Lacon Rehab: 13-Day Wound Care Delay - IL
The resident, who was receiving hospice care due to advanced dementia, was admitted to Lacon Rehab and Nursing in early April with multiple conditions including depression and anxiety. Staff documented a pressure injury to the coccyx as "non-staged" during the admission assessment on April 2.
Yet no treatment orders were written until April 15, when a wound specialist finally examined the patient and prescribed cleaning with saline and hydrocolloid dressing changes every two days.
The Braden Scale assessment classified the resident as high risk for pressure injuries. These standardized evaluations help predict which patients need aggressive prevention measures to avoid painful, potentially dangerous wounds.
Federal inspectors found the facility had planned for the wound specialist to see the patient on April 8 — six days after admission. But the resident wasn't placed on the doctor's list for that visit.
"R1 was supposed to see [the wound doctor] on 4/8/25 to obtain treatments but R1 was not on the list to be seen at that time," the Director of Nursing told inspectors on August 22.
The wound measured 1.5 centimeters by 1 centimeter with a depth of 0.1 centimeters when finally assessed. By then, nursing staff had been applying dressings to the area without proper medical orders for nearly two weeks.
The Director of Nursing said she believed the resident had wound treatment orders upon admission and noticed dressings on the coccyx when she checked the area. The facility's electronic treatment records show orders didn't begin until April 15 — the same day the wound specialist completed the initial assessment.
"Wound treatment should be obtained as soon as the wound was discovered to promote wound healing," the Assistant Director of Nursing told inspectors.
The facility's own policy emphasizes early intervention. Their Skin Prevention, Assessment and Treatment guidelines, updated in May 2024, call for identifying residents at risk for pressure ulcers and promoting systematic monitoring for existing wounds.
The policy specifically aims "to promote healing of existing pressure ulcers" and establish monitoring processes for residents with skin breakdown risks.
Pressure injuries develop when sustained pressure cuts off blood flow to skin and underlying tissue. They're particularly dangerous for elderly residents with limited mobility and underlying health conditions. The National Pressure Injury Advisory Panel estimates these wounds affect up to 2.5 million Americans annually.
For residents with dementia, pressure injuries pose additional complications. These patients may not communicate pain effectively or understand instructions for repositioning to relieve pressure on vulnerable areas.
The resident's admission documents noted the pressure injury was already present, suggesting the wound developed before arriving at the facility. However, federal regulations require nursing homes to prevent existing wounds from worsening and obtain appropriate treatment orders promptly.
The former Administrator, who also served as a Licensed Practical Nurse, documented that the wound company had been "notified" and would see the resident on the "next visit due" on April 8. This notation appeared in the April 2 admission assessment.
When that scheduled visit apparently didn't occur, no one followed up to reschedule or obtain alternative treatment orders. The resident remained without proper wound care protocols for an additional week.
The inspection was conducted in response to a complaint, though the report doesn't specify whether the wound care delay was the subject of that complaint or discovered during the investigation.
Lacon Rehab and Nursing operates as a 60-bed facility in this small Illinois community about 20 miles northeast of Peoria. The August inspection found the wound care violation affected "few" residents, indicating similar problems weren't widespread throughout the facility.
The 13-day gap between wound discovery and treatment orders represents the kind of care coordination failure that can have serious consequences for vulnerable residents. While this particular resident's wound was relatively small, untreated pressure injuries can rapidly deteriorate, leading to infections, hospitalizations, and in severe cases, life-threatening complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lacon Rehab and Nursing from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LACON REHAB AND NURSING in LACON, IL was cited for violations during a health inspection on August 22, 2025.
Staff documented a pressure injury to the coccyx as "non-staged" during the admission assessment on April 2.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.