Inspection·August 15, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's schedule II narcotic was free from misappropriation for two of three residents (R1 and R3) reviewed for misappropriation of property in a sample of three. Residents Affected - Few Findings include: The facility's Abuse Prevention Program, revised 11/28/16, documents that it is the right of the resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This form documents that misappropriation of resident property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. R1's current Physician Order Sheet, documents for R1 to take Hydrocodone (schedule II)-Acetaminophen 5mg (milligrams)325mg every six hours as needed. The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record. R3's Physician Order Sheet, dated 8/1/23-8/11/23, documents to take Hydrocodone-Acetaminophen 5mg-325mg every six hours. The facility's pharmacy shipment details sheet documents that on 8/2/23 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility. R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the quantity delivered was 60 tablets, but only 30 tablets are accounted for. This form documents that 14 tablets of R3's Hydrocodone-acetaminophen 5mg-325mg were signed out as given at the facility and 16 were sent home with R3 at the time of her discharge on [DATE]. Thirty of R3's Hydrocodone-Acetaminophen 5mg-325mg were not accounted for. On 8/15/23 at 10:30am, V2, Director of Nursing, stated that R1 and R3's Hydrocodone-Acetaminophen 5mg-325mg tablets could be accounted for. On 8/15/23 at 1:00pm, V1, Administrator, verified that Controlled Substance Proof of Use could not be found for R1 and R3. 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: 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 08/15/2023 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)