Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lacon Rehab And Nursing during CMS and state inspections, most recent first.
Two residents were not provided meal options that accommodated their food dislikes, despite a facility policy stating that resident likes and dislikes would be considered for substitutions. One resident ate a fish entrée he disliked only by covering it with tartar sauce and reported that the only alternative offered was a peanut butter and jelly sandwich, which he also disliked, and he was not offered a substitute for a dessert he did not eat. Another resident, who also disliked fish, skipped the facility meal and obtained outside food instead. The Dietary Manager reported there was no anytime menu and that available substitutes were limited to peanut butter and jelly or possibly a cheese sandwich, which were acknowledged as not nutritionally equivalent to the main meal.
The facility failed to follow its own policy requiring all transported food to be covered and maintained at proper temperatures, contributing to ongoing complaints about cold and poorly executed meals. During an observed lunch service, plated meals were transported from the kitchen to the dining room uncovered and placed on tables before residents arrived, with no warming plates used. A resident later found his fish only slightly warm and reported that this occurs frequently, while two other residents’ plates sat uncovered for an extended period before being removed. Staff acknowledged that plates are usually covered and that covers were available, and the Dietary Manager confirmed both the requirement to cover transported food and the presence of repeated complaints about cold food.
Surveyors found that multiple residents were living in rooms that were not clean, well-maintained, or safely equipped. One resident’s bathroom sink was inoperable with a black, slimy ring and torn wallpaper on the walls. Another resident’s call light was reportedly always on due to a short, leaving them without a reliable way to summon help, and their bathroom had a strong urine odor and a large puddle of yellowish liquid on the floor that remained wet later in the day. A third resident’s toilet had dried bowel movement on the seat, rim, and front of the bowl, with urine odor extending into the hallway and visible splatter on enabler bars, despite a housekeeper stating the room had been cleaned. Nursing staff reported that housekeeping was expected to clean rooms and bathrooms daily and as needed, and to address issues such as the soiled floor.
The facility failed to maintain adequate heating and hot water, and did not effectively implement its emergency protocols during extreme cold. On one wing, hallway and room temperatures were documented as low as the mid-50s°F, while residents and staff reported that it had been cold there for an extended period. A resident with spinal stenosis, chronic severe pain, and opioid use reported that the persistent cold increased back spasms and pain and prevented comfort, while other residents reported that the cold worsened breathing and pain. The DON could not explain why residents were not relocated to warmer rooms or why additional heat sources were not obtained, and the Administrator’s account of temperature checks conflicted with later low readings. In addition, one side of the building had no true hot water for weeks, with residents reporting they had to go to the other side for showers and staff using kettles for basic hygiene, while measured water temperatures on the affected side were near cold and the other side only lukewarm. Leadership acknowledged ongoing mixing valve problems and that the affected side had been without hot water for about a month.
The facility failed to develop and implement required discharge care plan interventions for four of five residents reviewed for discharge planning. Policy required a post-discharge plan addressing care preferences, access and payment for services, coordination among caregivers, specific discharge needs (e.g., ADLs, self-medication, diet, dressings, therapy), referrals, and preparation for discharge, as well as measurable objectives and timetables. One resident reported discharge was not discussed until an involuntary discharge notice was issued, and others stated no one had discussed discharge with them, with one relying on family to explore home health independently. In each of these cases, the EMR and care plans lacked any documented discharge plan or interventions. The MDS Director/RN stated discharge planning should begin on admission and identified the Social Service Director as responsible for the discharge portion of the care plan, and the Social Service Director admitted she had fallen behind and confirmed the absence of discharge plans for these residents.
The facility failed to maintain its boiler in working order, causing indoor temperatures to fall into the mid to upper 50s Fahrenheit, despite policies requiring regular maintenance of heating systems and safe, comfortable temperature levels. On the day of the deficiency, a seam in the boiler had broken, leaving the building without heat, and staff confirmed the low temperatures. Multiple residents were observed wearing winter coats, stocking caps, and several blankets while in bed or seated in common areas, and a family member reported that a resident’s room was very cold and that the resident’s head was cold to the touch upon arrival. The census records showed that 60 residents were present at the time, all with the potential to be affected by the lack of adequate heat.
The facility failed to maintain adequate heating, hot water, functional call systems, and building repairs, resulting in cold rooms, lack of hot water, and unsafe, unsanitary conditions. Water temperatures were appropriate on one hall but only in the mid‑70s°F on another, with the Maintenance Director citing unresolved mixing valve and boiler issues. Several bathrooms lacked running water, had clogged sinks and toilets, wet and stained bath blankets on the floor, black slimy material in toilets, and suspected mold-like areas, while ceiling tiles in a main hallway were stained and associated with a mildew odor. Multiple residents were observed bundled in coats, blankets, and shawls, reporting that their rooms were cold and that prior complaints to staff went unanswered; one resident’s room temperature was documented at 63°F. Call systems were unreliable or absent, including cords with exposed wires, call lights that only worked while held down, call lights that stayed on continuously or activated spontaneously, and a resident resorting to a handheld bell for assistance. Staff confirmed long‑standing issues with water temperature and call lights and reported heating water in an electric tea pot at the nurses’ station for bathing and hygiene.
Surveyors found that the facility's dishwasher was not properly monitored for required sanitizing temperatures, with staff using incorrect test strips and unable to provide temperature logs or appropriate testing materials. Both dietary and maintenance staff were unfamiliar with proper procedures and responsibilities, resulting in a failure to ensure dishes were sanitized according to facility policy for all residents.
Water temperatures in several resident rooms were found to exceed the facility's policy limit, with one resident reporting that the water was sometimes too hot. The Maintenance Director confirmed that routine water temperature checks had not been conducted as required.
