Health inspection·February 3, 2026

F 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility failures resulted in two deficient practices.A. Based on observation, interview, and record review, the facility failed to provide adequate heating to the St. [NAME]/100 Hallway and rooms and failed to follow facility emergency protocol. These failures have caused R1 to have increased pain from muscle spasms due to being tense from the cold. These failures have the potential to affect all 31 residents residing on St. [NAME] wing, R1, and R3-R32. This failure resulted in an Immediate Jeopardy.B. Based on observation, interview, and record review the facility failed to provide adequate hot water to the entire building. This has the potential to affect all 59 residents residing in the facility. Findings include:A. The Immediate Jeopardy began on 1/12/26 around 8:00 AM. While the Immediate Jeopardy was removed on 2/3/26, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. The facility's Homelike Environment policy, initiated 12/27/23, documents the facility is to have comfortable and safe temperature levels. The facility's Cold Weather policy, revised 11/24/25, documents not in its entirety, Extreme cold can occur independent of any snow, ice, or storm systems. Extreme cold events involve an extended period of temperature at or below 32 degrees F (Fahrenheit). The risk to the health and personal safety during extreme cold is exacerbated by utility service interruption or loss. Therefore, the facility maintains its building systems ahead of any extreme weather projections. The facility acknowledges and prepares for the possibility of short staffing due to road conditions. Conduct regular building maintenance and inspections, including maintenance of heating and air conditioning systems and thermostats.Routinely monitor the indoor facility temperature when the outdoor temperature is below 65 degrees Fahrenheit to ensure the indoor temperature in residents' rooms and all common areas is maintained. Develop resident assessment protocol, including vital sign checks focusing on core temperature and comfort checks. Develop procedures for internal relocation of residents to warmer parts of the facility. Document vendors for additional heating units.Conserve heat: avoiding unnecessary opening of doors/windows; close off unoccupied rooms; cover windows. If heating equipment has failed, regularly monitor individual room temperatures.R1's admission record documents R1's date of admission to the facility was 10/1/25 and his diagnoses include but not limited to Spinal Stenosis, Site Unspecified, Diabetes Mellitus due to Underlying condition with foot ulcer, Morbid (Severe) Obesity due to excess calories, and Restless Legs Syndrome.R1's Minimum Data Set (MDS) assessment, dated 10/3/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition intact and document that R1 has frequent, severe pain.R1's current care plan documents R1 currently takes an Opioid Pain Medication and has chronic lower back pain.On 1/29/26 at 9:00 AM tour of facility was conducted with the temperature on the St. [NAME] wing (100 Halls) noted to be chilly with hallway thermostat reading 64 degrees Fahrenheit on the Northwest wing and 65 degrees on the Northeast wing. Multiple room thermostats observed to be running Page 1 of 4 146123 146123 02/03/2026 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 62-68 degrees Fahrenheit.On 1/29/26 at 10:00 AM, R1 stated that it has been cold in his room (117) since it got cold out earlier in the month and has not changed. R1 is lying in bed covered with multiple blankets. R1 stated, Being cold all the time has me all tense which causes an increase in my back spasms and pain. I just can't get comfortable when I'm cold all the time.On 1/29/26 at 10:55 AM, R4 stated, It's always cold down here and especially in my room (106-1). It really messes with my breathing.On 1/29/26 at 10:58 AM, V5 (Licensed Practical Nurse/LPN) stated he has worked on the St. Jospeh wing for the past two days and it has been cold both days. V5 is noted to be wearing a fleece jacket.On 1/29/26 at 11:00 AM, V6 (Certified Nursing Assistant/CNA) stated, Honestly, I couldn't tell you when it hasn't been cold down on this wing, it's been too long. They say the heat is working down here but you can see it's still cold down here. V6 is noted to be wearing a fleece jacket.On 1/29/26 at 11:30 AM, V4 (Maintenance Director) observed using temperature gun to check air temperature on the hallways of St. [NAME] wing and multi rooms down both halls. Temperatures noted to range from 54-63 degrees Fahrenheit. V4 stated, The boiler is running great since being