Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Dawson Health And Rehabilitation during CMS and state inspections, most recent first.
A bathroom shared by two rooms on C Hall was not maintained in a clean, safe, and sanitary condition. Surveyors observed a ceiling vent covered with dirt and dust, a pool of clear liquid on the floor, and detached linoleum where baseboards would normally be located. The ADM and Maintenance Director confirmed the pooling water and dirty vent.
The facility failed to submit a PASARR Level II for a resident reviewed for PASRR. The resident had onset psychosis, moderate cognitive impairment on BIMS, active dx of depression, anxiety, and psychotic disorder, and was receiving antipsychotic and antidepressant meds, including Risperdal for hallucinations. The BDS confirmed the resident had qualifying dx for a PASRR II but it was not submitted because there had not been an increase in behaviors.
Controlled Drug Record Not Signed After Narcotic Administration. Surveyors found mismatched narcotic counts for three residents after review of two medication carts. A resident with a stage 4 pressure ulcer, a resident with an artificial knee joint, and a resident with severe cognitive impairment all had scheduled opioid orders, but the physical tablet counts did not match the Controlled Drug Record. An RNS confirmed the discrepancies, and an LPN stated she had administered two of the narcotics without signing the controlled sheet afterward.
Failure to perform hand hygiene during catheter care. A CNA did not sanitize her hands between glove changes while providing catheter care to a resident with a Foley catheter and a stage 4 sacral pressure ulcer. The resident’s MDS documented intact cognition and an indwelling catheter, and the CNA, an LPN, and the DON all acknowledged that hand hygiene should occur after glove removal and before donning clean gloves.
A resident with severe cognitive impairment was physically abused by a CNA, witnessed by three other CNAs who failed to intervene or report the incident immediately. The abuse included hitting, arm twisting, and suffocation attempts, causing physical harm. The facility's policy on immediate reporting of abuse was not followed, leading to a deficiency in resident protection.
A resident was found unresponsive with an arm trapped between a bedrail and mattress due to incorrect mattress dimensions and lack of informed consent for bedrail use. The facility failed to ensure bedframes were equipped with the correct mattress size, affecting 47 residents and increasing entrapment risk. Staff interviews revealed inadequate policies and education on bedrail use.
The facility failed to ensure correct mattress sizing for 47 beds, leading to a resident's entrapment and subsequent unresponsiveness. Additionally, a resident was physically abused by staff, with witnesses failing to intervene. These incidents highlight significant deficiencies in resource management and resident protection.
A resident with intact cognition was found with medication at their bedside without a self-administration assessment, contrary to facility policy. Staff interviews confirmed that medications should not be left at the bedside without proper authorization, highlighting a lapse in policy adherence.
A facility failed to accurately document a resident's code status, leading to a potential risk of unwanted CPR. The resident's POLST indicated a DNR status, but the EMR and physician's orders showed a full code. Interviews with staff confirmed the inconsistency, which could result in actions contrary to the resident's and family's wishes.
A resident experiencing acute pain due to trauma missed three doses of prescribed tramadol because the medication was not delivered, and the physician was not notified. Additionally, the resident could not complete a scheduled x-ray due to pain, and again, the physician was not informed. Interviews with facility staff revealed an expectation for the nursing staff to notify the physician in such situations, which was not met, preventing necessary adjustments to the resident's care plan.
A facility failed to accurately complete a comprehensive social assessment for a resident with undifferentiated schizophrenia and mild intellectual disabilities. The resident's diagnoses were not reflected in the assessments signed by the Social Service Director, who was unaware of these conditions. The RAI Director confirmed the expectation for accurate assessments, although no specific policy was in place.
A facility failed to conduct an accurate Level I PASRR for a resident with Undifferentiated Schizophrenia and mild intellectual disabilities. The resident's EMR showed these diagnoses, but the Comprehensive Social Assessment did not, and the SSD marked no history of mental illness. The hospital's Level I PASRR inaccurately marked 'No' for serious mental illness or intellectual disability, leading to the absence of a Level II screening. The SSD was unaware of the resident's diagnosis and followed a 'Best Practice for PASRR' document due to the lack of a specific policy.
A facility failed to develop a baseline care plan within 48 hours of a resident's admission, as required by policy. The Resident Assessment Instrument Director, responsible for this task, was on leave, and the duty was to be covered remotely by someone from the corporation, but it was not completed. The resident's electronic medical record showed no evidence of a baseline care plan.