A resident admitted with Alzheimer's dementia and high risk for pressure injuries had a coccyx pressure ulcer identified at admission, but wound treatment orders were not obtained until nearly two weeks later. The delay occurred because the resident was not seen by the wound care provider as scheduled, resulting in a lapse in timely wound care.
A resident with full cognitive capacity was repeatedly gotten out of bed for meals against her wishes, resulting in emotional distress. Despite the facility's policy supporting resident choice, staff followed instructions to get her up, disregarding her expressed preferences. Leadership later confirmed that residents should not be forced to get up if they do not want to.
Surveyors found that the outdoor trash dumpster was missing two lids, with trash piled above the top and no surrounding security, allowing potential access by pests or animals. The Dietary Manager confirmed the dumpster should be kept closed and secured, in accordance with facility policy.
Medications and treatment supplies were left unsecured in a resident's room, contrary to facility policy, while multiple residents with cognitive impairment and wandering behaviors were able to enter another resident's room repeatedly. One such intrusion resulted in a resident being injured when a confused resident fell onto her, and no follow-up or investigation was documented by staff.
Staff failed to consistently follow infection control protocols, including proper use of PPE and hand hygiene, when caring for residents on contact precautions for ESBL and VRE and during wound care procedures. An LPN and other staff entered isolation rooms without required gowns, did not perform hand hygiene before or after glove use, and handled shared medication carts and supplies, increasing the risk of cross-contamination.
Two residents receiving psychotropic medications did not have specific behaviors or non-pharmacological interventions documented prior to medication administration. For one, the MAR only showed check marks without detailed progress notes, and the care plan behaviors did not match those recorded. For the other, behavior monitoring was noted but lacked specifics, and progress notes described combative behaviors without documentation of attempted interventions.
A resident was placed on contact isolation due to an active infection, with visible signage and a physician order in place. However, the care plan was not updated to reflect the new isolation precautions, despite facility policy requiring care plan revisions when a resident's condition changes.
A resident with a history of depression and recent bereavement expressed suicidal ideation, leading a psych NP via telehealth to order a hospital evaluation. Facility staff failed to document any physical or behavioral assessment, did not record vital signs or details of the resident's statements, and did not update the care plan or provide required follow-up monitoring. The DON confirmed that documentation and monitoring were inadequate following the incident.
The facility failed to ensure residents retained their personal items, affecting all 54 residents. Complaints were made about missing items and slow clothing returns due to a broken washing machine. The Housekeeping Supervisor noted understaffing and issues with marking resident clothing, leading to confusion and items being placed on a missing items rack.
The facility did not ensure that prior survey investigations were accessible or that signs were posted to inform residents and families of their availability. During a survey, it was found that Resident Council Members were unaware of the state investigations, and no notices or binders were visible. The Activity Director located the binder hidden behind the guest sign-in book, and the Administrator confirmed the lack of notification signs.
The facility failed to maintain a safe kitchen environment, with deficiencies in the dishwasher sanitation system and unsanitary conditions. The dishwasher's rinse cycle did not reach the required temperature, and there were leaks from a hole in the exhaust fan. Additionally, the steam table was unclean, and water pooled on the floor due to dishwasher splashes. These issues could affect all 54 residents.
A facility failed to implement enhanced barrier precautions (EBP) for a resident as ordered. The EBP policy required gowns and gloves during high-contact care activities, with signage on the door. However, no EBP sign or PPE was available outside the resident's door, and an LPN was unaware of the EBP order.
The facility failed to implement an effective antibiotic stewardship program, lacking documentation and monitoring of antibiotic use and infections. A resident hospitalized for severe infections was not properly documented in the facility's logs, and the DON acknowledged the tracking system's incompleteness.
The facility failed to follow its elopement policy and did not document the testing of elopement devices for residents at high risk for wandering. Residents with severe cognitive impairments were not consistently monitored, and some were found without proper elopement devices. Additionally, residents at high risk for falls were observed unsupervised, despite care plans requiring frequent rounding and supervision. Staff acknowledged these lapses, indicating a failure to implement safety protocols effectively.
The facility failed to monitor refrigerator and freezer temperatures as required, compromising the safe storage of medications. Temperature records were incomplete for the refrigerator/freezer in the Saint [NAME] Linen Room and the Saint [NAME]'s Medication Room, affecting the storage of medications like Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. This deficiency could impact the health of residents relying on these medications.
A facility failed to provide a resident and their representative with a written notice of transfer to a hospital. The resident's medical record lacked evidence of such notification, and the facility administrator confirmed the oversight.
A facility failed to provide a resident or their representative with a copy of the bed hold policy upon the resident's transfer to a hospital. The resident's medical record lacked documentation of written notice regarding the policy. This was confirmed by the facility's administrator during an interview.
A facility failed to update a resident's care plan to include bilateral lower extremity edema and daily weight monitoring, despite the resident's diagnoses of congestive heart failure and the presence of a left ventricular assist device. The care plan did not reflect these critical needs, and there were significant gaps in the documentation of daily weights, contrary to the physician's orders. The DON acknowledged the oversight, noting the necessity for the care plan to specify daily weight monitoring and the protocol for contacting the cardiovascular team.
The facility failed to obtain daily weights for two residents, one on diuretic therapy and another with a Left Ventricular Assist Device, as per physician orders. Additionally, the facility did not ensure Hospice care plans were available and updated in residents' records, with one resident's plan not specific to the services needed and another's records inaccessible due to electronic documentation by Hospice staff.
A facility failed to create a person-centered dementia care plan for a resident with dementia and agitation. The care plan only included monitoring for changes and task segmentation, lacking individualized interventions. The Care Plan Coordinator confirmed the absence of person-centered strategies, contrary to the facility's dementia care policy.
The facility failed to implement fall prevention measures for two high-risk residents. One resident, with a history of falls, was not provided with a double cord call light and fell during a transfer without a gait belt. Another resident lacked non-skid strips in front of her recliner, as required by her care plan, increasing her fall risk. These deficiencies highlight a lack of adherence to the facility's fall prevention policies.
