Lacon Rehab and Nursing

Inspectors wroteBased on interview and record review, the facility failed to timely remit and provide final accounting of resident personal funds for one (R1) of three residents reviewed for personal funds and billing in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement menus that addressed residents' dislikes for two of six residents (R5 and R6) in a sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to cover individual plated lunch meals during transport for three of three residents (R5, R6, and R8) reviewed for meal service in a sample of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the building in good repair and cleanliness for three of four (R3, R4, and R7) residents reviewed for homelike environment in a sample of seven. The facility's Homelike Environment/Maintenance policy, revised 12/1/25, documents that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. This form documents that the facility is to be comfortable and have safe temperature levels. The facility's Resident Call Bells policy, revised 11/5/24, documents that the facility will be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to centralized staff work area from each resident's bedside, toilet, and bathing facilities. [...]

Inspectors wroteFacility 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.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan discharge interventions for four of five residents (R1-R4) reviewed for discharge plans in a sample of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the boiler was in working order to provide heat. This failure has the potential to affect 60 residents residing in the facility. The facility's Homelike Environment/Maintenance policy, revised 12/1/25, documents that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. This form documents that the facility is to be comfortable and have safe temperature levels. The facility's Cold Weather policy, revised 11/24/25, documents that the facility will conduct regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. On 1/18/26 at 1:30pm the temperatures throughout the facility ranged from 56.0 degrees Fahrenheit to 58.0 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate heating and hot water and failed to maintain the building in good repair. This has the potential to affect 59 residents residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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 (R2, R4, R6, R7, R9 and R10) reviewed for safe water temperatures in a sample of 10.

Inspectors wroteBased on interview and record review the facility failed to obtain treatment orders for a resident with pressure injury for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to allow one resident (R18) to make her own decisions of sixteen residents reviewed for choices in a total sample of fifty-seven. This failure caused R18 emotional distress and crying. Findings Include: The Facility's undated Resident Rights Policy and Procedure documents Self-determination. Every resident has the right to, and the facility must promote and facilitate, resident, self-determination through support of resident choice, including but not limited to the rights specified in this section. A. each resident has right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 57 residents residing in the facility.

Inspectors wroteFindings Include: B. On 05/20/25 at 10:30 AM R49 was lying in bed and talking on her cell phone. (R28/another wandering resident) entered resident room with shuffling gait and mumbling. R49 stated Hi (R28), this isn't your room, turn around. R49 kept talking on her phone. R28 continued into the room. R49 stated into the phone I am going to have to let you go, I have to get her out of here. R49 transferred herself to her wheelchair and put on slippers and said come on (R28), you walk in front of me. R28 grabbed R49's hand and was easily walked out the residents door and continued on down the hallway. On 5/20/25 at 10:35 AM R49 stated this happens all the time. (R28) doesn't really bother me because she will leave easily, she's just very confused. (R11) is the one who wanders in and won't get out. [...]

Inspectors wroteB. The facility's policy titled Hand Hygiene, reviewed/revised 4/24/24, documents, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. [...]

Inspectors wrote2. R32's admission Record documents that R32's date of admission to the facility was 3/5/25 and his diagnoses on admission include Unspecified Dementia, Severe, with agitation, Anxiety Disorder, Depression, Hypertension, Altered Mental Status and Adult Failure to Thrive. R32's Minimum Data Set (MDS) dated [DATE] documents cognition as severely impaired and Section E documents physical behaviors, verbal behaviors, and behavioral symptoms directed toward others. R32's Physician Order dated 3/7/25 documents that R32 has an order for Quetiapine Fumarate/Seroquel (antipsychotic) 50mg (milligrams) by mouth twice a day for agitation related to Unspecified Dementia, Severe, with agitation and Ativan 1mg-Benadryl 25mg-Haldol 2mg (combination of antianxiety, antihistamine, antipsychotic) cream apply one milliliter (ml) topically every four hours as needed for aggression/anxiety. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to update/revise Care Plans, to include contact precautions, for one resident (R48), of one resident, reviewed for Care Plan revisions, in a total sample of 57 residents.

Inspectors wroteBased on interview and record review the facility failed to thoroughly document an instance of suicidal ideation and failed to monitor one resident after verbalization of suicidal ideation (R18) of five residents reviewed for mood and behavior in a total sample of fifty-seven. Findings Include: The Facility's Responding to Intent of Self-Harm policy dated 3/13/2023 documents the purpose of the policy is to establish a process to identify and respond to the risk of self-harmful thoughts, behaviors and action to ensure resident safety. Suicidal Ideation-verbal expressions of thoughts of harming oneself that may or may not lack specific intent or associated actions and which are generally vague, passing thoughts related to poorly defined, circumstantial issues. [...]

