Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Lawrence County Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiplegia, and total dependence for ADLs alleged that a CNA punched them during incontinence care after the CNA was later seen with a bloody nose and lip. A CNA reported the resident’s allegation to an LPN, who documented the staff injury and notified the DON and physician by text but did not document the resident’s abuse allegation in the progress note and did not ensure immediate administrative or state notification. Administration did not learn of the allegation until the next day, and the self-report to the State Survey Agency occurred about 16 hours after the initial report to the charge nurse, exceeding the facility’s policy requirement to report abuse allegations within two hours.
A resident with severe cognitive impairment, hemiplegia, and total ADL dependence alleged that a CNA punched them during care after the CNA was seen leaving the room with a bloody nose. The resident told staff they no longer wanted that CNA in the room and reported being hit in the stomach, ribs, and leg. An LPN was informed and notified the DON and physician but only documented the CNA’s bloody nose and the notification, omitting the resident’s abuse allegation, any initiation of an investigation, or immediate protective actions. The CNA was allowed to continue working independently on another hall for the rest of the shift, and administration did not become aware of the abuse allegation or begin the formal investigation until the following day.
Eight cards of narcotic medications for multiple residents were found unsecured in the former DON's office desk, contrary to facility policy requiring double-locked storage and proper accounting. Staff interviews confirmed that narcotics should only be stored in locked medication carts or rooms, and the police removed the medications for investigation.
Two residents experienced misappropriation of property when a staff member used a resident's credit card without permission for vending machine purchases, and another staff member, along with the DON, was involved in the handling and subsequent loss of a large sum of cash belonging to a resident. Both incidents involved residents with cognitive or psychiatric diagnoses and resulted in unauthorized use or loss of their funds.
Unsafe hot water temperatures were found in multiple resident rooms and in a common bath/shower room, with sink readings ranging from 125.6 to 138 degrees Fahrenheit and the water heater on one hall set at 140 degrees. Residents affected included individuals with dementia, cognitive impairment, mobility limitations, diabetes, stroke, and other chronic conditions. Staff interviews showed no active temperature monitoring or logging process, the last logs were from 2023, and staff were unclear who was responsible for checking water temperatures.
Surveyors found multiple food storage violations, including opened food left unsealed and open to air, unlabeled frozen items with visible ice crystals, and refrigerated foods kept beyond the facility’s stated storage timeframes. Staff and leadership described expectations for sealing, dating, and discarding food, but the observed kitchen conditions did not match those standards. Surveyors also found the dishwasher operating below the posted manufacturer minimums for wash and rinse temperatures, and the temperature log showed the machine had not reached the required levels.
The facility failed to document required EDL and NA Registry checks for four of ten sampled staff members, including a housekeeper, CNA, and dietary staff. The facility policy required background screening to avoid employing individuals with findings related to abuse, neglect, exploitation, mistreatment, or misappropriation, but personnel records for each of the four staff members lacked documentation of the required checks. The Administrator stated the BOM completed the checks prior to hire and that EDLs should be completed quarterly.
The facility failed to obtain PASARR documentation for two residents with significant cognitive and psychiatric diagnoses. One resident had neurocognitive disorder with Lewy bodies, dementia, psychosis, and anxiety, while the other had schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety, and dementia; both records lacked Level I or Level II PASARR forms. The Bookkeeper stated PASARRs were not done for private pay residents, although the Administrator said all residents were expected to have Level I and Level II PASARRs, if indicated, on admission.
Pureed meals were not prepared or served according to approved recipes and menu portion sizes. Dietary staff used scoop amounts and thickener without consulting the recipe, combined jambalaya with rice instead of following the specified preparation, and served portions that did not match the menu. The DM stated staff did not follow recipes or menus for puree meals, while the RD and Administrator stated staff should follow the menu for portion sizes and preparation.
Delayed cardiology follow-up for a resident with a pacemaker. A resident with CHF, atrial fibrillation, and a pacemaker reported needing a cardiology checkup and staff documented a cardiology referral, but the record did not show the appointment was scheduled or followed up on for months. Interviews with the resident, an LPN, Medical Records, the DON, the Medical Director, and the Administrator showed the referral process was not communicated or tracked, and the cardiology appointment was only scheduled much later.
