Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Foxes Sr Living & Rehab during CMS and state inspections, most recent first.
A resident with dementia, Parkinson’s disease, urinary retention, BPH, CKD, and a chronic indwelling catheter had physician orders and a care plan requiring monthly catheter changes, monitoring of intake/output, and prompt reporting of UTI and retention signs. During one month, the catheter was not changed as ordered, and documentation showed a steady decline in urine output, culminating in minimal output one day and no documented output the next. Nursing staff noted dark, sedimented urine, vomiting, poor intake, lethargy, and a distended abdomen, but the physician was not notified for many hours, catheter irrigation was delayed, and no catheter change was attempted until after prolonged absence of urine. When the resident was finally sent to the ED, more than 1800 ml of foul, brown, sediment-laden urine was drained after catheter replacement, and the resident was diagnosed with sepsis, complicated UTI, hydronephrosis with obstruction, acute renal failure, and AKI on CKD, and was transferred to another hospital for further care.
A resident with dementia, Parkinson’s disease, urinary retention, and an indwelling catheter experienced vomiting, loose stools, refusal or inability to eat and drink, and then no documented urine output overnight. Despite care plan directives and facility policies requiring prompt reporting of decreased or absent urine output and changes in condition, nursing staff on the evening/night and early morning shifts did not notify the physician, attributing the symptoms to overeating and not acting on the lack of urine output. Later that morning, another nurse found the resident lethargic with a distended, rigid lower abdomen and no catheter output, contacted the MD, and the resident was sent to the ED, where a markedly distended bladder and large volume of dark, malodorous urine with sediment were documented.
A resident with a history of falls and cognitive impairments was not provided with necessary fall prevention interventions, such as foot pedals on her wheelchair and supervision within staff's line of sight. Staff were unaware of these requirements, and the resident was observed multiple times without foot pedals and unsupervised, contrary to the care plan and facility policy.
The facility failed to administer pneumococcal vaccinations to three residents who had consented to receive them. Despite having medical conditions that could increase their risk, the facility's records showed no documentation of the vaccinations being given, nor were there any active orders for them. The facility's policy requires offering the vaccine within 30 days of admission, but the administrator was unaware of the residents' vaccination needs, leading to the deficiency.
Failure to Monitor Catheter Output and Respond to Urinary Retention Leading to Complicated UTI and Sepsis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections and urinary retention for a resident with an indwelling catheter. The resident had multiple diagnoses including Parkinson’s disease, unspecified dementia, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic kidney disease. The care plan and physician orders required monitoring and documenting intake and output, monitoring for and reporting signs and symptoms of UTI and urinary retention, and changing the 18 Fr coude catheter with 10 cc balloon every 30 days on night shift. The Treatment Administration Record for the entire month of December shows no catheter change, despite the monthly change order. The TAR also documents a progressive decline in daily urinary output from mid-December, with outputs dropping from over 900 ml per day to 200 ml on one day and then no documented urine output on the following day. Nursing notes show that on 12/08 the RN documented dark amber urine with white sediment in the catheter tubing, with fluids encouraged and a message to the DON, and on 12/09 the urine was still dark yellow, though improved. On 12/16, a note documented that the catheter was not changed at a doctor visit and that there was a new order to change monthly. On 12/19, the DON documented a new order from the urologist to change the catheter to an 18 Fr coude with 10 cc balloon monthly, with a plan to change when supplies were received and a follow-up appointment scheduled. On 12/25, the resident vomited, had a large bowel movement, and was noted to be afebrile in the morning; later that day the resident refused food, took medications with water, had a small amount of amber urine in the catheter bag, and had a low-grade temperature of 99.5 for which Tylenol was given. The LPN caring for the resident on 12/25 reported that there were times when the resident’s urine would get darker and staff would encourage fluids, and she attributed the vomiting to overeating while out with family. Overnight into 12/26, the DON, who was the nurse on duty, received report that the resident had been sick all day, had not eaten or drunk anything, and had vomited the previous day. She also received report that day shift had flushed/irrigated the catheter without issue, and she did not attempt to irrigate the catheter herself. She did not notify the physician, believing the resident was sick from overeating, and later stated that the resident had no urine output all night; she passed this information to the oncoming day nurse and did not take further action. On the morning of 12/26, an LPN reported being told that the resident had not taken medications, had no urine output, and had not eaten; she assessed the resident, attempted to irrigate the catheter without success, and then notified the physician, who ordered transfer to the emergency department. Another LPN who passed medications that morning stated she did not notify the physician, did not provide catheter care, and did not recall being told there was no urine output. The facility’s catheter care policy required observing urine levels for noticeable increases or decreases and reporting if the level stayed the same or increased rapidly, and required immediate reporting of signs and symptoms of urinary retention or UTI. The output policy required reporting abnormal output within 24 hours. The urology nurse later stated that, given the resident’s diagnosis, prior catheter issues, and decreasing urine output, action should have been taken when decreased output was first noted and when no urine output was observed, including flushing or changing the catheter before complete absence of output. When the resident arrived at the local hospital emergency department on 12/26, he was lethargic, hypotensive, and had a distended bladder with no drainage in the catheter bag. A bladder scan showed more than 1570 ml of urine. When the existing 18 Fr coude catheter balloon was deflated, brown, foul-smelling urine began flowing around the catheter, and after replacement with an 18 Fr straight-tip Foley catheter, 1850 ml of very malodorous, nearly brown urine with a large amount of sediment was drained. Photos from the hospital showed dark brown, cloudy urine with large amounts of sediment. The ED records documented clinical impressions including hydronephrosis with ureteropelvic junction obstruction, sepsis with acute renal failure and septic shock, and unspecified acute renal failure type, and the resident was transferred to an out-of-state hospital. The out-of-state hospital records documented admission and discharge diagnoses of sepsis, complicated UTI, chronic indwelling catheter, and acute kidney injury on chronic kidney disease stage 3B. The urology nurse reported that, in the urologist’s professional opinion, when no urine output was noticed, something should have been done at that point rather than waiting additional hours, and that with decreasing urine output and an indwelling catheter, the catheter should have been flushed or changed before there was no urine output.