Failure to Provide Adequate Menu Substitutions Based on Resident Dislikes
Penalty
Summary
The facility failed to implement menus that addressed residents’ dislikes, despite a substitutions policy stating that residents’ likes and dislikes will be considered when making substitutions. One resident was observed at lunch with baked fish, broccoli, hash brown casserole, and baked apples; he stated he does not like fish and used three packets of tartar sauce to mask the taste so he could eat it, reporting that if he did not eat the fish he would not get anything else. He further stated that the only substitute offered is a peanut butter and jelly sandwich, which he also does not like and does not consider an appropriate substitute for the main meal, and he was not offered any substitute for the baked apples he disliked and left uneaten. Another resident’s lunch tray with fish was left on the dining room table while she was absent; staff later stated she had food delivered because she does not like fish, and the resident confirmed she does not like fish and therefore ordered outside food instead of eating the facility meal. The Dietary Manager stated that the facility does not offer an anytime menu and that the only substitutes available are a peanut butter and jelly sandwich or possibly a cheese sandwich, and verified that these substitutes are not equal in nutritional value.
Uncovered and Poorly Temperature-Controlled Meals During Transport and Service
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring all food transported from the kitchen to other parts of the building to be covered and maintained at proper temperatures. The facility’s Transportation of Food policy, revised 11/5/19, states that all food must be covered during transportation and that food must maintain proper temperatures while being transported. Resident Council Meeting Minutes from two separate meetings document multiple complaints about meal execution, including burnt or overcooked items, cold food, undercooked or soggy eggs/omelets, and cold or late meals. On the observed lunch meal service, a cart with already-plated meals was taken from the kitchen to the dining room without any covers or warming plates to protect the main meal. The plates were set on the table uncovered before the residents were present. One resident arrived at the table and found his fish only slightly warm, stating that this happens all the time and that there was no one in the dining room to reheat the meal. Two other residents’ plates remained uncovered on the table for an extended period until a staff member removed them, with the staff member acknowledging that plates are usually covered but not knowing why they were not covered that day. The Dietary Manager confirmed that all transported food is supposed to be covered, that covers were available next to the service line, that no warming plates are used, and that there have been complaints about cold food.
Failure to Maintain Clean, Repaired Environment and Functional Call System
Penalty
Summary
Surveyors identified failures to maintain the building in good repair and cleanliness and to ensure a functional call system for multiple residents. For one resident, the bathroom sink had no running water, with a sign posted instructing not to turn on the water, and the sink bowl had a black, slimy ring. The wallpaper inside the door was ripped from the ceiling to about three feet from the floor in a section approximately two feet wide, with another large piece missing near the heating vent. The Assistant Maintenance Director confirmed that the sink was not working and the wallpaper was peeled off the walls. Another resident was observed sleeping in bed with the call light activated while a CNA in the hallway stated that this resident’s call light was always on due to a short or similar issue and suggested the resident should have a handheld bell, which could not be located. When asked how the resident would request help if they fell, the CNA stated she did not know. The same resident’s bathroom had a strong urine odor and a large puddle of yellowish liquid in front of the toilet with footprints leading from the toilet to the bed; later in the day the floor remained wet with paper towels covering the puddle and the odor unchanged. A third resident’s toilet had dry bowel movement on the seat, around the top rim, and down the front of the bowl, with a strong urine smell extending into the hallway and visible yellow and brown splatter on the enabler bars. A housekeeper reported she had finished cleaning that room and described her duties as emptying garbage, cleaning floors, and dropping off paper products, while the toilet and bathroom remained unchanged. A RN stated that housekeeping was supposed to enter the room several times a day to empty garbage and that rooms, including bathrooms, were to be fully cleaned daily and as needed, and verified that housekeeping should have cleaned the floor in the other resident’s room.
Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable indoor temperatures and to follow its emergency protocols during periods of extreme cold, as well as its failure to provide adequate hot water throughout the building. The facility’s own Homelike Environment and Cold Weather policies require maintaining comfortable and safe temperature levels, conducting regular maintenance and inspections of heating systems, and routinely monitoring indoor temperatures when outdoor temperatures fall below 65°F. Despite these policies, surveyors observed on 1/29/26 that the St. [NAME] wing (100 Hall) was chilly, with hallway thermostats reading 64–65°F and multiple room thermostats between 62–68°F. When the Maintenance Director used a temperature gun, hallway and room air temperatures on that wing ranged from 54–63°F. Staff interviews confirmed that the wing had been cold for an extended period, with staff wearing fleece jackets and stating they could not recall when it had not been cold on that wing. Residents reported ongoing cold conditions and associated discomfort. One resident in room 117, with diagnoses including spinal stenosis, diabetes with foot ulcer, morbid obesity, and restless legs syndrome, and documented as cognitively intact with frequent severe pain and chronic lower back pain requiring opioid medication, stated that it had been cold in his room since earlier in the month and that being cold all the time made him tense, increased his back spasms and pain, and prevented him from getting comfortable. Another resident in room 106-1 stated it was always cold on the wing and that it affected his breathing. A resident in room 118 reported that the constant cold made her tense and increased her pain. The Director of Nursing could not explain why residents had not been moved to open rooms on a warmer hall or why additional heating sources had not been obtained, and stated she was not part of those conversations with corporate while the Administrator was on vacation. The Administrator later acknowledged that staff had contacted her around 2:00 a.m. when temperatures began dropping, and that the Maintenance Director had checked temperatures and reported higher readings than those later observed by surveyors, indicating a lack of effective implementation of the facility’s emergency protocol as temperatures continued to fluctuate and remain low. The deficiency also includes the facility’s failure to provide adequate hot water to the entire building, particularly on the St. [NAME] side. Residents and staff reported that there had been hot water issues for weeks, with residents from the affected side needing to come to the other side to shower, and staff using kettles to warm water for face, hands, armpits, and perineal care. On 1/30/26, surveyors measured hot water temperatures and found zero hot water on the St. [NAME] wings, with room readings as low as 15.4°F, while the other side of the building had lukewarm water in the 86.7–93.7°F range. The Administrator stated that not all mixing valves had been replaced on the St. [NAME] wings and that this side of the building had been without hot water since a prior complaint survey on 1/12/26. Multiple residents confirmed that there had been no hot water on their side for about a month. The Maintenance Director and Regional Maintenance Director stated that the St. [NAME] side had been with and without hot water throughout the month, describing the problem as intermittent and related to mixing valves in the main system, the main shower, and individual room showers, with several room mixing valves identified as broken.