A resident's care plan was not updated to address pain management despite complaints of lower back pain and administration of PRN Tylenol. The facility's policy requires care plans to address identified pain, but the resident's plan lacked any problems, goals, or interventions related to pain. This oversight was confirmed by facility staff, including the RN, RAI Director, and Medical Director, highlighting a risk for ineffective pain management.
A resident with a history of falls and mobility issues was found crawling on the floor without necessary safety measures in place, such as a low bed and fall mats, as outlined in their care plan. The resident sustained injuries due to inadequate supervision and failure to implement prescribed interventions, despite facility policies requiring such measures.
A resident experienced untreated pain due to the facility's failure to procure and administer tramadol as ordered by the physician. The resident, who had acute pain from a fall, missed three doses of the medication because the pharmacy was waiting for a signed prescription. The nursing staff did not follow procedures to use the emergency medication kit or notify the physician, leading to the resident's discomfort and an incomplete x-ray examination.
A facility failed to provide a written bed hold agreement for a resident transferred to a behavioral facility for medication stabilization. The resident, with moderate cognitive impairment and multiple health conditions, did not receive a signed agreement explaining room rates after the Medicaid bed hold expired, contrary to the facility's policy.
Bathroom Not Maintained in Clean and Safe Condition
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one bathroom shared by two rooms on C Hall. The facility policy titled Housekeeping stated the intent was to maintain a clean and sanitary center free from odor and other environmental factors that may affect quality of life. During observations on 03/3/2026, 03/4/2026, and 03/5/2026, the bathroom ceiling vent was covered in a brownish gray substance, the linoleum floor had a pool of clear liquid substance resembling water, and the linoleum was detached from the wall where baseboards would normally be located. During interview on 03/5/2026, the Administrator and Maintenance Director confirmed the bathroom floor was pooling water and the ceiling vent was covered in dirt and dust.
Failure to Submit PASARR Level II for Resident with Qualifying Psychiatric Diagnoses
Penalty
Summary
The facility failed to submit a PASARR Level II for one of two residents reviewed for PASARR. R3 was admitted with diagnoses including onset psychosis in April 2021, and the quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment, with active diagnoses of depression, anxiety, and psychotic disorder. The MDS also showed R3 received antipsychotic and antidepressant medications during the look-back period, and physician orders dated 11/06/2025 showed Risperdal 0.25 mg at bedtime related to hallucinations from psychosis. During interview, the Business Development Specialist confirmed R3 did not have a PASRR II and stated the resident had qualifying diagnoses for a PASRR II, but one was not submitted because the resident had not had an increase in behaviors.
Controlled Drug Record Not Signed After Narcotic Administration
Penalty
Summary
The facility failed to ensure the Controlled Drug Record was signed after narcotic administration for three sampled residents during review of three medication carts. The facility policy titled Controlled Substance Medication Accountability required the licensed nurse administering a controlled medication to promptly document the date and time of administration, the amount administered, and the nurse’s initials on both the MAR and the Controlled Drug Record Sheet. During the survey, the Controlled Drug Record counts did not match the actual remaining tablets for oxycodone-acetaminophen 5/325 for one resident, hydrocodone-acetaminophen 5/325 for another resident, and oxycodone HCL 10 mg for a third resident. One resident had a stage 4 sacral pressure ulcer, intact cognition with a BIMS score of 15, and a scheduled pain medication regimen for pain that was almost constant. Another resident had an artificial knee joint, a BIMS score indicating the resident was rarely or never understood, and a scheduled pain medication regimen for arthritis-related pain. The third resident had disorders of bone density and structure, a BIMS score of 5 indicating severely impaired cognition, and a scheduled pain medication regimen for continuous pain. Each resident had physician orders for scheduled narcotic pain medication, and surveyors observed discrepancies between the number of tablets physically present in the medication cart and the number documented on the Controlled Drug Record. During interview, the RNS confirmed the mismatched counts and stated the narcotics were checked on both carts and three missing signatures were found. The LPN confirmed she had administered the narcotics to two of the residents and had not signed the Controlled Drug Record afterward. She stated the controlled sheet should be signed as soon after administration as possible and that failure to do so could affect the narcotic count. The DON stated her expectation was that nurses sign the Controlled Drug Record after administration of narcotics so the record remains consistent and accounts for the medications when they are removed from the packets.