Inspectors wroteBased on interview, document review and observation, the facility failed to ensure residents retained their personal items. This failure has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure prior survey investigations were available and signs were posted to notify residents/families of the availability of the survey investigations. These failures have the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe kitchen environment, failed to test the dishwasher sanitation system and failed to educate staff on the use of the dishwasher. This has the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented as ordered for 1 of 5 (R19) residents who had an order for enhanced barrier precautions in a sample of 34 residents.

Inspectors wroteBased on interview and record review the facility failed to implement an antibiotic stewardship program that included assessment and monitoring of residents for signs and symptoms of infections and failed to ensure that the antibiotic usage was appropriate and failed to the use of a recognized surveillance criteria to define the infections. This deficiency has the potential to affect all 54 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their elopement policy, failed to document the testing of the elopement device and failed to ensure an elopement device was in place for three of five residents and reviewed for elopement (R14, R18, R32) and failed to provide supervision for high fall risk residents (R24, R40) residents for 5 of 5 residents reviewed for supervision, in a sample of 34.

Inspectors wroteBased on record review, observation and interview, the facility failed to monitor refrigerator/freezer temperatures to ensure safe storage of resident's medications. This failure has the potential to affect 24 residents (R5, R7, R9, R10, R14, R17, R19, R20, R22, R26, R27, R30, R34, R35, R36, R46, R47, R48, R49, R53, R55, R56, R162, R212) who reside on the Saint [NAME] Wing and R15, R18, R21 on the Saint [NAME] Wing.

Inspectors wroteBased on interview and record review the facility failed to provide the resident and resident representative with a written notice of transfer, for one of one resident (R18) reviewed for hospitalizations, in a sample of 34. Findings Include: R18's medical record documents that R18 was transferred to a local hospital on 7/30/23. No evidence of a facility notification to R18 of a transfer/discharge was present on R18's chart. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a written notice of transfer.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for one of one resident (R18), reviewed for bed holds, in the same of 34. Findings Include: R18's medical record documents that R26 was hospitalized on [DATE]. R18's medical record does not contain documentation of written notice to R18 or R18's resident representative, of the facility bed hold policy. On 6/26/24 at 1:30 P.M., V1/Administrator verified that the facility did not provide R18 or his representative with a Bed Hold Policy or a written Notice of Transfer.

Inspectors wroteBased on interview, and record review the facility failed to update the Care Plan to reflect the bilateral lower edema and daily weights for one of three residents (R212) in a sample of 34. Findings Include: The facility policy titled, Comprehensive Care Plan, revised June 25, 2020, documents the following: An individualized comprehensive care plan that includes measurable objectives and time able to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 3.) Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas. 5.) Care plans are revised as changes in the resident's condition dictate. R212's Diagnosis Sheet, dated 5/9/2024, documents R212's admission date as 5/9/2024. The Order Summary Report, dated 6/26/2024, documents the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to obtain physician ordered daily weights for two of two residents (R18), reviewed for edema, and failed to ensure Hospice plans of care were available to staff and kept updated in the resident's record for one of two residents (R14 and R32) reviewed for Hospice in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered dementia plan of care for one of one resident (R50) reviewed for dementia care, in the sample of 34. Findings Include: The facility policy, Care of resident with Dementia, dated November 5, 2019, directs staff, A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practical physical, mental and psychosocial well-being. The facility will provide dementia treatment and services which may include, but are not limited to the following: Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety and utilizing individualized non-pharmacological approaches to care. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was free of dirt/grime buildup in that the tops of stationary equipment, and surrounding, cooking surfaces, were covered with buildup-including the overhead exhaust. This failure has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refuse receptacles [trash dumpster's] where food/trash is discarded outside are securely covered. This failure has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately notify a resident's physician of a new skin impairment, failed to implement treatment orders for new skin impairments, failed to measure, monitor, assess, and document residents' wounds and failed to follow physician orders for splints for four of 14 residents (R29, R32, R43, R51) reviewed for quality of care in the sample of 29. Findings Include: The facility's Skin Prevention, Assessment and Treatment Policy, revised 5/2/22, states, Purpose: To identify factors that place the residents at risk for the development of pressure ulcers. To implement appropriate interventions to prevent the development of clinically avoidable wounds. 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. Treatment Guidelines: [...]

Inspectors wroteBased on interview and record review the facility failed to complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one resident (R49) of one resident reviewed for PASARR screenings in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a resident's plan of care to include mechanical lift transfers and splints for foot drop for one of 14 residents (R51) reviewed for care plans in the sample of 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to transfer a resident using a mechanical lift with two staff members for one of five residents (R51) reviewed for accidents in the sample of 29.

Inspectors wroteBased on record review and interview the facility failed to follow the Facility Policy to obtain four weeks of admission weights for three Residents (R29, R43, 51) of 24 Residents reviewed for weight monitoring in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility infection control policy and procedure during medication pass for two (R16 and R53) of 24 residents observed for infection control in the sample of 29.