Inspection·November 13, 2025

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 and record review, the facility failed to provide a safe transfer for 1 of 1 resident (R6) reviewed for accidents in the sample of 16. Findings include:R6's admission Record, print date of 10/2/25, documents R6 was admitted on [DATE] and has diagnoses of Alzheimer and Dementia.R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired, uses wheelchair, is dependent on staff for toileting, showers, lower body dressing, personal hygiene, and all mobility except rolling in bed.R6's Care Plan, dated 12/12/23, documents, (R6) has a Self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activities of Daily Living) related to dx (diagnosis): ALZHEIMER'S DISEASE, UNSPECIFIED, HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE. Intervention: Transfer: Two person physical assistance required Date Initiated: 12/13/2024.R6's Therapy to Nursing Recommendations, dated 8/21/25, documents R6 transfers with assist of 2 with a wheeled walker.R6's Health Status Note, dated 9/3/2025 08:53, documents, Residents daughter/POA (Power of Attorney) (V16) approached nurses station to report that resident had redness discoloration/bruising noted to the top of both hands this AM and a small skin tear present to the top of her left hand. Upon assessment this nurse noted that resident does have reddish discoloration/bruising present to the top of both hands and wrist area. ROM (range of motion) appears to be unaffected, and resident denies pain/ discomfort at this time. Does have a small skin tear present to the top of her left hand with absence of any drainage or discharge from open area. MD (Medical Doctor), DON (Director of Nurses) and Administrator notified of incident. Skin tear cleaned with wound cleanser and steri-strips applied as ordered.R6's Health Status Note, dated 9/3/25, documents, Made (V17) office aware of skin tear and reddish discoloration/bruising to bilateral hand and wrist. Made aware of skin tear to top of left hand and treatment started.R6's Health Status Note, dated 9/6/24, documents, Discoloration continues to bilateral wrists, s/sx (signs and symptoms) of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/7/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/7/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/8/25, documents, Discoloration continues to bilateral wrists, no s/sx of tenderness noted to discoloration. Two steri strips to left hand intact, no s/sx infection noted. Resident continues scheduled tylenol.R6's Health Status Note, dated 9/20/25, documents, Bruises to Lt (left) wrist and arm are resolved. continue monitoring Rt (right) wrist and arm.R6's QA (quality assurance) report, dated 9/3/25, documents, General Information Type: Skin Issue. Incident Location unknown Prior caregiver (V18, Certified Nurse Aide (CNA)), other treatments: steri strips and wound cleanse to top of left hand. Details: Skin (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: 145456 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 145456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626 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)