A resident with CHF, morbid obesity, and COPD was placed on a restorative nursing program for weakness and limited mobility, with a goal to rehab to home. The program called for restorative services 3 times weekly, including UE ROM, resistance band work, arm bike, sit-to-stands, and assisted ambulation, but the resident received sessions only about once per week and had no documented refusals for most missed visits. The RA, DON, and Administrator stated the resident was supposed to receive therapy 3 times weekly, but staffing shortages and the RA being pulled to the floor prevented completion of the planned sessions.
Loose Bed Rail Not Properly Secured: A resident with a left femur fracture, cognitive symptoms, anxiety, and dependence for transfers and bed mobility had ordered side rails for assistance and safety. Staff and family had agreed to the rails, but surveyors observed the right rail was loose and unstable, and the resident reported it was hard to use and had been reported to staff and maintenance without repair. Interviews showed inconsistent oversight of bed rail checks, unclear responsibility for loose rail inspections, and incomplete weekly audits.
Staff, including the DON, made demeaning and upsetting comments to a resident in front of others, discussed the resident's behaviors and health status publicly, and threatened to revoke smoking privileges for two residents if they shared cigarettes. These actions led to feelings of humiliation, fear, and self-isolation among residents, and were acknowledged by staff as inappropriate and contrary to facility policy.
A resident with chronic pain and metastatic cancer did not receive consistent and appropriate pain management due to staff failing to accurately document pain levels, interventions, and physician notifications. Staff restricted access to narcotic pain medications without a physician order, and communicated to the ED that the resident could not receive narcotics or return if prescribed, despite the resident's diagnosis. Facility staff prioritized non-narcotic interventions based on the resident's history of substance abuse, leading to inadequate pain control and the resident's dissatisfaction with care.
A resident with severe cognitive impairment and high fall risk was injured during a Hoyer lift transfer when a CNA left the resident unsupervised, resulting in a tibial fracture. Facility policy required two staff members for such transfers, but one CNA stepped away, leading to the incident.
Failure to Timely Report Allegation of Staff-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of possible physical abuse was reported immediately to management and within two hours to the State Survey Agency, as required by facility policy. The facility’s abuse policy states that every staff member must immediately report any observed or suspected abuse and that the DON will ensure all alleged violations involving abuse are reported not later than two hours after the allegation is made. In this case, staff became aware of an allegation of possible staff-to-resident physical abuse on the evening of 01/27/26, but administration and the Department of Health and Senior Services (DHSS) were not notified until the following day, approximately 16 hours after the initial report to the charge nurse. The resident involved had severe cognitive impairment, hemiplegia of the left side, diabetes mellitus, and high blood pressure, and was dependent on staff for all ADLs, using a wheelchair. The resident’s care plan noted that the resident could be resistive to care at times and that staff should provide clear explanations of care activities. On the evening of 01/27/26, a CNA responded to the resident’s call light for incontinence care. Shortly afterward, another CNA observed this CNA running down the hall with blood on the CNA’s face. The resident later stated that the CNA had punched the resident in the stomach and leg, and that the resident did not want that CNA in the room anymore. The CNA who heard this allegation reported it to the charge nurse (LPN A), who then questioned the resident. LPN A documented in a progress note that the CNA reported having a bloody nose and lip after the resident allegedly hit the CNA, and that the DON and physician were notified. However, the progress note did not document the resident’s allegation that the CNA had punched the resident. During interview, LPN A stated that the resident reported the CNA had punched the resident in the right leg, and that LPN A texted the DON and physician about the incident but received no response and was unsure what to do next. Administration did not become aware of the allegation until late morning on 01/28/26, and the self-report to DHSS was submitted shortly thereafter, 16 hours after the incident was initially reported to the charge nurse, contrary to the policy requirement for reporting within two hours of an abuse allegation.