Removal Plan
- In-service all staff members present on the facility's Comprehensive Emergency Manual Policy by the Administrator and Human Resources.
- In-service the Maintenance Director on the facility's Cold Weather Policy by the Administrator.
- Notify the Medical Director of the Immediate Jeopardy and update on the plan by the Administrator.
- Move residents on the affected wing to available rooms on the same wing; offer remaining residents a transfer to another facility or warmer parts of the building; provide extra blankets and warm beverages to residents who choose to stay.
- Immediately assess identified residents by the DON and Nurse Practitioner to ensure needs are met and comfort is maintained; assess all other residents by nursing staff and outside physicians.
- Assess the air handler, determine the cause of fluctuating temperatures, install new blower fans into the air handler, and complete repairs to ensure adequate hot air circulation.
- Monitor temperatures in each resident room on the affected unit every hour.
- Initiate shift-by-shift temperature monitoring and continue until extreme cold weather has abated as determined by the QAPI committee.
- Assess and continuously monitor all residents remaining on the affected unit for pain, respiratory comfort, and general comfort until heat is fully stabilized; implement interventions to address identified distress or pain and monitor effectiveness.
- Install temporary flannel window coverings to reduce heat loss in rooms on the affected wing.
- Educate all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather Policy; educate staff unavailable prior to their next scheduled shift.
- Develop and implement a plan to monitor preventative maintenance for the heating system, including regular audits of maintenance logs by the Administrator to ensure HVAC inspections and radiator filter cleanings are completed; review results during scheduled QAA meetings; continue audits.
- Implement a mandatory education schedule ensuring all staff are educated on the facility emergency policies and procedures; make training a permanent part of orientation for all new hires and conduct annually for all existing staff by Human Resources.
Failure to Develop and Implement Discharge Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive discharge care plan interventions for four of five residents reviewed for discharge planning. Facility policy on discharge care planning requires that, when a resident is discharged, a post-discharge plan be provided to the resident and/or representative, including the resident and family’s preferences for care, how services will be accessed and paid for, coordination of care among multiple caregivers, identification of specific needs at discharge (such as ADLs, self-administration of medications, diet, sterile dressings, and therapy), appropriate referrals by social services, and preparation for discharge. The comprehensive care plan policy also requires an individualized plan with measurable objectives and timetables to meet each resident’s medical, nursing, mental, and psychological needs. Despite these policies, the electronic medical records for four residents admitted for care did not contain discharge plans or related interventions. One resident reported that discharge plans were not discussed until an involuntary discharge notice was given, and his current care plan lacked any discharge planning or interventions. Another resident’s record similarly showed no documented discharge plan or interventions. A third resident, who stated he would be going home after completing therapy, reported that no one had discussed discharge plans with him, that his family was independently looking into home health services, and that discharge was never addressed during his care plan meeting; his care plan also lacked discharge planning or interventions. A fourth resident was admitted and later discharged home without any documented discharge plan or interventions in the care plan. The Minimum Data Set Director/RN stated that discharge planning is supposed to be initiated upon admission and that the Social Service Director is responsible for documenting the discharge portion of the care plan. The Social Service Director acknowledged being responsible for discharge care planning, stated she had fallen behind, and confirmed that these four residents did not have discharge plans on their care plans.
Failure to Maintain Boiler Resulting in Inadequate Indoor Temperatures
Penalty
Summary
The facility failed to maintain the boiler in working order to provide adequate heat, resulting in indoor temperatures ranging from 56.0°F to 58.0°F throughout the building. The facility’s own Homelike Environment/Maintenance policy, revised 12/1/25, requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior with safe temperature levels, and its Cold Weather policy, revised 11/24/25, requires regular building maintenance and inspection, including maintenance of heating and air conditioning systems and thermostats. On 1/18/26 at 1:00 p.m., the maintenance staff (V3) confirmed that a seam had broken in the boiler, leaving the facility without heat and temperatures in the mid to upper fifties, and the Administrator (V1) verified at 1:30 p.m. that the heat was out in the facility. On 1/18/26 at 1:30 p.m., residents were observed bundled in multiple layers of clothing and blankets due to the cold environment: one resident was in bed with several blankets and a stocking cap, and that resident’s family member reported the room was very cold and that the resident’s head was cold to the touch when she arrived and he was not yet wearing a cap; another resident remained in her room wearing a winter coat and several blankets; and a third resident sat in the front hall wearing a winter coat, stocking cap, and several blankets on his lap, stating that it was very cold in the facility. The Administrator later confirmed that the census on 1/18/26 was 60 residents, as documented on the Daily Census sheet dated 1/17/26, indicating that all 60 residents had the potential to be affected by the lack of heat.
