Health inspection·February 9, 2023

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. Based on observation, interview, and record review, the facility failed to provide supervision during toileting for a resident with a diagnosis of Dementia and failed to ensure fall prevention alarms were functioning for two of two residents (R25, R84) reviewed for falls in the sample of 31. Findings include: The facility's Fall Prevention Program, dated 10/24/22, states Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 1. R84's Fall Risk Assessment, dated 1/11/23, documents R84 is at moderate risk for falls. R84's Pre-admission History and Physical, dated 11/27/22, documents R84 had a couple falls at home. R84's Minimum Data Set assessment, dated 1/17/23, documents R84 requires extensive assistance with transfers, ambulation, and toileting. R84's Care Plan, dated 1/2/23, documents the following: R84 had a fall at home, prior to facility admission, that resulted in a sacral fracture; R84's post fall intervention, dated 1/06/2023, to implement a pressure pad alerting device in bed and chair at all times to notify staff if R84 is attempting to self-transfer/ambulate as she does not always remember to ask for assistance. R84's Event Report, dated 1/6/23, documents R84 fell in her room while trying to move a bedside table and lost her balance. The Event Report ,dated 1/6/23, documents the Root Cause Analysis for R84's fall was (R84) attempting to self-transfer without assistance. R84's Hospital Record, dated 1/6/23, documents R84 fell at the facility and sustained a Lumbar Compression Fracture with Sacral Pain and a Scalp contusion. R84's Event Report, dated 2/8/23 at 2:37 AM, documents R84 was found on the floor next to her bed on her hands and knees. (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 2 Event ID: 145596 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 145596 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snyder Village 1200 East Partridge Metamora, IL 61548 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)