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to follow its Hand Hygiene policy during catheter care for a resident with a Foley catheter. The policy stated that hand hygiene is the single most important means of preventing the spread of infection, that gloves do not replace hand washing, and that staff should perform hand hygiene immediately after glove removal and before donning clean gloves. During observation of catheter care, a CNA did not sanitize her hands between removing gloves and putting on clean gloves. The resident involved had a diagnosis that included a stage 4 pressure ulcer of the sacral region and was documented in the MDS as having intact cognition with an indwelling catheter. The care plan addressed the urinary catheter related to the stage 3-4 wound, and physician orders included an indwelling urinary catheter to bedside drainage with monthly catheter changes. During interview, the CNA confirmed she did not sanitize her hands between glove changes and stated she should have washed or sanitized her hands after removing gloves and before putting on clean gloves. An LPN and the DON both stated that hands should be washed or sanitized between glove changes.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA1), which was witnessed by three other CNAs (CNA2, CNA3, and CNA4) who did not intervene or report the incident immediately. The abuse involved CNA1 hitting the resident in the face, twisting her arm, and placing a pillow over her face, causing physical harm. The incident was not reported to the Administrator or Director of Nursing (DON) until 30 minutes after it occurred, allowing the abuse to continue and putting other residents at risk. The resident involved, identified as R23, had a severely impaired cognitive status due to Alzheimer's dementia, as indicated by a Brief Interview for Mental Status (BIMS) score of 99. Her care plan noted cognitive impairment, memory problems, and behaviors such as physical aggression and agitation. Despite these challenges, the facility's staff failed to protect her from abuse and did not follow the care plan interventions, which included maintaining a calm manner and using a gentle tone of voice. The facility's investigation revealed that the CNAs who witnessed the abuse did not take immediate action to stop it or report it promptly. The DON confirmed that the CNAs were unable to explain their inaction and had not been adequately trained to intervene in such situations. The facility's policy required immediate reporting of abuse, but this was not adhered to, resulting in a deficiency in protecting residents from abuse and neglect.
Improper Bedrail and Mattress Use Leads to Resident Entrapment
Penalty
Summary
The facility failed to ensure that residents' bedframes were equipped with the correct mattress dimensions as per the manufacturer's manual, which increased the risk of entrapment. This deficiency was identified when a resident, referred to as R155, was found unresponsive with his upper left extremity trapped between the bedrail and the mattress. The facility's records revealed that 47 out of 55 residents had bed frames with incorrect mattress dimensions, posing a significant risk of entrapment. The report highlights that R155 was admitted to the facility and had bedrails added to his bed without obtaining informed consent. The assessment for the use of bedrails did not include necessary information such as medical necessity or alternative options. Observations showed that the bedrails had significant movement due to the incorrect mattress size, which was not in compliance with the manufacturer's recommendations. The Maintenance Director confirmed that the mattress used was not the recommended size, and the bedrails were installed with excessive movement, which contributed to the entrapment risk. Interviews with facility staff, including the Maintenance Director and the Regional Corporate Nurse, revealed a lack of policy or procedure related to bedrail use and inadequate education on the risks and benefits of bedrails. The Medical Director stated that consent for bedrail use was not typically obtained before implementation. The facility's inspection records showed that bed frames were not inspected as frequently as recommended by the manufacturer's manual, further contributing to the deficiency.
Deficiencies in Mattress Sizing and Resident Protection
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in two significant deficiencies. Firstly, the facility ordered mattresses that did not meet the manufacturer's recommended dimensions for the bed frames, affecting 47 out of 55 beds with bedrails. This oversight placed residents at risk of entrapment. A critical incident occurred when a resident was found unresponsive with their upper left extremity trapped between the mattress and bedrail, preventing a fall to the floor. Unfortunately, the resident could not be revived, highlighting the severe consequences of the facility's failure to ensure the correct mattress size. Secondly, the facility failed to protect a resident from physical abuse by a staff member, which was witnessed by three additional staff members who did not intervene. This incident underscores a failure in the facility's responsibility to prevent and report patient abuse, as outlined in the Administrator's job description. The survey team identified these systemic failures, resulting in Immediate Jeopardy related to the administration of the facility, specifically concerning the deficiencies in patient safety and protection from abuse.