Failure to Maintain Adequate Heat, Hot Water, Call Systems, and Building Repairs
Penalty
Summary
The facility failed to provide adequate heating, hot water, and building maintenance, resulting in an environment that was not safe, clean, or comfortable for residents, staff, and the public. Facility policies on homelike environment, cold weather, and resident call bells required maintenance of safe temperature levels, regular inspection and maintenance of heating and air conditioning systems, and a functional call system accessible from resident beds, toilets, and bathing areas. During a tour with the Maintenance Director, water temperatures on one hall measured 110–116°F, while on another hall they were only 75–77°F. The Maintenance Director acknowledged an ongoing problem with a mixing valve on the affected hall and stated that it was supposed to have been fixed by a plumber but was not. Multiple bathrooms were in disrepair: one resident’s bathroom had chipped paint and missing drywall under the sink; two other rooms had no running water to sinks or toilets, wet and stained bath blankets on the floor under sinks, black slimy-looking substances in toilets, and a black mold-like area in front of a toilet. The Maintenance Director stated that the sink and toilet were clogged and he had not had a chance to fix them. Ceiling tiles across the front hallway were discolored with brown stains and a mildew smell was noted; the Maintenance Director attributed this to condensation leaking into the tiles when boilers were turned up and stated he was the only maintenance person and had difficulty keeping up with repairs. Residents reported and demonstrated discomfort and lack of access to required systems. One resident was observed sitting in his room wearing a jacket and wrapped in a blanket, stating it was always cold on the southeast side of the building and that it smelled moldy in the front where ceiling tiles appeared wet; the wall behind his chair had gouges with crumbling plaster on the floor. When this resident pressed his call light, it illuminated only while the button was held down, and the second bed’s call cord consisted of open wires with no call button. Another resident was observed wearing a long-sleeve shirt and coat, reporting that his room had been warm until a recent weekend, that he told staff it was too cold but received no response, and that he stayed in bed wrapped in covers. A third resident, dressed in warm clothing with a shawl and blanket, stated her room was cold; a wall clock in her room showed 63°F. Another resident was using a handheld bell to call for assistance, stating he had no call light, and he and other residents confirmed there was no hot water in their rooms. Staff verified that certain room call lights stayed on all day or activated by themselves, that water on one side of the building only became warm but not hot, and that they heated water in an electric tea pot at the nurses’ station for showers and washing. The Administrator confirmed that water and room temperatures were not at proper levels and that many repairs were needed, while the Maintenance Director confirmed ongoing problems with the mixing valve and boiler and that water temperatures on one side of the building were in the mid‑70s°F.
Dishwasher Sanitization Failure Due to Improper Monitoring and Lack of Staff Knowledge
Penalty
Summary
The facility failed to ensure that the dishwasher used for sanitizing dishes was operating in accordance with professional standards and facility policy. During the survey, staff used quaternary ammonia test strips on a high-temperature dishwasher, which is not the correct method for verifying hot water sanitization. The test strips did not register any sanitizer, and staff were unable to locate appropriate hot water test strips in the building. Additionally, the final rinse temperature was not displayed on the dishwasher, and there were no temperature logs available for review. The Dietary Manager and Maintenance Director were both unfamiliar with the proper procedures for monitoring and servicing the dishwasher, and neither knew who was responsible for its maintenance or which company serviced it. These failures affected all 56 residents in the facility, as the dishwasher was not properly monitored or tested to ensure it reached the required sanitizing temperature of at least 180 degrees Fahrenheit, as specified in the facility's policy. The lack of proper testing materials, absence of temperature logs, and staff's lack of knowledge regarding the dishwasher's operation and maintenance contributed to the deficiency in food service sanitation.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that water delivered to resident rooms was maintained at a safe and comfortable temperature, as required by facility policy. During an observation, water temperatures from bathroom sinks in multiple resident rooms were found to exceed the policy limit of 110 degrees Fahrenheit, with specific readings recorded for six residents. One resident reported that the water was sometimes too hot. The Maintenance Director acknowledged that water temperatures in resident areas should not exceed 110 degrees Fahrenheit and admitted that required water temperature checks had not been performed due to lack of time. The facility's policy, dated 12/30/2024, specifies that water temperatures in resident rooms should not exceed 110 degrees Fahrenheit.
Delayed Pressure Ulcer Treatment Orders for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's dementia, depression, and anxiety was admitted to the facility and identified as high risk for pressure injuries based on the Braden Scale. Upon admission, the resident had a pressure injury to the coccyx, which was documented as non-staged. The admission assessment indicated that the wound care company was notified and scheduled to see the resident on a future date. However, the resident was not seen by the wound care provider as planned, and no treatment orders were obtained at the time of admission. It was not until approximately 13 days after admission that a wound assessment was completed by the wound care physician, and specific treatment orders were initiated. During this period, the resident's wound care was delayed, as confirmed by interviews with the Director of Nursing and Assistant Director of Nursing, who acknowledged that wound treatment should be obtained as soon as a wound is discovered. Facility policy requires prompt identification and treatment of pressure ulcers, but this was not followed in the resident's case.
Resident Denied Right to Self-Determination Regarding Daily Routine
Penalty
Summary
A cognitively intact resident, as evidenced by a BIMS score of 15/15, was observed in emotional distress and crying in the dining room, expressing that she did not want to be out of bed and felt as though she was being punished. The resident reported pain, discomfort from the light, and stated that her repeated requests to return to bed were ignored by staff, who would say they would get help but did not return. The facility's policy affirms residents' rights to self-determination, including choices about daily routines and care. Interviews with staff revealed that a CNA acknowledged the resident's desire to remain in bed but stated that nurses instructed her to get the resident up for meals. An LPN confirmed the resident's ability to make her own care decisions but expressed personal opinions about the resident's dietary and activity choices, suggesting she should not always be allowed to decide for herself. Facility leadership, including the Administrator and Social Service Director, confirmed that residents should not be gotten up against their wishes, and the CNA involved believed she was following proper procedure until educated otherwise.