Failure to Timely Notify Physician of Resident’s Change in Condition and Absent Urine Output
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician of a significant change in condition for one resident with multiple comorbidities, including Parkinson’s disease, unspecified dementia, aortic valve stenosis, dysphagia, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, and cognitive communication deficit. The resident had an indwelling urinary catheter and a care plan directing staff to monitor intake and output and to report signs and symptoms of urinary tract infection or urinary retention, including no urine output, altered mental status, and changes in eating patterns. The resident’s MDS showed severe cognitive impairment, and the Treatment Administration Record documented that on one day the resident’s oral intake was minimal (10 ml on day shift, 240 ml on evening shift, and 0 on night shift) and that the resident ate 0% of all three meals. On the morning of that day, a progress note documented that when staff attempted to get the resident out of bed for breakfast, there was dried emesis of undigested food in the bed, the resident was incontinent of a large bowel movement, and although afebrile, the resident clenched teeth when staff attempted feeding or medication administration. A later note that same day documented that the resident was up in a wheelchair for lunch but continued to clench teeth when staff attempted to feed. The TAR documented 0 urinary output from 10 p.m. that night through 6 a.m. the following morning. Despite these findings of vomiting, loose stools, refusal or inability to eat and drink, and no documented urine output overnight, the nurse on the 7 p.m. to 6 a.m. shift did not notify the physician, stating she believed the resident was sick from overeating the previous day. The nurse passing medications the following morning also did not notify the physician, despite being aware the resident had been sick with emesis and loose stools and had not eaten or drunk that morning. Later that morning, another nurse documented that the resident was lethargic with a distended and rigid lower abdomen and that there had been no urine output from the indwelling catheter, at which point the physician was contacted and ordered transfer to the emergency department. In the hospital, the resident was noted to be responsive only to painful stimuli, with a distended bladder and no drainage in the catheter bag; bladder scan showed more than 1570 ml, and after catheter replacement, 1850 ml of very malodorous, nearly brown urine with large sediment was drained. The facility’s policies on change in condition and catheter care required prompt notification of the physician and supervisor for changes in medical condition, including decreased or absent urine output and signs of urinary retention or infection. Interviews with the attending physician and urology staff indicated that action should have been taken when decreased or absent urine output was first noticed, and that waiting additional hours before intervention was not appropriate given the resident’s condition and history.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident who was at risk for falls due to gait and balance problems, dementia, and a history of falls. The resident was admitted with a fractured right femur and had experienced two falls without injury since admission. Despite the care plan specifying that the resident should have foot pedals on her wheelchair and remain within staff's line of sight, these interventions were not consistently implemented. On multiple occasions, the resident was observed without foot pedals on her wheelchair and was not within the line of sight of staff, contrary to the care plan requirements. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, were unaware of the requirement for the resident to have foot pedals on her wheelchair. The Director of Nursing confirmed that the resident should have had foot pedals on at all times, especially during transport, and should not have been left in her room without staff present. The facility's policy on managing falls and fall risks emphasized the need for resident-centered fall prevention plans and monitoring of interventions, which were not adequately followed in this case.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to three residents, despite having signed consent forms indicating their willingness to receive the vaccines. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, hypertensive heart disease, chronic kidney disease, and dementia, which could increase their vulnerability to pneumococcal infections. The facility's records did not document any pneumococcal vaccinations given to these residents, nor were there any active orders for the vaccinations in their Order Summary Sheets. The facility's policy, dated August 2016, requires that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and offered the vaccine within 30 days unless contraindicated or previously vaccinated. However, the facility administrator admitted to having no documentation for the vaccinations and was unsure if the residents needed them or which specific vaccines were required. This lack of documentation and follow-through on the facility's vaccination protocol led to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mcleansboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mcleansboro Rehab & Hlth C Ctr | 0.7 mi | ★★★★★ | 0 | 0 |
| Eldorado Rehab & Healthcare | 19.7 mi | ★★★★★ | 1 | 0 |
| Wabash Senior Living & Rehab | 20.1 mi | ★★★★★ | 10 | 1 |
| White County Rehab And Nursing | 20.3 mi | ★★★★★ | 2 | 0 |
| Stonebridge Nursing & Rehab | 21.3 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.