Failure to Assess for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which led to a potential safety issue. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, was observed with two capsules in a medicine cup on his bedside table. The resident was unaware of the medication's identity and mentioned that a Certified Medication Aide (CMA) had given them to him before he fell asleep. The facility's policy prohibits leaving medications at the bedside unless a self-administration assessment has been conducted and approved by the interdisciplinary team (IDT), which was not done in this case. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Administrator, a Registered Nurse (RN), and the Director of Nursing (DON), confirmed that the facility does not allow residents to self-administer medications without a proper assessment and doctor's order. The staff reiterated that medications should not be left at the bedside, and the facility's policy requires any unauthorized medications found at the bedside to be reported and returned. The incident highlighted a lapse in following the facility's medication administration policy, as the resident was left with medication without the necessary assessment and authorization.
Discrepancy in Code Status Documentation
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's code status in the medical record, which could lead to the resident receiving unwanted cardiopulmonary resuscitation (CPR). The discrepancy was found in the records of a resident with severe cognitive impairment, diagnosed with Alzheimer's disease and dementia. The physician's order and the electronic medical record (EMR) indicated a full code status, while the Physician Orders for Life-Sustaining Treatment (POLST) signed by the resident's daughter and physician indicated a Do Not Attempt Resuscitation (DNR) status. Interviews with the Director of Nursing (DON), Social Service Director (SSD), and Assistant Director of Nursing (ADON) confirmed the inconsistency in the resident's code status documentation. The SSD verified that the POLST, which was signed upon the resident's admission, indicated a DNR status, aligning with the family's wishes. However, the EMR and physician's orders incorrectly documented a full code status. This discrepancy was further highlighted when a Licensed Practical Nurse (LPN) stated she would initiate CPR based on the EMR's full code status, contrary to the POLST directive.
Failure to Notify Physician of Missed Medication and Incomplete X-ray
Penalty
Summary
The facility failed to notify the physician regarding a resident's missed medication doses and inability to complete a medical test due to pain. The resident, who was experiencing acute pain due to trauma, was prescribed tramadol, an opioid pain medication, to be taken twice daily. However, the resident missed three doses of tramadol because the medication was not delivered by the pharmacy, and the physician was not informed of this issue. Additionally, the resident was unable to complete a scheduled thoracic spine x-ray due to excessive pain, and again, the physician was not notified. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Director of Nursing (DON), and the Medical Director, revealed that there was an expectation for the nursing staff to notify the physician when the medication was not available and when the x-ray could not be completed. The failure to communicate these issues to the physician prevented the medical provider from making necessary adjustments to the resident's plan of care, which could have addressed the resident's pain and facilitated the completion of the x-ray.
Inaccurate Social Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an accurate comprehensive social assessment for a resident diagnosed with undifferentiated schizophrenia and mild intellectual disabilities. The resident's electronic medical record (EMR) indicated these diagnoses under the Diagnosis tab, but the Comprehensive Social Assessment V2.0, completed on multiple dates, did not reflect these diagnoses. Each assessment was signed by the Social Service Director (SSD), who noted no history of mental illness in the Mental Development section. Upon inquiry, the SSD stated she was unaware of the resident's diagnoses. The Registered Nurse Resident Assessment Instrument (RAI) Director confirmed that the SSD was expected to review the assessments for accuracy, although the facility did not have a specific policy, relying instead on the RAI manual instructions.
Failure to Conduct Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of Undifferentiated Schizophrenia and mild intellectual disabilities. Upon review of the resident's electronic medical record (EMR), it was found that the admitting and current diagnosis included these conditions. However, the Comprehensive Social Assessment did not reflect these diagnoses, and the assessments were signed by the Social Services Director (SSD) with a note indicating no history of mental illness. The resident's EMR lacked documentation of a Level I or Level II PASRR. The SSD provided a Level I PASRR completed by the hospital, which inaccurately marked 'No' for the presence of a serious mental illness or intellectual disability. This error resulted in the absence of a Level II screening for specialized services. The SSD admitted to being unaware of the resident's mild intellectual disability diagnosis and stated that the facility followed a document titled 'Best Practice for PASRR' as they did not have a specific policy. The document indicated that PASRR status should be reviewed for all new admissions, and the SSD should maintain an active list of PASRR patients.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy, reviewed on 12/27/24, mandates the creation of a baseline care plan to ensure person-centered continuity of care and communication with the resident and their representative. The resident in question was admitted to the facility, but a review of their electronic medical record revealed no documented evidence of a baseline care plan. During an interview, the Resident Assessment Instrument Director admitted that the baseline care plan was not developed due to her being on leave, and the responsibility was supposed to be covered remotely by someone from the facility's corporation.