Improper Disposal and Securing of Outdoor Trash Dumpster
Penalty
Summary
Surveyors observed that the facility failed to ensure the outdoor trash dumpster was properly maintained according to facility policy. During an initial kitchen tour with the Dietary Manager, it was noted that the dumpster was missing two lids, and trash was piled above the top of the dumpster. The dumpster was not secured by any walls or access doors, and the open condition allowed for the possibility of pests or animals accessing discarded food and trash. The Dietary Manager confirmed that the dumpster should be kept closed and secured to prevent such access. Facility policy requires all garbage containers to have tight-fitting lids and to be kept covered when not in continuous use, as well as to store garbage in a manner inaccessible to vermin. At the time of the survey, 57 residents were documented as residing in the facility.
Failure to Secure Medications and Prevent Resident-to-Resident Intrusions
Penalty
Summary
The facility failed to store medications and treatment supplies in a secure environment, as observed with a bottle of Dakins solution and a tube of Therahoney left unattended in a resident's room. According to facility policy, such items should be locked away when not in use to prevent access by unauthorized individuals. Staff confirmed that these items should not have been left in the room, especially given the presence of multiple residents with wandering behaviors who could potentially access them. Additionally, the facility did not adequately address the issue of confused residents entering another resident's room. Two residents with documented cognitive impairments and high risk for wandering were observed entering the room of another resident on multiple occasions. The resident whose room was entered reported frequent disturbances, including one incident where a confused resident fell onto her, resulting in soreness and bruising. Despite these repeated intrusions, staff did not implement effective measures to prevent such occurrences. Furthermore, the facility failed to investigate and document follow-up care after the incident in which a confused resident fell onto another resident, causing physical discomfort. There was no evidence in the medical record of any assessment or follow-up regarding the injury, and the administrator was unable to provide information on steps taken to prevent further incidents or to investigate the reported injury. This lack of action left the affected resident without appropriate support or intervention following the event.
Failure to Follow Infection Control Protocols for PPE and Hand Hygiene
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies regarding the use of personal protective equipment (PPE) and hand hygiene in rooms under transmission-based precautions. In one instance, an LPN entered a resident's room, who was on contact precautions for ESBL in the urine, without donning a gown and without performing hand hygiene before putting on gloves. The LPN touched the resident and her environment, administered insulin, and then left the room with the insulin pen still in her gloved hand. The LPN then accessed the medication cart, removed the needle, and placed the insulin pen back with other residents' medications, removed her gloves, and failed to perform hand hygiene at any point during or after the process. The LPN later acknowledged that she should have worn a gown and performed hand hygiene as required by facility policy. Other staff, including a speech therapist and housekeeping staff, were observed not wearing the required PPE when entering rooms of residents on contact precautions for ESBL and VRE. The speech therapist stated she only wore gloves when seeing a roommate not on isolation and was unaware a gown was required. Housekeeping staff admitted to sometimes only wearing gloves, depending on how rushed they felt, despite being educated on the need for full PPE. The Assistant Director of Nursing confirmed that all staff, including therapy and housekeeping, are required to wear gloves and gowns when entering rooms of residents on contact precautions. Additionally, the Director of Nursing was observed performing wound care on a resident with pressure ulcers and skin impairment without performing hand hygiene between glove changes. The DON removed and replaced gloves multiple times during the procedure without washing or sanitizing hands, contrary to the facility's hand hygiene policy. The DON later confirmed that hand hygiene should have been performed between glove changes.
Failure to Document Behaviors and Non-Pharmacological Interventions Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to properly track and document specific behaviors and non-pharmacological interventions prior to administering psychotropic medications for two residents. For one resident with a history of fetal alcohol syndrome, intellectual disabilities, and various behavioral issues, the care plan listed multiple behaviors, but the Medication Administration Record (MAR) only showed check marks or a code for behavior without corresponding progress notes detailing the specific behaviors or any non-pharmacological interventions attempted. The administrator confirmed that there was no documentation describing what behaviors occurred or what interventions were tried, and that the behaviors listed on the care plan did not match those recorded on the MAR. During the survey, this resident was observed to be pleasantly confused and interacted with staff and other residents without agitation or aggression. Another resident, admitted with severe unspecified dementia, agitation, anxiety disorder, and depression, was prescribed antipsychotic and antianxiety medications. The care plan indicated the use of these medications but did not specify the indications for use. The MARs for several months documented behavior monitoring but did not specify the behaviors or any non-pharmacological interventions. Progress notes for this resident recorded combative and resistive behaviors but did not document any attempted interventions during these behaviors or prior to administering psychotropic medications.
Failure to Update Care Plan for Contact Isolation Precautions
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was placed on contact isolation precautions due to an active infection with transmissible significant pathogens. Observation showed the resident's room door was closed, with contact isolation signage and a PPE cart present. The resident's electronic medical record included a physician order for contact isolation, specifying that the resident was to be isolated in the room without a roommate, and that all activities and services were to be brought to the resident. Despite these documented precautions and the visible implementation of isolation measures, the resident's care plan was not revised to reflect the new contact isolation status. The facility's policy requires care plans to be updated as changes in a resident's condition occur, but this was not done in this case. The administrator confirmed that the care plan should have been updated to include the contact isolation precautions.
Failure to Document and Monitor After Suicidal Ideation
Penalty
Summary
The facility failed to thoroughly document and monitor a resident after she verbalized suicidal ideation. According to the facility's policies, any staff member who becomes aware of a resident's intent to inflict self-harm is required to report the behavior to the Nursing Supervisor without delay, and the charge nurse or Nurse Supervisor must immediately assess the situation and determine necessary interventions. In this case, a resident with diagnoses including metabolic encephalopathy, anxiety, and major depressive disorder expressed suicidal ideation, stating she wanted to die by a specific date and did not want to live anymore. The psychiatric nurse practitioner, via telehealth, ordered the resident to be sent to the emergency room for evaluation, but there was no documentation of a physical or behavioral assessment, vital signs, or details of what the resident said to prompt the transfer. The nurse's notes only indicated the resident was sent to the hospital for being suicidal and later returned after being declared not suicidal, with no further documentation of assessments or follow-up. Additionally, the resident's care plan was not updated to reflect the suicidal ideation or to include new interventions or increased monitoring. The facility's documentation policy requires alert charting for incidents or changes in condition for at least 72 hours or until stable, but this was not completed. The Director of Nursing confirmed that follow-up alert charting should have been done and acknowledged the documentation was very poor in this case. The lack of thorough documentation and monitoring after the resident's expression of suicidal ideation constitutes the deficiency identified by the surveyors.