Failure to Timely Investigate Abuse Allegation and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of staff physical abuse and to immediately protect residents after the allegation was made. Facility policy required that the DON immediately initiate an abuse incident report, begin an investigation, and prevent further potential abuse, including reassigning or suspending the involved employee. However, after an evening incident in which a CNA reported being hit by a resident and the resident alleged the CNA had punched them, the investigation was not initiated until the following day, and there was no immediate documentation of protective measures for residents. Resident #1, who had severe cognitive impairment, hemiplegia, diabetes, high blood pressure, and was dependent on staff for all ADLs, allegedly told staff that a CNA punched them in the stomach, leg, and ribs during in-room care. The resident was known to be resistive to care at times and required clear explanations of care activities. On the evening of the incident, a CNA observed the accused CNA running down the hall with blood on their face after answering the resident’s call light. The resident then stated they did not want that staff member in the room anymore and alleged that the CNA had punched them, which the CNA reported to the charge nurse. The charge nurse (LPN) documented only that the resident had needed changing, that the CNA reported a bloody nose and lip, and that the DON and physician were notified, but did not document the resident’s allegation, initiation of an investigation, or steps taken to protect residents. The LPN stated the resident reported the CNA had punched them, and that the CNA continued to work the remainder of the shift on another hall, with no immediate suspension or reassignment documented. Administration did not become aware of the abuse allegation until late the following morning, at which time interviews and a physical assessment were conducted. The record and interviews showed that staff did not document or implement immediate protective measures for all residents at the time the allegation was made, and the accused CNA continued to work independently with residents until the next day.
Narcotics Improperly Stored in Unsecured Office Desk
Penalty
Summary
The facility failed to provide proper pharmaceutical services to ensure the accurate acquiring, receiving, and accounting of all drugs, specifically narcotics, for eight residents. Eight cards of narcotic medications, including oxycodone, hydrocodone-acetaminophen, oxycodone-acetaminophen, and tramadol, were found unsecured in the former Director of Nursing's (DON) office desk drawer, which was not locked. Facility policy requires that narcotics be stored under a double lock system, counted at the beginning and end of each shift, and that discontinued narcotics be placed in a locked box in the medication room with their narcotic sheets attached. The medications found included various quantities of narcotic pain relievers for eight different residents, all with original order or fill dates documented. Interviews with staff, including an LPN, a Certified Medication Technician (CMT), the interim DON, and the Administrator, confirmed that narcotics are to be stored in a locked medication cart or medication room, always behind two locks, and never in an office or desk. Staff were unaware of why the narcotics were found in the former DON's office and reiterated that this was not in accordance with facility policy. The police were involved and confirmed the discovery and removal of the medications for investigation. The facility census at the time was 64.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
The facility failed to ensure that all residents were free from misappropriation of property, as evidenced by two separate incidents involving staff and residents' funds. In the first incident, a resident with diagnoses including non-Alzheimer's dementia, schizophrenia, depression, and moderately impaired cognition reported that their billfold and credit card went missing. Subsequent review of bank records revealed multiple unauthorized charges at the facility's vending machine, totaling approximately $55.40. The facility's administrator confirmed that the former Director of Nursing (DON) was present at the facility on each day a charge was made, and video evidence later captured the former DON using the resident's credit card at the vending machine. The police were notified, and the resident's credit card was found in the former DON's possession, leading to their arrest. In the second incident, another resident, who was cognitively intact and diagnosed with psychosis, reported approximately $16,000 in cash missing. The resident had received life insurance payouts and, lacking a bank account, sought assistance from the former DON, who arranged for the facility's IT Person to help cash the checks. The IT Person deposited the checks into their own account, withheld $1,500 as a fee, and delivered the remaining cash to the resident, who then directed significant amounts to be given to the former DON for safekeeping. The facility's investigation could not confirm how much money was given to the former DON or how many times cash was handed over, and no safe or cash was found in the former DON's office after their arrest. Both incidents demonstrate a failure by the facility to protect residents from misappropriation and exploitation, as defined in the facility's own abuse policy. The actions of the former DON and the IT Person resulted in unauthorized use and loss of residents' funds, with the facility unable to account for the missing money or prevent staff from taking advantage of residents' trust and vulnerabilities.