Failure to Update Care Plan for Pain Management
Penalty
Summary
The facility failed to revise the care plan to address pain management for one of the residents, identified as R29. The facility's policy mandates that each patient with identified pain should have a care plan addressing pain management. However, despite R29's complaints of lower back pain and the administration of PRN Tylenol as per a telephone order from the Nurse Practitioner, the care plan did not include any problems, goals, or interventions related to pain. This oversight was confirmed during interviews with the RN, RAI Director, and the Nurse Practitioner, all of whom acknowledged that the care plan should have been updated to reflect the resident's pain issues. The deficiency was further highlighted by the fact that R29 was unable to complete an x-ray due to excessive discomfort, indicating ongoing pain issues. The Medical Director, who was also the resident's attending physician, expressed that it was his expectation that the care plan would have included pain as a problem area following the resident's complaints. The failure to update the care plan placed the resident at risk for ineffective pain management, as the necessary interventions and goals were not documented or implemented.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement safety measures for a resident identified as being at high risk for falls. The resident, who has a history of falls, a right below the knee amputation, highly impaired vision, and an unsteady gait, was observed on multiple occasions without the necessary interventions in place. These interventions, as outlined in the resident's care plan, included the use of a low bed and fall mats to prevent injury. Despite these documented needs, the resident was found crawling on the floor on several occasions, including an incident where he sustained a skin tear to his right stump and elbow. Observations revealed that the resident's bed was not in the lowest position, and mats were not placed on the floor as required. The facility's policy on fall management mandates providing residents with adequate supervision and assistive devices to minimize fall risks. However, the resident was left unsupervised in his room, which was located far from the nursing station, and staff were not present to prevent or respond promptly to his attempts to get out of bed or his chair. The Director of Nursing confirmed that the safety measures were not in place as per the care plan, acknowledging that the bed should have been lowered and mats should have been on the floor to prevent such incidents.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medication was procured and administered as ordered by the physician for one resident, identified as R29. The deficiency was identified when three doses of tramadol, an opioid pain medication, were not available from the pharmacy and thus not administered to the resident. The facility's policy required that when medications are unavailable, the nurse should contact the dispensing pharmacist for further instructions and notify the prescriber. However, this procedure was not followed, leading to the resident experiencing untreated pain. R29 was admitted to the facility with a diagnosis of acute pain due to trauma from a fall. On September 8, 2024, the resident complained of severe lower back pain, which was assessed to be a 10 on a scale of 1-10. The resident was administered PRN acetaminophen, which reduced the pain level to one. On September 10, 2024, the physician ordered tramadol to be administered twice daily for seven days. However, the medication was not delivered on time, and the resident missed three doses on September 10 and 11, 2024. Interviews with facility staff revealed that the pharmacy was waiting for a signed prescription from the physician, which delayed the delivery of tramadol. The Director of Nursing and the Medical Director both stated that the nursing staff should have contacted the pharmacy to use the emergency medication kit, which contained tramadol, and notified the physician for an order. The failure to follow these procedures resulted in the resident experiencing untreated pain and an incomplete x-ray examination due to discomfort.
Failure to Provide Bed Hold Agreement
Penalty
Summary
The facility failed to provide a written bed hold agreement for a resident who was transferred to a behavioral facility for medication stabilization. The resident, who was his own responsible party, had a history of schizophrenia, type 2 diabetes mellitus, hypertension, depression, and gastro-esophageal reflux disease. The resident's cognitive assessment indicated moderate cognitive impairment. Despite these conditions, the facility did not have a signed and acknowledged bed hold agreement explaining the room rates after the Medicaid bed hold expired. The facility's policy on bed holds during hospital stays and therapeutic leaves requires offering residents or their designees the choice to pay to hold the bed or release it. However, during the review of the resident's medical record, it was found that no such agreement was provided or acknowledged by the resident. This oversight was identified during a closed record review and was confirmed through staff interviews, highlighting a lapse in the facility's adherence to its own policy.
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What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Dawson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lee County Health And Rehabilitation | 15.9 mi | ★★★★★ | 0 | 0 |
| Lillian Carter Health Center By Harborview | 18.8 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Palmyra | 19.2 mi | ★★★★★ | 8 | 0 |
| Wynfield Park Health And Rehabilitation | 20.4 mi | ★★★★★ | 0 | 0 |
| Joe-anne Burgin Health And Rehabilitation | 21.3 mi | ★★★★★ | 1 | 0 |
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