Failure to Ensure Residents Retain Personal Items
Penalty
Summary
The facility failed to ensure that residents retained their personal items, which has the potential to affect all 54 residents residing in the facility. During a resident council meeting, three residents complained about missing items and a slow response in returning clothes due to a broken washing machine that has not been repaired for over a year. The Resident Council Monthly Meeting minutes from October 2023 through June 2024 document ongoing complaints of missing clothes and slow return of clothing and items. The Housekeeping Supervisor stated that once a month, the Activity Director provides a form listing missing items, which the supervisor attempts to locate. However, the washing machine has been broken for over a year, and despite promises of parts arriving, the issue remains unresolved. The facility is understaffed in the laundry department, with only two staff members struggling to keep up with the workload. Resident clothing is often not properly marked with identifiers, leading to confusion and items being placed on a missing items rack. Observations confirmed that resident items were hanging on a rack and a bin labeled as missing items.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that prior survey investigations were accessible and that signs were posted to inform residents and families about the availability of these survey investigations. This deficiency was observed during a survey conducted on June 24, 25, and 26, 2024. Three Resident Council Members confirmed that they were unaware of the availability of state investigations for review. During observational tours, no posted notice or state survey inspection binder was visible. The Activity Director, upon inquiry, found the survey investigation binder hidden behind the guest sign-in book at the entrance, in a non-patient care area, making it inaccessible to residents and families. The Administrator acknowledged that signs were not posted to notify residents and families about the survey investigation binder's availability.
Deficiencies in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a safe kitchen environment, specifically in the operation and maintenance of the dishwasher sanitation system. The Dietary Manager admitted to not testing the dishwasher, relying solely on the temperature gauge, and was unable to explain the testing process. A Dietary Aide conducted a test strip through the dishwasher cycle, revealing that the rinse cycle only reached 143 degrees Fahrenheit, below the required temperature for proper sanitation. Despite daily testing claims, the rinse cycle consistently failed to meet the necessary temperature. Additionally, the dish room had multiple soaked ceiling tiles with a brown substance, and several ceiling lights were out. The Maintenance Director confirmed a hole in the dishwasher exhaust fan, causing leaks into the ceiling and near light fixtures, with no approval from Corporate to fix the issues. Further observations revealed unsanitary conditions, including a portable steam table with black crumbly substances and brown grease-like substances in its compartments, with no record of recent cleaning. A large pool of water was observed on the floor from the dishwasher room to the kitchen, attributed to splashes from the dishwasher pooling in a low spot, with the drainage system located on the opposite side of the room. These deficiencies have the potential to affect all 54 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as ordered for a resident who required such measures. The EBP policy, dated March 27, 2024, mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices to prevent the transmission of infectious organisms. On April 16, 2024, a physician's order specified that staff should wear gowns and gloves during direct patient contact with the resident, and signage should be posted on the door. However, on June 24, 2024, it was observed that there was no EBP sign posted at the resident's door, and no personal protective equipment was available outside the door. A Licensed Practical Nurse (LPN) admitted to being unaware of the order for enhanced barrier precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of assessment and monitoring of residents for signs and symptoms of infections, and the absence of appropriate documentation for antibiotic usage. The facility's policy on Infection Control with Antibiotic Stewardship, dated January 2024, mandates the development of antibiotic use protocols and a system to monitor antibiotic use, including written documentation of clinical justification. However, the facility's Infection Control Logs for April and May 2024 were incomplete, lacking specific antibiotic usage details, justification for antibiotic use, and ongoing surveillance data for infections. A specific case involved a resident who was hospitalized from May 7 to May 28, 2024, for acute respiratory failure, hypotension, pneumonia, sepsis, and a urinary tract infection. Upon discharge, the resident was diagnosed with sepsis and MRSA infection, requiring isolation. The facility's Infection Control Monthly Log for May 2024 did not document the resident's infection details, such as the source and organisms. The Director of Nurses acknowledged the incompleteness of the Antibiotic Stewardship Tracking, which lacked a surveillance plan and justification for antibiotic use.
Failure to Monitor Elopement Devices and Supervise High-Risk Residents
Penalty
Summary
The facility failed to adhere to its elopement policy and did not document the testing of elopement devices for several residents identified as high risk for wandering or elopement. Specifically, residents with severe cognitive impairments and a history of wandering, such as those diagnosed with Alzheimer's Disease, were not consistently monitored. For instance, one resident's wander guard was not documented for placement or functionality in seven out of twenty-five opportunities, and another resident's wander guard was similarly neglected in eight out of twenty-five opportunities. Additionally, a resident identified as medium risk for elopement was not properly monitored, as evidenced by an incident where the resident set off an alarm and was later found without an elopement device secured to their person. The facility also failed to provide adequate supervision for residents at high risk for falls. Residents with severe cognitive impairments and physical weaknesses were observed unsupervised in various areas of the facility, despite care plans indicating the need for frequent rounding and supervision in high-visibility areas. One resident, who had a documented history of 19 unwitnessed falls, was repeatedly found unattended in common areas, contrary to their care plan's directives. Another resident, also at high risk for falls, was observed wandering without staff supervision, despite the care plan's requirement for increased monitoring. The Director of Nursing and other staff members acknowledged the lapses in documentation and supervision, confirming that the required checks and monitoring were not consistently performed. The facility's policies on fall reduction and elopement prevention were not effectively implemented, leading to multiple instances where residents were left vulnerable to potential accidents or elopement. These deficiencies highlight significant gaps in the facility's adherence to safety protocols and resident care plans.
