Inspection·July 13, 2022

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 implement fall prevention interventions to prevent falls for two (R2 and R11) of three residents at risk for and reviewed for falls in the sample of twenty three. Findings include: 1. On 07/10/22 at 10:32am, R2 was observed lying in his bed asleep. Gripper strips were noted to be adhered to the floor beside R2's bed. R2's Care Plan with a review date of 05/11/22 documented a problem area of (R2) is at risk for falls, with a corresponding intervention, (Staff) educated on replacing nonskid strips to floor after waxing floor. R2's Fall Investigations documented the following: 03/17/22: Resident was sitting on bathroom floor in front of toilet. Injuries: None noted. Conclusion: Replaced gripper strips in front of the toilet as an intervention. 04/07/22: (R2) was on the edge of the bed when he slid to the floor. No apparent injuries. Conclusion: We will replace the nonskid appliques on the floor beside the bed . 04/24/22: Resident had an unwitnessed fall, found in floor of resident room. Injuries: Hematomas left forehead, left shoulder, left upper arm. Conclusion: Residents room was just recently waxed and nonskid strips were not in place. (V1 Administrator) educated staff on ensuring that fall interventions are properly in place (for) all residents. 2. R11's Care Plan with a review date of 06/15/22 documented a problem area,(R11) is at risk for falls, with a corresponding intervention, Nonslip strips to the floor at the bedside. R11's Fall Investigations document the following: 10/14/21:Resident was (found) on floor against bed on her buttocks. Injuries: None noted. Conclusion: Floor recently waxed by maintenance, gripper strips not intact, staff reeducated on the importance of fall interventions. A Fall Prevention Policy (S.A.F.E.) with a revision date of February 2014 documented, Definition: The S.A.F.E. Program promotes Safety Assessment, fall prevention, and Education of both staff and (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 3 Event ID: 146146 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 146146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Silver Foxes Sr Living & Rehab 609 South Marshall McLeansboro, IL 62859 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)