Lacon Rehab And Nursing

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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 obtain treatment orders for a resident with pressure injury for 1 of 3 residents (Resident R1) reviewed for pressure injury in the sample of 10.The findings include:Resident R1's Electronic Face Sheet documents Resident R1 was admitted to the facility on [DATE REDACTED] with diagnosis of Alzheimer's dementia, depression, and anxiety. Resident R1 was on hospice services due to Alzheimer's dementia.Resident R1's Braden Scale (assessment use to predict pressure risks) show Resident R1 was high risk to for pressure injury. Resident R1's admission assessment under skin dated 4/2/25 by V15 (former Administrator/LPN) documents pressure to coccyx as non-staged. Under treatment: {Wound Company} notified, will see Resident R1 on next visit due (4/8/25)Resident R1's Wound Assessment and Plan with initial visit dated 4/15/25 by V17 (Wound MD) show: Wound Location-coccyx, Wound Type-Pressure Injury, Wound Measurements-1.5 centimeters (cm) x 1cm x 0.1 cm.

Wound Order: Coccyx wound- cleanse with normal saline or sterile water apply Hydrocolloid to wound every 2 days and PRN.On 8/22/25 at 1PM. V2 (Director of Nursing-DON) said Resident R1 was admitted with pressure injury. V2 (DON) said she thought Resident R1 had wound treatment upon admit. Resident R1 had dressings to coccyx when she checked Resident R1's coccyx wound. V2 also said Resident R1 was supposed to see V17 (Wound Md) on 4/8/25 to obtain treatments but Resident R1 was not on the list to be seen at that time.Resident R1's Electronic Treatment Sheet documents: coccyx wound- cleanse with normal saline or sterile water apply hydrocolloid to wound bed every two days and as needed. Start date 4/15/25 (approximately 13 days after admission).On 8/22/25 at 2:30 PM, V16 (Asst Director of Nursing) said wound treatment should be obtained as soon as the wound was discovered to promote wound healing.The Facility Policy on Skin Prevention, Assessment and Treatment dated 5/7/2024 show, to identify factors that place the residents at risk for the development of pressure ulcers, to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown and to promote healing of existing pressure ulcers.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

observation, interview, and record review the facility failed to ensure that water was delivered at a safe and comfortable temperature. This applies to 6 of 7 residents (Resident R2, Resident R4, Resident R6, Resident R7, Resident R9 and Resident R10) reviewed for safe water temperatures in a sample of 10. The findings include: On 8/22/25 at 10:05AM the temperatures of the water coming out of the bathroom sinks on the St. [NAME] wing of the facility were checked. The readings were as follows: Resident R2 and Resident R4's room [ROOM NUMBER].9 degrees Fahrenheit, Resident R6's room [ROOM NUMBER].3 degrees Fahrenheit, Resident R7's room [ROOM NUMBER] degrees Fahrenheit, Resident R9's room [ROOM NUMBER].6 degrees Fahrenheit and Resident R10's room [ROOM NUMBER].7 degrees Fahrenheit.On 8/22/25 at 10:30 AM Resident R9 stated, Sometimes the water is too hot.On 8/22/25 at 1:00PM V4 (Maintenance Director) stated, The water should be 110 degrees in the resident areas and 160 in the kitchen. I am supposed to do water temps but I am not going to lie, I have not had time to do them and I have not been doing them.The facility policy entitled Water Temperatures dated 12/30/2024 states, Water temperatures in resident rooms should not exceed 110 degrees Fahrenheit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview and record review the facility failed to ensure the dishwasher was reaching 180 degrees Fahrenheit to sanitize the dishes and prevent cross contamination. This applies to all 56 residents in the facility. The findings include: On 8/22/25 the facility census showed a total of 56 residents residing in the facility. On 8/22/25 at 9:30AM Surveyor asked V8 (Dietary Aid) to check the Sanitizer level in

the dishwasher. V8 used a Quaternary Ammonia strip and ran it through a cycle of the dishwasher. The strip came out a light blue color. Comparing it to the key and the package of strips V8 stated, It's supposed to be between this one (400ppm) and that one (500ppm). We check the dishwasher once a day. Surveyor then showed V7 (Dietary Manager) the test strip and V7 looked at the dishwashing machine and stated she would have to get maintenance because she doesn't know anything about it.At 9:45AM V4 (Maintenance Director) Came to inspect dishwasher. V4 tried to run the final rinse cycle with no numbers showing on the screen for the final rinse temperature. V4 stated, I didn't know I was responsible for the dishwasher.At 9:50AM V7 (Dietary Manager) stated, I have never had to have the dishwasher serviced. I'm not sure who

we use.On 8/22/25 at 12:03PM V5 (Maintenance Director from a Sister Facility) stated, The dishwasher is a high temp machine- the machine is designed to get to 190 degrees but I don't know why it is not displaying

the temp. The wash temp is reading fine, but I can't get the final rinse temp to show. The machine is showing 200 on the strips. Surveyor asked to accompany V5 to the dishwasher for another test. V5 again used Quaternary strips and ran one through a cycle on the dishwasher. The strip did not register any quaternary ammonia. Surveyor pointed out that the strips were to test quaternary ammonia and this is a hot water machine. V5 then went to look for strips to test for hot water and returned stating they did not have any hot water test strips available in the building. At 12:10PM Surveyor requested temperature logs for the dishwasher from V7 and V7 stated, we don't have those. The facility policy entitled Dish Machine Use dated December 30, 2024 states, Dish machine hot water sanitation rinse temperature may not be more than194 degrees F, or less than 180 degrees F for all other machines.

Event ID:

Facility ID:

If continuation sheet