Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on interview and record review, the facility failed to ensure resident safety prior to repositioning for
one of three residents (R1) reviewed for incidents and accidents in the sample of three. This failure resulted
in R1 sustaining a deep leg laceration requiring a hospital visit, receiving 13 stitches, and antibiotic
treatment.
Findings include:
The facility's Skin condition Monitoring policy and procedure, dated 1/18, documents It is the policy of this
facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities.
1. Upon notification of a skin lesion, wound, or other skin abnormality, the Nurse will assess and document
the findings in the nurses' notes and complete the QA (Quality Assurance) form for Newly Acquired Skin
condition . 3. Any skin abnormality will have a specific treatment order until area is resolved . 4.
Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until
the area is healed. Documentation of the area must include the following: c. Prevention techniques that are
in use for the resident.
The Residents' Rights for People in Long-Term Care Facilities, dated 1/18, documents Your rights to safety
includes the following: The facility must provide services to keep your physical and mental health at their
highest practical levels and Your facility must be safe, clean, comfortable and homelike.
The undated Certified Nurses Aide/CNA Job Summary documents CNAs provide personal care and
assistance to residents to assure their safety and comfort and demonstrates support of the philosophy of
(the facility) by adhering to policies, procedures, and established Standards of Nursing Practices.
The Clinical Medical Record for R1 documents R1 with the following diagnoses: Chronic Obstructive
Pulmonary Disease, Emphysema, Dysphagia, Scoliosis, Osteoporosis, Abnormal Posture, and Muscle
Wasting.
The Nurse Progress Note for R1, dated 2/4/25 at 6:44 am, documents nurse was notified of R1 with leg
injury and noted R1 with deep tissue skin tear. CNA reported R1 was injured during transfer from bed to the
chair and was sent to the local hospital.
The Skin Tear report for R1, dated 2/4/25, documents Nurse was notified by V6 CNA that R1's leg was
injured with deep tissue skin tear to her right lower leg, No injuries observed at the time of incident, and
was sent to the local hospital for evaluation.
(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:
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
03/21/2025
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)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
The local hospital record for R1, dated 2/4/25, documents the reason for R1's visit as Laceration of right
lower extremity, initial encounter. Primary Dx (diagnosis): Leg pain, anterior right with laceration repair. The
Medication Administration Record documents R1 received the pain medication Norco 7.5-325 mg
(milligrams) one time at 8:44 am and lidocaine-Epinephrine 1% 10 ml (milliliters) was injected one time on
2/4/25 at 10:03 am. An x-ray of R1's right tibia and fibula was obtained on 2/4/25 at 9:02 am and findings
as: Laceration related soft tissue changes are seen overlying the mid anterior tibia. R1 was treated for a
laceration of right lower extremity.
The current Order Summary Report for R1, documents a 2/5/25 physician order for Cephalexin (antibiotic)
500 mg (milligrams) one capsule four times daily for leg wound.
The Infection Progress Note for R1, dated 2/4/25, documents R1 to receive Keflex 500 mg (milligrams) one
capsule four times daily for 7 days for leg wound.
The Nursing Progress Note for R1, dated 2/4/25 at 1:47 pm, documents R1 returned from the local hospital
with 10.5 cm (centimeter) deep tissue laceration with 13 stitches to R1's right leg mid-calf.
The Nursing Progress Note for R1, dated 2/4/25 at 8:09 pm, documents New order for Abt (antibiotic) d/t
(due to) laceration on LLE (left lower extremity).
The current Care Plan for R1, documents 2/4/25 Laceration to right lower extremity with intervention to
monitor for s/s of infection and on 2/10/25 exchange bed frame.
The Incident Progress Note for R1, dated 2/10/25, documents After investigation it was determined that the
skin tear/laceration occurred while CNA was titling (reclining wheelchair) back due to restlessness. (R1) put
her leg over side of chair and received a 10.5 cm (centimeter) laceration to right lower extremity from
bottom edge of bed requiring 13 stitches. Intervention: replace bed frame, terminate CNA (V6), and monitor
s/s (signs and symptoms) of infection.
The facility Investigation for R1's incident, dated 2/4/25, documents V5 CNA assisted V6 Former CNA to
mechanically transfer R1 from her bed to a reclining back wheelchair and left R1 in her room. V5 reported
there were no injuries at the time of the transfer. Shortly after V6 saw R1, in her room, attempting to get out
of the wheelchair. V6 reported R1's leg got stuck under edge of bed as V6 was tipping R1's reclining
wheelchair backward. V4 RN (Registered Nurse) was notified and assessed R1 with a large bleeding
wound on lower anterior and lateral aspect of right lower leg. V3 ADON (Assistant Director of Nursing)
reported assessed R1's leg and noted a large skin tear to anterior/lateral aspect of distal right leg. V6
Former CNA reported to V3 ADON that R1 was attempting to get out of the reclining wheelchair, so V6
Former CNA attempted to recline R1 back and R1's leg hit the lower edge of the bed causing the skin tear.
The facility Final Notification Form for R1, dated 2/10/25, documents R1 received a laceration to right lower
leg, was sent to the local hospital. After investigation it was determined that skin tear/laceration occurred
while CNA (V6) was tilting (reclining) chair back due to restlessness. (R1) put her leg over side of chair and
received a 10.5 cm (centimeter) laceration to right lower extremity from bottom edge of bed requiring 13
stitches. Intervention: Replaced bed frame, terminated CNA and monitor for s/s (signs and symptoms) of
infection.
The Incident Log dated 3/20/25 documents R1 with skin tear on 2/4/25.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145266
If continuation sheet
Page 2 of 3
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
03/21/2025
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)
F 0689
Level of Harm - Actual harm
On 3/20/25 at 11:00 am. V1 AIT (Administrator in Training) stated R1 required help for everything, was not
cognitively intact, and did not move around on her own. V6 Former CNA was moving R1's wheelchair and
caught R1's leg on a bolt on the bend of the bed causing a skin tear to R1's leg. R1 was sent out to the
hospital and came back with stitches.
Residents Affected - Few
On 3/21/25 at 12:12 pm, V3 ADON (Assistant Director of Nursing) stated she was called down to R1's room
to assess R1's right leg due to the nurses doing shift change report and noted a deep open wound bleeding
wound to R1's right leg and a small amount of blood on R1's bed frame. V6 reported (V6) reclined R1's
wheelchair and R1's right leg hit the lower edge of the bed frame causing the skin tear. V3 ADON confirmed
V6 should have looked to see where R1's legs were prior to moving R1's wheelchair and that V6 was
terminated for sleeping on third shift and causing the skin care.
On 3/21/25 at 12:20 pm, V5 CNA stated she helped V6 mechanically lift R1 from her bed into her
wheelchair, there were no injuries during that time, and then V5 left R1's room. V5 stated she didn't see
R1's wound until R1 returned from the hospital. It was a pretty large skin tear that was stitched back up.
On 3/21/25 at 3:30 pm, V1 AIT stated V6 should have looked to see where R1's legs were prior to moving
R1 and V6 was terminated after working that shift for poor work performance and sleeping on the job. V1
stated the facility does not have a QA form for Newly Acquired Skin condition for R1 due to no longer using
the form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145266
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 21, 2025 survey of Fondulac Rehabilitation and Health Care Center?
This was a inspection survey of Fondulac Rehabilitation and Health Care Center on March 21, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Fondulac Rehabilitation and Health Care Center on March 21, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.