 had MRR's completed on 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024.
4. R22's admission Record documented an admission date of 5/15/24 with diagnoses that included Alzheimer's disease with late onset, insomnia, hallucinations, anxiety, restlessness and agitation.
R22's MDS dated [DATE] documents a BIMS score of 3, indicating that R22 was severely cognitively impaired.
R22's Order Summary sheet documented an active order for eighteen oral medications.
R22's Progress Notes documented a MRR was completed for R22 on 5/22/24.
A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R22 had a MRR completed on 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024.
5. R26's admission Record documented an admission date of 1/14/23 with diagnoses that included anxiety disorder, Alzheimer's disease, depression, and insomnia.
R26's MDS dated [DATE], documented a BIMS score of 7, indicating R26 was severely cognitively impaired.
R26's Order Summary sheet documented an active order for sixteen oral medications.
R26's Progress Notes documented MRR's were completed for R26 on 3/20/24, 4/22/24, 5/22/24 and 6/5/24.
A facility document titled Consultant Pharmacist Medication Regimen Review (MRR) and Physician Notification was provided that documented R26 had MRR's completed for 3/20/24, 4/22/24 and 5/22/24. There was no documentation produced to show that MRR's were completed for the months of June, July, August and September 2024.
On 10/22/24 at 2:41 PM, V2 (Director of Nursing/DON) stated the missing months of MRR's were because the pharmacist ran out of MRR papers.
On 10/23/24 at 2:40 PM, V2 stated there would be a progress note if a MRR had been done.
On 10/24/24 at 10:03 AM, V11 (Consultant Pharmacist) stated he did MRR's for the residents every month at the pharmacy but was not in the facility. V11 stated that he had not documented them in the resident's medical record. V11 stated he had just recently discussed with V2 (DON) how they were going to document the MRR's. V11 stated that he used to chart in the resident's medical record before they started using this new program for electronic medical records. V11 stated when they switched, he started using a paper form. V11 stated he ran out of the paper form and was unable to order more because they had been discontinued.
A facility document titled (Name of Facility) Monthly Summary September 2024 signed by V11 (Consultant Pharmacist) states that all charts were reviewed and signed on September 25, 2024 and that all charts were in order.
The facility was unable to produce any resident specific documentation by V11, to show that the medications were reviewed, or charts were signed in June, July, August and September 2024.
The undated Facility Policy titled Pharmacy Provider documents under Section II, titled Consultant Pharmacist that it is the responsibility of the consultant pharmacist to maintain a log of all visits and activities within the facility and to submit written reports to the LTC (Long Term Care) manager on a monthly basis. It further documents that it is the responsibility of the consultant pharmacist to review the drug regimen of each resident on a monthly basis and report any irregularities to the medical director, LTC manager, and the resident's personal physician. Under Section III, titled Resident Drug Regimen Reviews it documents that the consultant Pharmacist shall provide the facility with documentation that he/she has reviewed each resident's drug regimen at least monthly. If the Consultant Pharmacist determines that there are no irregularities, he/she shall record in the resident medical record that he has performed the review and shall sign and date the entry.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provided the services of a Registered Nurse (RN) for 7 days a week for 8 consecutive hours per day. This failure has the potential to effec...
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Based on interview and record review, the facility failed to provided the services of a Registered Nurse (RN) for 7 days a week for 8 consecutive hours per day. This failure has the potential to effect all 29 residents living at this facility.
Findings Included:
On 10/22/2024 at 1:50 PM, V2 (Director of Nursing/DON) stated the facility did not have the required 8 hours per day, 7 days a week of RN coverage for the dates of 5/11/24, 5/19/24, 5/27/24, 6/9/24 and 6/30/24. V2 said they did not have a policy for Registered Nurse coverage.
On 10/22/2024 at 10:00 AM, V1 (Administrator) stated that nurse's calling off has contributed to a few days of not having Registered Nurse coverage.
The facility nursing schedule for May and June of 2024 revealed the facility did not have the required 8 hours of Registered Nurse coverage for the following dates: 5/11/24, 5/19/24, 5/27/24, 6/9/24 and 6/30/24.
The Long Term Care Application for Medicare and Medicaid (Form CMS 671) dated 10/21/24 documents that there are 29 residents living in the facility.
Sept 2023
2 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**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 ...
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**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.
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 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. R27 had not fallen or any other incident. No further signs of pain or discomfort after giving pain medication.
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.
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.
R27's Medication Administration Record nor the Treatment Administration Record dated 07/01/2023 - 7/31/2023 has any pain monitoring for either document.
