Health inspection·June 6, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 ensure safe resident transfer and fall intervention implementation for two (R2 and R3) of three residents reviewed for falls in a sample of five. Residents Affected - Few Findings include: 1. R2's current Physician Order Sheet (POS) documents diagnoses including but not limited to: Lack of Coordination; Unsteadiness on Feet; Unspecified Tear of Unspecified Meniscus, Current Injury, Left and Right; Repeated Falls; Overactive Bladder; and Urge Incontinence. R2's Minimum Data Set/MDS assessment, dated 3/11/24, documents R2 is cognitively intact. R2's Fall Risk Assessments, dated 4/18/24 and 5/20/24, document R2 is a high fall risk. R2's current Care Plan Fall Interventions include but are not limited to Exchange single cord call light for double cord call light for additional access points in room to request assistance. R2's Care Plan also documents R2 has an alteration in her ability to care for self and needs assistance due to cognitive impairment, decreased strength and endurance, weakness. Interventions include R2 requires total dependence on one to two staff for toilet use. On 6/6/24, at 11:45am, R2 sat in a wheelchair in her room with a single cord call light clipped to her recliner. There is no double cord call light in R2's room. At this time, V15 Licensed Practical Nurse/LPN confirmed there is only a single cord call light in R2's room and stated She used to have one. She was recently moved to this room. It is a cord that splits at the end, and she used to have one so there was one on her bed and one on her recliner. Now she has to rely on staff to move it which we should be doing anyway. Prior to checking R2's room for the double cord call light, V15 reviewed R2's Care Plan and confirmed that R2 is supposed to have a double cord call light. R2's Nurse Progress Note, dated 5/19/24 at 9:10am, documents Called to residents' room by CNA (Certified Nursing Assistant) (V16) as resident had slipped when being transferred from WC (wheelchair) to toilet by CNA, (R2) landed on the floor. No gait belt applied by CNA prior to transfer and per resident not attempted to place on her. Resident was sitting on buttocks on shower ledge and had hit her left side of back on ledge of shower. R2's Nurse Progress Note, dated 5/19/24 at 10:26am Spoke with resident once settled in her recliner after falling in bathroom and resident informed need to always wear her gait belt. 'He didn't put it on me, I didn't refuse.' Discussed to not allow anyone to transfer her unless she has a gait belt (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: 146123 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 146123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540 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)