fixed on 1/9/26 and again on 1/18/26. Not sure why the temperatures down here are fluctuating so much. Seems to be an airflow issue.1/29/26 at 3:00 PM, V2 (Director of Nursing/DON) stated I can't answer why residents haven't been moved to open rooms on St. [NAME] wing (200 Hall) or why we haven't gotten any other heating sources. I'm not part of those conversations with Corporate. The Administrator (V1) would be, and she is on vacation. On 1/30/26 at 9:05 AM, V1 (Administrator) who stated with V4 (Maintenance Director) present, when asked what the facility's process is if staff notice temperatures getting colder, staff are instructed to contact the Maintenance Director and/or the Administrator, or if the Administrator is unavailable, the Director of Nursing. When asked whether colder temperatures would warrant implementation of the facility's Emergency Protocol, V1 (Administrator) stated, yes. When asked if V1 (administrator) felt this process had been followed, V1 stated, I'm not entirely sure at that moment, as the situation was ongoing. Immediately following the interview, V1 came to surveyor and explained that staff did, in fact, contact her on Wednesday morning at approximately 2:00 a.m. when they began to feel that temperatures were dropping. Upon notification, V1 contacted V4 (Maintenance Director), who came into the building and checked temperatures on both hallways. He (V4/Maintenance Director) reported that the supply air temperature on the St. [NAME] wing was approximately 95 degrees, and the St. [NAME] wing was approximately 74 degrees.On 1/30/26 at 9:05 AM V4 (Maintenance Director) stated that he was not aware the temperature had dropped Wednesday, 1/28/26, after he left the building until Thursday, 1/29/26, morning when this surveyor arrived at the building.On 1/30/26 at 10:00 AM R5 stated that it has been constantly cold in her room (118) and the wing. R5 stated, The constant cold makes me tense up and increases my pain.On 1/30/26 at 11:11 AM V1 (Administrator) stated that State surveyors have been to the facility for heating issues on 1/12/26 and was cited so they found the issue and fixed corroded pipes on the boiler and then stated State surveyors were back on 1/18/26 for heating issues and cited for a second time so the facility found another issue with the boiler having a crack and had that repaired.Immediate Jeopardy Removal Plan:The facility submitted its original Abatement plan on 2/1/26 at 7:10pm.Regional Office returned Abatement plan for corrections on 2/2/26 at 1:41pm.The facility submitted the Abatement plan with corrections on 2/2/26 at 2:02pm.Regional Office returned Abatement plan with more corrections on 2/2/26 at 2:25pm.The facility submitted plan with corrections on 2/2/26 at 3:26pm.Regional Office returned Abatement plan for additional corrections on 2/2/26 at 4:54pm.The facility submitted the Abatement plan with more corrections on 2/2/26 at 5:05pm.The facility's Abatement plan was accepted on 2/3/26 at 7:13am.On 2/3/26 this surveyor confirmed through interview and record review that the facility took the following steps to 146123 Page 2 of 4 146123 02/03/2026 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some remove the immediacy:1. On 1/30/26 all staff members present were in-serviced on the facility's Comprehensive Emergency Manual Policy by V1 (Administrator) and V18 (Human Resources). 2. On 1/30/26 V4 (Maintenance Director) was in-serviced on the facility's Cold weather Policy by V1 (Administrator).3. On 1/30/26 V19 (Medical Director) was notified of the Immediate Jeopardy and updated on the plan by V1 (Administrator).4. On 1/29/26 11 residents on the St. [NAME] wing were moved to available rooms on the St. [NAME] wing. All remaining residents on the St. [NAME] wing were offered a transfer to another facility or warmer parts of the building. Those who chose to stay were provided with extra blankets and warm beverages. This action was directed by V1 (Administrator). 5. On 1/30/26 R1, R4, and R5 were immediately assessed by V2 (Director of Nursing/DON) and V20 (Nurse Practitioner) to ensure their needs were met and they were comfortable. All other residents were assessed by nursing staff and outside physicians. 6. On 1/30/26 V4 (Maintenance Director) assessed the air handler and determined the fluctuating temperatures were due to an airflow issue. Two new blower fans were installed into the air handler on 01/30/2026, to ensure adequate hot air circulation, and repairs were completed by 7:00 PM on 1/30/2026. 