Failure to Monitor Refrigerator/Freezer Temperatures for Medication Storage
Penalty
Summary
The facility failed to adequately monitor refrigerator and freezer temperatures, which is essential for the safe storage of medications. The policy requires that temperatures be recorded daily, with specific acceptable ranges for refrigerators and freezers. However, the temperature records for the refrigerator/freezer in the Saint [NAME] Linen Room showed a lack of monitoring for 25 out of 47 required times in June 2024. Additionally, the refrigerator/freezer in the Saint [NAME]'s Medication Room was not monitored 37 out of 62 times in May 2024 and 13 out of 50 times in June 2024. This lack of monitoring could potentially affect the safe storage of medications for multiple residents. During observations, it was noted that the refrigerator/freezer in the Saint [NAME]'s Medication Room contained several injectable pens and multidose vials that require refrigeration. These included medications such as Basaglar, Insulin Lispro, Tresiba, Humalog, and Tuberculin Purified Protein. The failure to consistently monitor and record temperatures as per the facility's policy could compromise the efficacy and safety of these medications, potentially affecting the health of the residents who rely on them.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a resident and their representative with a written notice of transfer. This deficiency was identified during a review of a resident's medical record, which documented a transfer to a local hospital. The record lacked evidence of a facility notification to the resident or their representative regarding the transfer or discharge. The facility administrator confirmed that no written notice was provided.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or the resident's representative upon the resident's transfer to a hospital. The medical record of the resident, identified as R18, did not contain documentation of written notice regarding the facility's bed hold policy. This deficiency was confirmed during an interview with the facility's administrator, who acknowledged that neither the resident nor the representative received the necessary documentation or notice of transfer.
Failure to Update Care Plan for Edema and Daily Weights
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R212, to reflect the presence of bilateral lower extremity edema and the requirement for daily weight monitoring. The facility's policy mandates that care plans be revised as changes in a resident's condition dictate, yet this was not adhered to in the case of R212. The resident was admitted with multiple diagnoses, including congestive heart failure and edema in the lower extremities, which necessitated daily weight monitoring to manage the condition effectively. However, the care plan did not incorporate these critical aspects, leading to a deficiency in care planning. Additionally, there were significant gaps in the documentation of daily weights for R212, despite orders requiring daily monitoring due to the presence of a left ventricular assist device and the risk of heart failure. The Director of Nurses acknowledged the need for the care plan to specify the requirement for daily weights and the protocol to contact the cardiovascular team if there was a weight gain of five pounds. Despite staff claims of obtaining daily weights, several dates were missing from the records, indicating a failure in executing and documenting the prescribed care regimen.
Deficiencies in Weight Monitoring and Hospice Care Documentation
Penalty
Summary
The facility failed to obtain physician-ordered daily weights for two residents, one of whom was on diuretic therapy for edema and had specific orders to administer additional medication if a weight gain was observed. The resident's daily weight records showed numerous missing entries over several months, which was confirmed by the Director of Nurses. Another resident with a Left Ventricular Assist Device also had missing daily weight records, despite having a doctor's order to monitor weight gain closely and contact the cardiovascular team if a significant gain occurred. Additionally, the facility did not ensure that Hospice plans of care were available and updated in the residents' records. One resident's Hospice care plan was not specific to the services they should receive, and the updated plan was only received on the day of the survey. Another resident's Hospice records were not available for review, and the facility did not have access to the Hospice's electronic documentation. The LPN confirmed that the Hospice staff documented on their own software, and the facility lacked access to these records.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop a person-centered dementia care plan for a resident diagnosed with dementia with agitation. The facility's policy on dementia care, dated November 5, 2019, requires that residents with dementia receive appropriate treatment and services to maintain their highest practical well-being, including person-centered care that maximizes dignity, autonomy, and safety. However, the care plan for the resident, dated October 20, 2023, only included monitoring for changes in condition and task segmentation to support short-term memory deficits. The Care Plan Coordinator confirmed that the care plan lacked individualized person-centered interventions.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe resident transfer and fall intervention implementation for two residents, R2 and R3, who were identified as high fall risks. R2, who has diagnoses including lack of coordination, unsteadiness on feet, and repeated falls, was found without the required double cord call light in her room, which was supposed to provide additional access points for requesting assistance. During a transfer from a wheelchair to a toilet, R2 fell because the CNA did not use a gait belt, contrary to the resident's care plan and facility policy. The CNA claimed R2 refused the gait belt, but R2 denied ever refusing it, indicating a miscommunication or misunderstanding of the resident's needs. R3, also a high fall risk with diagnoses of lack of coordination and muscle weakness, was observed standing in front of her recliner without non-skid strips on the floor, which were specified in her care plan as a fall prevention measure. The absence of these strips was confirmed by an LPN, who was initially unaware of their necessity. R3 was seen leaning forward and wobbly, further highlighting the risk posed by the missing non-skid strips. The facility's policies on fall reduction and gait belt transfers emphasize the importance of providing an environment free of accident hazards and using assistive devices to prevent falls. However, the observations and interviews revealed that these policies were not adequately implemented for R2 and R3, leading to unsafe conditions and a fall incident for R2.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 153 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lacon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henry Rehab And Nursing | 6.4 mi | ★★★★★ | 0 | 0 |
| Arc At Chillicothe | 9.7 mi | ★★★★★ | 13 | 0 |
| Goldwater Care Toluca | 14.5 mi | ★★★★★ | 16 | 0 |
| Snyder Village | 16.6 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home | 19.2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.