Unsafe Hot Water Temperatures in Resident Rooms and Common Bath Area
Penalty
Summary
The facility failed to ensure resident-accessible hot water was maintained at a safe temperature in resident rooms and a common bath/shower room. Surveyors found hot water temperatures ranging from 125.6 to 138 degrees Fahrenheit in 12 resident rooms and in the main bathroom/shower room on the 200 hall. The facility census was 70, and the deficiency was cited at the immediate jeopardy level during the abbreviated survey. The report identified multiple residents whose room sinks measured above safe temperatures, including residents with dementia, Alzheimer disease, vascular dementia, stroke, aphasia, schizophrenia, diabetes, chronic kidney disease, multiple sclerosis, and mobility impairments. Several residents were cognitively impaired, used wheelchairs or walkers, or were dependent on staff for activities of daily living. For example, one resident with Lewy body neurocognitive disorder and dementia had a room sink temperature of 130 degrees Fahrenheit, while another resident with chronic kidney disease had a room sink temperature of 138 degrees Fahrenheit. Other resident room temperatures were documented at 136, 133.1, 133.3, 132, 127.9, 126.8, and 125.6 degrees Fahrenheit. The survey also found the main bathroom/shower room on the 200 hall unlocked and accessible to residents, with the sink water measuring 138 degrees Fahrenheit and the shower water measuring 127 degrees Fahrenheit. The water heater serving the 200 hall was observed set at 140 degrees Fahrenheit. Staff interviews showed there was no active process for monitoring or logging hot water temperatures, the last logs were from 2023, and staff were unclear who was responsible for testing. The Maintenance Supervisor stated no resident room or public restroom temperatures had been tested, the Housekeeping Supervisor said water temperatures should be between 105 and 115 degrees Fahrenheit, and the DON stated anything over 120 degrees Fahrenheit was too hot.
Food Storage and Dishwashing Temperature Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards of practice when surveyors found multiple food items in the kitchen that were not properly labeled, sealed, or stored. On 08/04/25, surveyors observed a 57-ounce carton of mashed potatoes left unsealed and open to air, an opened bag of mozzarella cheese in the walk-in cooler unsealed and open to air, and several items in the walk-in freezer that were unlabeled, unsealed, and open to air, including chicken fingers, a pizza with visible ice crystals, and hamburger patties. On 08/06/25, surveyors again observed an opened bag of mozzarella cheese unsealed and open to air in the cooler, along with an unlabeled pizza with visible ice crystals in the freezer and an unsealed box container of chocolate chips open to air. Surveyor review also identified refrigerated foods that remained in storage beyond the facility’s stated timeframes, including tomato soup and minestrone soup dated 07/30/25 and an angel food cake dated 07/28/25. During interviews, dietary staff and leadership stated opened foods should be sealed, labeled with the date opened and use-by date, and discarded after three to five days depending on the item; several staff also stated food with ice crystals should be discarded. The Registered Dietitian and Administrator both stated opened refrigerated foods should be kept for three days, while the Dietary Manager stated leftovers could be stored for five days but preferred not storing them over three days. The facility also failed to maintain the dishwasher at the manufacturer-recommended temperatures. The dishwasher’s posted minimum temperatures were 155 degrees F for wash and 180 degrees F for rinse, but surveyors observed wash temperatures of 130, 134, and 130 degrees F and rinse temperatures of 175, 172, and 168 degrees F. The temperature log from 08/01/25 to 08/06/25 showed the highest documented wash temperature was 152 degrees F. Staff interviews confirmed the expected wash and rinse temperatures and that temperatures were to be logged after each meal service.