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.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS (Minimu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS (Minimum Data Set) data to the CMS (Center for Medicare/Medicaid Services) System after a resident death for 1 (R10) of 1 residents reviewed for timely MDS transmittals.
Findings Include:
R10's facility Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses of Anxiety, Hypertension, Paroxysmal Atrial Fibrillation, Constipation, Atherosclerosis, Gastro-esophageal Reflux Disease (GERD), History of Transient Ischemic Attack (TIA), Iron Deficiency Anemia, and Urinary Tract Infection, and documents a discharge date of [DATE].
R10's Progress Note dated [DATE] documents in part .R10 continued on Hospice .expired at the facility at 10:15 PM .R10's body released to (name of funeral home).
R10's medical record documents the Minimum Data Set (MDS) dated [DATE] as a Significant Change in Status assessment, and as the last assessment completed for R10.
On [DATE] at 10:30 AM, V8 (MDS Coordinator) stated that she forgot to input R10's discharge date in her MDS. V8 stated that R10's last MDS was dated [DATE] and R10 expired at the facility on [DATE].
Aug 2022
1 deficiency
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to secure a foot strap during a sit to stand mechanical l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to secure a foot strap during a sit to stand mechanical lift transfer for 1 of 10 (R23) residents reviewed for falls in a sample of 27. This failure resulted in R23 receiving 4 sutures to the left 3rd and 4th toes.
Findings Include:
R23's Face Sheet documents R23 is a male resident with a date of birth of [DATE] and an admission date of [DATE]. R23's Face Sheet documents diagnoses including: Type 2 diabetes Mellitus, Chronic Diastolic heart failure, Unspecified Atrial Fibrillation, Vascular Dementia with behavioral Disturbance and Bell's Palsy. R23's Minimum Data Set (MDS) dated [DATE] Section C documents a Brief Interview For Mental Status (BIMS) score of 13, indicating R23 is cognitively intact. Section G documents: Extensive assistance with a one-person physical assist for transfers.
A final report sent to the Department on [DATE] documents in part, On Friday [DATE] at 4PM, R23 was being assisted up from the bed using a Sit to Stand mechanical lift. His foot slipped and he received lacerations under the third, fourth, and fifth toes of the left foot. He was transported to the E.D (Emergency Department) for treatment. He received dissolvable sutures to third and fourth toe.
R23's Emergency Department Summary of Care printed [DATE] documents in part, 79 y/o (year old) M (male) presents with lac (lacerated) plantar 3rd and 4th toes from sit to stand device Repair #1, Wound closed with: Sutures; Number Sutures/Staples Placed: 4
R23's Departmental Notes dated [DATE] at 9:27 PM document: sent resident to emergency room at approximately 4:15 PM. Resident's foot slipped while CNA (Certified Nurse Aide) was getting him up on the sit to stand. There is a laceration to left 3rd, 4th, and 5th underneath the toes. Two sutures to the 3rd, an 4th toes that will dissolve on their own were administered.
On [DATE] at 10:10 AM during the demonstration of the use of the sit to stand, while securing the leg strap, R23 stated to V8 (Certified Nursing Assistant/CNA), Is this new?
On [DATE] at 3:57 PM, V4 (Certified Nurse Aide/CNA) stated, during the incident with R23 she did not utilize the leg strap when she was lifting him. She went to set him back down and his foot slid off of the foot plate. V4 (CNA) stated, after she set him down she noticed blood on his foot and went and got the nurse. R23 did have non-skid socks on when the incident occurred. V4 (CNA) stated, the leg strap is supposed to be used, she does use it now, but she did not then.
On [DATE] at 4:40 PM, V5 (Certified Nurse Aide/CNA) stated, when she utilizes the sit to stand she has the resident sit on the side of the bed, she will already have the sit to stand there, she will put the harness on the resident, bend down to belt the legs down, attach the harness to the sit to stand and then begin the lift. V5 (CNA) stated, she would always use the foot strap, it would help them from stepping back. The sit to stands usually take one person to utilize it however, if the person is really shaky she may have another person assist her. The facility usually goes over one topic a month for training. The facility keeps a paper on each resident at the nurse's station that will give any needed information or any changes to a resident that is updated daily and there is a space to document if there was something with that resident on that shift.
On [DATE] at 5:03 PM, V6 (Certified Nurse Aide/CNA) stated, when using the sit to stand you place the resident's feet on the foot plate and put the leg strap on, put the harness on, and make sure they hold on. She was trained at the facility on how to use the sit to stand. She always uses the leg strap.
