Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Lacoba Homes Inc during CMS and state inspections, most recent first.
Staff failed to use a gait belt consistently and safely when transferring a resident with dementia, lower-extremity impairment, and dependence for transfers. Observations showed the belt placed on the resident’s chest instead of the waist, the belt slipping during transfers, the resident pulling at the belt and saying he/she did not want it on, and staff lifting under the arms while the resident’s knees were bent and the resident stated he/she was going to fall. Interviews showed conflicting understanding among CNA, RN, PT, DON, and the Administrator about proper transfer technique and when to use a gait belt, sit-to-stand, or mechanical lift.
A facility failed to follow infection control practices when CNAs did not wash or sanitize hands before gloving, after removing gloves, or between tasks while providing peri care and toileting assistance to a resident with dementia, impaired cognition, and substantial toileting assistance needs. The resident was transferred, toileted, and cleaned without proper hand hygiene, and staff only used hand sanitizer before leaving the room. Interviews with the CMT, RN, DON, and Administrator confirmed the expected hand hygiene practices.
A resident with a known sulfa drug allergy was administered Bactrim DS for a UTI, resulting in a severe allergic reaction and hospitalization. Despite electronic warnings and pharmacy inquiries, staff failed to verify the allergy with the physician or the resident, leading to the medication error.
The facility failed to date bread products, lettuce, and cheese stored in the kitchen, affecting all 59 residents consuming food prepared there. Undated bread products, some with mold, and undated cheese and browning lettuce were found during an inspection. The Dietary Manager confirmed staff were expected to date these items.
A resident with dysphagia and severe cognitive impairment was repeatedly observed with unthickened water within reach, despite orders for nectar thick liquids. Staff interviews confirmed the liquids should have been thickened, indicating a failure to adhere to the resident's care plan and physician's orders.
Improper Gait Belt Use During Resident Transfers
Penalty
Summary
The facility failed to ensure an environment as free from safety hazards as possible when staff did not transfer a resident with an appropriately placed gait belt and did not demonstrate a consistent understanding of the safest transfer method for that resident. The resident had diagnoses including vascular dementia without behavioral disturbance, polyneuropathy, poly-osteoarthritis, and anxiety disorder. The care plan identified the resident as needing maximal assistance of two staff to transfer with a gait belt, being unable to alert staff of toileting needs due to severe cognitive impairment, and requiring a scheduled toileting program. The resident’s MDS showed moderate cognitive impairment, impairment of both lower extremities, wheelchair use, and dependence for transfers. During observation, staff placed the gait belt on the resident’s chest rather than at the waist and transferred the resident while the resident repeatedly pulled at the belt and stated he/she did not want it on. Two staff lifted the resident under the arms and used the gait belt while moving the resident from the wheelchair to the toilet and back, and the belt slipped up on the resident’s chest during the transfer. The resident’s knees were bent during the transfer, and the resident stated, “I’m going to fall!” Staff continued the transfer, provided incontinence care, and quickly pivoted the resident back to the wheelchair. A later observation showed the same pattern, with the gait belt again placed above the waist on the chest, the belt slipping higher during the transfer, the resident’s legs bent at the knees, and the resident stating he/she was going to fall as the right foot slid forward. Interviews showed conflicting understanding among staff and leadership about proper gait belt placement and transfer technique. Some staff stated the belt could be placed on the chest if the resident refused waist placement or had certain conditions, while others stated it should generally be at the waist and that bent knees or weight-bearing difficulty should prompt therapy review or a lift transfer. The PT, RN, DON, and Administrator gave differing descriptions of when a gait belt, sit-to-stand transfer, or mechanical lift should be used. The resident’s record also showed that the care plan was updated to note that the resident could be combative and sometimes refused gait belts, but the observed transfers still involved chest-level belt placement and manual lifting under the arms.
