Inspection·July 5, 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 control a resident in a wheelchair during a transportation and prevent injury and failed to report a resident injury to the nurse for one resident (R1) out of three residents reviewed for accidents in a sample of three. Findings include: The facility's Notification for Change In Resident Condition or Status policy revised 12/7/17 documents The facility and/or facility staff shall promptly notify appropriate individuals of changes in the resident's medical/mental condition and/or status. 2. The nurse supervisor/charge nurse will notify the DON (Director of Nursing), physician and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the afore mentioned situations or: A. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. The facility's Transportation Driver job summary undated documents Responsibilities: e. Transports resident to and from scheduled appointment and approved locations in a safe and responsible manner. h. Responsible for the care and well-being of all residents. R1's minimum data set (MDS) documents a brief interview for mental status (BIMS) score of 15. A BIMS score of 12-15 indicates a resident is cognitively intact. R1's MDS also documents R1's locomotion off the unit requires a one person physical assist. On 7/5/23 at 8:25 AM, R1 observed sitting in her bed with bilateral bruising to her face, bloodshot right eye, bruising to the left arm, skin tear to her right first knuckle and a skin tear to her left forearm. R1 stated All this (point to her arm, facial bruising and skin tears to her right hand knuckle and left forearm) happened while I was getting in the van for dialysis on Saturday (7/1/23). I was going out the front door and all the sudden I started rolling downhill because the driver didn't have a hold of my wheelchair. They always hold my wheelchair when I come out of the facility because of that slope in the walkway. I started rolling and I couldn't stop myself. I wound up rolling downhill and slammed into the van's lift. The nurse never came out and looked at anything before I went to dialysis. On 7/5/23 at 9:00 AM, V3, Van Driver (VD), stated I pulled open the front door and (R1) started pushing herself through the doors with their feet. I didn't grab her wheelchair because she was wheeling herself toward the van. It looked like she lost control of the wheelchair and started rolling toward the van. She put her hands up in the air trying to brace herself for impact when she hit the lift. I didn't see her hit her head. When I looked at her, she had a cut on her right hand. I grabbed (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: 145266 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 145266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611 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)