On [DATE] at 1:05 PM, V2 (Director of Nursing /DON)) stated, they do competencies every year, in fact they are going on right now. Newly hired Certified Nurse Aides (CNAs) are trained by senior CNAs that have been deemed trainers. The trainers will go through a check list with the new CNAs and sign off when a skill has been completed. They have 90 days to get through the checklist. If there is an item they still feel uncomfortable with or a resident they feel uncomfortable with individually, they are encouraged to have another CNA assist them. V2 (DON) stated, she is the one that is in charge of the training and does train CNAs. V2 (DON) stated, when the CNAs are trained to use the sit to stand, they are always trained to utilize the leg strap and footwear or gripper socks to help secure their feet. They are instructed to use the leg strap in every situation. They do not have a CNA competency checklist for V4 (CNA). V2 stated V4 started at the facility as a Nurse Aide and became a CNA then left shortly after due to not being vaccinated, she was then vaccinated and was rehired at the facility. During this timeframe, her 90 had expired and her 90 days have not passed since her rehire.
On [DATE] at 1:30 PM, V1 (Administrator) stated, all CNAs are trained to secure the leg strap when utilizing the sit to stand. V1 (Administrator) stated, V4 has been trained on the sit to stand and if she felt uncomfortable with utilizing the sit to stand she should have had another CNA assist her. We are in-servicing all CNAs on utilizing the sit to stand.
On [DATE] at 1:42 PM, V7 (CNA) stated, she is a CNA trainer for the facility. She trains the new CNAs to utilize the leg strap on the sit to stand every time. The leg strap is supposed to be secured on the resident with the sit to stand before lifting the resident.
R23's Care Plan dated [DATE] for [DATE] under the heading Risk for Pressure Ulcers (handwritten in) documents: My foot slipped off the sit to stand lift platform when staff were transferring me. I have laceration to the under side of my left 3rd, 4th, and 5th toes. I went to the emergency room and have some stitches that will dissolve on their own. The interventions listed include: Treatment to laceration under the left 3rd, 4th, and 5th toes as ordered per doctor. Monitor for healing of the lacerations under my left 3rd, 4th, and 5th toes. Notify medical doctor with updates as needed. [DATE] Continue to use sit to stand for transfers. Ensure proper staff training of foot placement, sling placement, and preventing total weight left of device. [DATE] Treatment to top of left great toe nail area. Monitor top of left great toenail for healing. Notify medical doctor with updates as needed. Notify podiatrist with updates as needed.
The undated facility document titled, Safe Patient Handling and Movement states: Purpose: This policy is intended to ensure that employees use safe patient handling and movement techniques to reduce patient and employee injury. Statement of policy: #301 Direct care staff will be trained in patient handling and movement techniques, and identification of the safest methods to employ based on patient assessment and categorization. Additionally, mechanical lifting equipment and/or other approved patient handling aids should be utilized to prevent the lifting and handling of patients/resident except when absolutely necessary, such as a medical emergency. Zero-lift Policy: III. Staff Competency A. All direct care staff will receive education/training on this policy and proper use of the associated equipment upon hire and then, annually to ensure competency.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 39% turnover. Below Illinois's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 6 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $18,233 in fines. Above average for Illinois. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
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About This Facility
What is Fayette County Hospital's CMS Rating?
CMS assigns FAYETTE COUNTY HOSPITAL an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Fayette County Hospital Staffed?
CMS rates FAYETTE COUNTY HOSPITAL's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 39%, compared to the Illinois average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Fayette County Hospital?
State health inspectors documented 6 deficiencies at FAYETTE COUNTY HOSPITAL during 2022 to 2024. These included: 2 that caused actual resident harm and 4 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Fayette County Hospital?
FAYETTE COUNTY HOSPITAL is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 63 certified beds and approximately 28 residents (about 44% occupancy), it is a smaller facility located in VANDALIA, Illinois.
How Does Fayette County Hospital Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, FAYETTE COUNTY HOSPITAL's overall rating (4 stars) is above the state average of 2.5, staff turnover (39%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Fayette County Hospital?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Fayette County Hospital Safe?
Based on CMS inspection data, FAYETTE COUNTY HOSPITAL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Fayette County Hospital Stick Around?
FAYETTE COUNTY HOSPITAL has a staff turnover rate of 39%, which is about average for Illinois nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Fayette County Hospital Ever Fined?
FAYETTE COUNTY HOSPITAL has been fined $18,233 across 1 penalty action. This is below the Illinois average of $33,261. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Fayette County Hospital on Any Federal Watch List?
FAYETTE COUNTY HOSPITAL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.