Failure to Perform Hand Hygiene During Resident Peri Care
Penalty
Summary
The facility failed to provide appropriate infection control practices when staff did not wash or sanitize hands before and during personal care for one resident out of 14 sampled residents. The facility policy on hand hygiene stated that hand hygiene is the single most important means of preventing the spread of infections, and that staff must perform hand hygiene before and after contact with a resident, after contact with blood or body fluids, after contact with contaminated surfaces or objects, and after removing PPE. The routine peri care policy also stated that staff were to wash their hands each time they changed gloves and after cleansing was complete. Resident #8 was admitted on 03/03/22 and had diagnoses including vascular dementia without behavioral disturbance, polyneuropathy, poly-osteoarthritis, and anxiety disorder. The resident’s care plan noted impaired balance with fall risk and a history of PTSD, with moderate staff assistance needed for personal hygiene. The quarterly MDS showed short- and long-term memory problems, moderately impaired cognition, no rejection of care, toileting hygiene requiring substantial/maximal assistance, and personal hygiene requiring partial/moderate assistance. During observation of personal care, CNA A entered the room and put on gloves without performing hand hygiene, assisted the resident to sit up, and helped with shoes. When the resident said he/she had to go to the bathroom, CNA B joined the care. CNA A removed gloves without hand hygiene, and CNA B did not perform hand hygiene. The CNAs transferred the resident to the wheelchair and toilet, donned gloves again without hand hygiene, and provided peri care. Afterward, they did not change gloves or perform hand hygiene while assisting the resident back to the wheelchair and bed area, including attaching the call light and handling soiled linen bags. Both CNAs used hand sanitizer only before leaving the room. Interviews with a CMT, RN, DON, and Administrator confirmed expectations that staff should sanitize or wash hands before gloving, between glove changes, after removing gloves, and when hands are soiled.
Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of an antibiotic to a resident who was allergic to it. The resident, who had a history of allergies to sulfa drugs, was given Bactrim DS for a urinary tract infection. Despite the electronic medical record system providing pop-up warnings about the resident's allergies, the order was entered and the medication was administered without verifying the allergy status with the resident or the physician. The resident experienced a negative reaction, including a head-to-toe rash, diarrhea, and swollen legs, which led to hospitalization. Interviews revealed that the RN who entered the order did not check the allergy list, and the pharmacist's inquiry about the allergy was dismissed by another RN, who assumed the physician's order was sufficient. The Director of Nursing, who was not present at the facility, had communicated the physician's order to the RN without reviewing the resident's allergy information. The facility's policy on antibiotic stewardship emphasizes the importance of assessing and monitoring residents for drug allergies and interactions. However, the staff failed to adhere to these protocols, resulting in the resident's adverse reaction. The electronic system's warnings were ignored, and the pharmacy's concerns were not adequately addressed, leading to the administration of a contraindicated medication.
Failure to Date Food Items in Kitchen
Penalty
Summary
The facility failed to date bread products, lettuce, and cheese stored in the kitchen, which had the potential to affect all 59 residents consuming food prepared there. During an initial kitchen inspection, it was observed that packages of hamburger buns, hot dog buns, and bread were undated, with some hot dog buns showing mold growth. The Dietary Manager (DM) confirmed that staff were expected to date bread products when they removed them from the freezer to thaw, and the bread vendor recommended using bread products within seven days after thawing. Additionally, an opened and undated five-pound bag of shredded cheese and a large bag of shredded lettuce, which had started to turn brown, were found in the walk-in refrigerator. The DM confirmed that these items were not dated and that staff were expected to date food when opened. The facility's policy titled 'Food Storage and Supply' indicated that food should be properly stored to preserve flavor, nutritive value, and appearance. However, the undated storage instructions from the facility's bread vendor showed that bread should be stored in the freezer or thawed and stored at room temperature for immediate use, with a best-used-by date of seven days after thawing. The DM acknowledged the failure to date the food items and the presence of mold on the hot dog buns, as well as the browning of the lettuce, indicating a lapse in adherence to the facility's food storage policies.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
The facility failed to provide thickened liquids in the prescribed consistency for a resident diagnosed with dysphagia. The resident was observed multiple times with a pitcher of unthickened water and ice within reach, despite having orders for nectar thick liquids. The resident's care plan and physician's orders specified the need for nectar thickened liquids due to the risk of aspiration, but these orders were not followed. Observations on different days confirmed the presence of unthickened water within the resident's reach, and interviews with staff, including a CNA, the Administrator, the Dietary Manager, the SLP, and the Medical Director, corroborated that the resident should have received nectar thickened liquids as per the current diet order. The resident's medical history included severe cognitive impairment, dysphagia, and dementia, necessitating a mechanically altered diet. Despite these requirements, the facility's staff failed to ensure that the resident's liquids were thickened to the prescribed consistency. The Dietary Manager explained that the nursing staff was responsible for thickening fluids provided to residents in their rooms, but this was not done correctly. The SLP and Medical Director both confirmed that the resident should not have had access to unthickened fluids, highlighting a significant lapse in adherence to the resident's care plan and physician's orders.
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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.
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Nursing homes near Monett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ascend At Aurora | 13.4 mi | ★★★★★ | 4 | 0 |
| Mt Vernon Nursing | 13.9 mi | ★★★★★ | 0 | 0 |
| Lawrence County Manor | 14.1 mi | ★★★★★ | 14 | 1 |
| Sarcoxie Health Care Center | 14.6 mi | ★★★★★ | 6 | 0 |
| Cassville Health Care Center | 16.5 mi | ★★★★★ | 31 | 2 |
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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.