Health inspection·November 14, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to implement fall prevention interventions for 1 of 5 residents (R35) reviewed for falls in a sample of 24. Findings include: R35's admission Record documents R35 was admitted to this facility on 10/12/2024 with diagnoses of fractured right femur, dementia, weakness and reduced mobility among others. R35's MDS (Minimum Data Set) dated 10/19/2024 documented in Section C, Cognitive Patterns, that R35 is never understood, has short and long term memory problems and due to this, R35 could not participate in a BIMS (Brief Interview for Mental Status) test. The same MDS documents in section J, Health Conditions, that R35 has had 2 falls with no injury since her admission or prior assessment. A form titled Illinois Department of Public Health documented on 10/18/24, R35 fell out of her wheelchair while being transported by staff in the dining room. According to the form, R35 put her foot down and lunged forward out of the wheelchair and onto the floor. R35 was hospitalized and returned to the facility on [DATE]. R35's care plan was reviewed and new interventions put into place. R35's Care plan, with initiation date of 10/11/2024 documented the focus area of: I am (at) risk for falls due to gait/balance problems, unaware of safety needs and hx (history) of actual fall with fx (fracture) . Planned fall intervention with a start date of 10/18/2024, documented R35 will have her foot pedals on her wheelchair. Another fall intervention with a start date of 10/16/2024 documented R35 will remain within staff's line of sight when out of bed. On 11/13/2024 at 8:30am, R35 was observed in the facility's dining room in her wheelchair, with staff but without foot pedals on her wheelchair. On 11/13/2024 at 11:10am, R35 was observed siting in her wheelchair at the nurse's station with V3 (Licensed Practical Nurse) and V5 (Certified Nursing Assistant). R35 did not have foot pedals on her wheelchair. V3 was asked about R35's missing foot pedals and replied, I didn't know she (R35) was supposed to have foot pedals on her wheelchair. V5 then transported R35 from the nurse's station to the group room down the hallway without foot pedals on R35's wheelchair. When asked about the missing foot pedals, V5 said she did not know if R35 was supposed to have on foot pedals. On 11/13/2024 at 12:15pm, R35 was observed in the same group room, in her wheelchair and without foot pedals on her wheelchair. (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 4 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 11/14/2024 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)