7. On 1/30/26 V1 (Administrator) prior to the completion of the fan installation temperatures in each resident room on the affected unit were monitored every hour. 8. On 1/30/26 V1 (Administrator), after fan installation, initiated shift-by-shift temperature monitoring completed and shift by shift monitoring will continue until the extreme cold weather has abated as determined by the QAPI committee. 9. On 1/30/26 all residents remaining on the St. [NAME] unit were assessed and continuously monitored for pain, respiratory comfort, and general comfort until heat is fully stabilized by the shift nurses on duty at that time. If any distress or pain is identified, on duty nursing staff will implement interventions to address the root cause and monitor effectiveness. 10. On 1/31/26 V13 (Housekeeping) and V21 (Dietary) installed temporary flannel window coverings to reduce heat loss in rooms on St. [NAME] wing. 11. On 1/30/26 and 1/31/26 V1 (Administrator), V18 (Human Resource), V22 (Housekeeping Director), V23 (Minimum Data Set Coordinator) educated all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather policy. Staff unavailable will be educated prior to their next scheduled shift. 12. Quality Assessment and Assurance (QAA) Committee has developed and implemented a plan to monitor preventative maintenance for the heating system. This plan includes regular audits that began on 01/30/2026 of maintenance logs by the Administrator to ensure all HVAC inspections (Daily) and radiator filter cleanings (Quarterly) are completed according to the established schedule. The results of these audits will be reviewed during scheduled QAA meetings to ensure ongoing compliance and system reliability. The duration of these audits will be continuous.13. The facility has implemented a mandatory education schedule ensuring all staff are educated on the facility Emergency policies and procedures. This training is now a permanent part of the orientation for all new hires and will be conducted annually for all existing staff December 30, 2024, documents not in its entirety, It is the policy of this facility to maintain temperatures comfortable for residents. The facility's Homelike Environment policy, initiated 12/27/23, documents the facility is to have comfortable and safe temperature levels.On 1/29/26 at 10:20 AM R1 stated that they have had hot water issues on the other side of the building (St. [NAME] side) that has been going on for a while now so those people have to come over here to take showers.On 1/29/26 R2 stated the facility had been without hot water a few weeks ago.On 1/30/26 at 11:30 AM temperatures performed on the hot water in the building with the following findings: This building has two distinct sides and there is zero hot water on the St [NAME] wings room [ROOM NUMBER]-18.1 F (Fahrenheit); room [ROOM NUMBER]-24.9 F; and room [ROOM NUMBER]- 15.4 F. On the other side, St. 146123 Page 3 of 4 146123 02/03/2026 Lacon Rehab and Nursing 401 9th Street Lacon, IL 61540

F 0921 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some [NAME] wings, shower room temped at 93.6 F, room [ROOM NUMBER]- 93.7 F; room [ROOM NUMBER]-91.4 F; room [ROOM NUMBER]-91.8 F; room [ROOM NUMBER]-93.6 F; room [ROOM NUMBER]-86.7 F; room [ROOM NUMBER]-90.2 F and room [ROOM NUMBER]-87.4 F.On 1/30/26 at 11:32 AM, V17 (Registered Nurse/RN) stated that there has not been hot water for a couple of weeks on the St. [NAME] side, some days better than others but they are using kettles to warm up water for face, hands, armpits and peri-areas.On 1/30/26 at 1:06 PM, V1 (Administrator) stated not all the mixing valves have been replaced on St. [NAME] wings so that is why there is still no hot water. V1 stated that they had to order more mixing valves to finish so that side of the building has been without hot water since State was in for complaint survey on 1/12/26.On 2/3/26 R2, R16, R34, R40, R48, and R49 all verified that there has been no hot water on their side of the building (St. [NAME]) for about a month.On 2/3/26 at 12:50 PM, V4 (Maintenance Director) and V8 (Regional Maintenance Director) stated that the St. [NAME] side of the building has been with and without hot water this whole month, spotty, then lose it; intermittent problem. V4 stated, I've been chasing mixing valves. Replaced the main mixing valve the first week or two of January. V5 stated then the mixing valve in the main shower on St. [NAME] was not working around the middle of January, leaking the cold water into the hot water so that was replaced and every individual room on the St. [NAME] side of the building has a shower in the bathroom which has a mixing valve component so all rooms were checked; verified that there are 5 (five) rooms that were broken so parts were ordered and arrived so they are now replacing those. 146123 Page 4 of 4