Failure to Document Abuse and Neglect Screening Checks
Penalty
Summary
The facility failed to implement its abuse and neglect prevention policies when it did not document completion of required Employee Disqualification List (EDL) checks and Nurse Aide (NA) Registry checks for four of ten sampled staff members. The staff members identified were a housekeeper, a CNA, a dietary aide, and a dietary staff member. The facility census was 70. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, showed the facility was to conduct employee background checks and not knowingly employ or otherwise engage individuals with findings or disciplinary actions related to abuse, neglect, exploitation, mistreatment, or misappropriation of property. Personnel record review showed the housekeeper had a hire date of 06/18/25, the CNA had a hire date of 06/11/25, the dietary aide had a hire date of 03/27/24, and the dietary staff member had a hire date of 07/03/24. For each of these four staff members, facility staff did not document completion of an EDL check or a check of the NA Registry. During interview, the Administrator stated the Business Office Manager completed EDL and NA Registry checks on all staff prior to hire and that periodic EDLs should be completed quarterly on all staff.
Missing PASARR Screening Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that all residents were appropriately screened for PASARR prior to nursing home placement when it did not obtain documentation of Level I or Level II PASARR screenings for two residents. The facility policy stated that all applicants to a Medicaid-certified nursing facility must have a preliminary assessment for serious mental illness or intellectual disability, and that all clients entering or residing in a Medicaid-certified bed must have a Level I form completed. However, the resident records reviewed did not contain PASARR documentation for either resident. One resident was admitted with diagnoses including neurocognitive disorder with Lewy bodies, dementia, psychosis not due to a substance or known physiological condition, and anxiety disorder; the quarterly MDS showed severely impaired cognition, and the care plan identified impaired cognitive function and thought processes. The other resident was admitted with schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified dementia; the care plan noted a public administrator guardian, wandering, destructive and inappropriate behaviors related to schizophrenia, psychiatric physician involvement, impaired cognition and thought processes, delirium, and use of antipsychotic, antianxiety, and antidepressant medications. During interview, the Bookkeeper stated PASARRs were not done for private pay residents, and the Administrator stated the expectation was that all residents have a Level I and Level II PASARR, if indicated, upon entering the facility.
Pureed Meals Not Prepared or Served Per Approved Recipes
Penalty
Summary
The facility failed to ensure the nutritional needs of all residents were met when staff did not prepare pureed diets according to approved recipes and did not provide the approved serving sizes for pureed meals. The facility census was 70. Review of the policy titled "Puree Step by Step Guide" showed staff were to count portions, add hot liquid to a pudding-like consistency, remove lumps, and reheat the puree product to 165 degrees Fahrenheit or greater. The facility’s recipes for pureed jambalaya and pureed white rice with gravy specified exact preparation methods and serving amounts, including one cup portions or two #8 scoops for jambalaya and one-half cup of rice with gravy for the rice dish. The menu spreadsheet for 08/06/25 showed residents should receive one cup of pureed jambalaya and one-half cup of pureed white rice with gravy. During observation, Dietary staff began pureeing the lunch meal for six puree diets but used six-ounce scoops to place six servings of jambalaya with rice mixture into the processor, even though the recipe called for eight ounces of jambalaya per serving and one cup of rice per serving or for the items to be pureed separately. The staff member used seven tablespoons of powdered thickener while pureeing the jambalaya and stated a recipe was not consulted during the process. Later that day, the same staff member served a three-ounce scoop in the pureed jambalaya mixed with rice and gravy and used two three-ounce scoops, equal to six ounces, for one pureed portion. In interviews, the staff member stated he/she did not follow a recipe for puree meals and relied on what the Dietary Manager told him/her to use. The Dietary Manager stated staff did not follow recipes or menus for preparing or serving puree meals and instead used set scoop amounts based on training. The Registered Dietician and Administrator both stated staff should follow the menu for portion sizes and preparation of pureed meals.
Delayed cardiology follow-up for resident with pacemaker
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards when it did not follow up on a cardiology referral for a resident with a pacemaker in a timely manner. The resident’s diagnoses included chronic systolic CHF, paroxysmal atrial fibrillation, and presence of a cardiac pacemaker. The resident’s quarterly MDS showed the resident was cognitively intact and used a walker and wheelchair, with primary medical conditions including debility and cardiorespiratory conditions. On 03/31/25, a progress note documented that the resident complained of taut skin around the pacemaker site and requested follow-up with a cardiologist for a pacemaker checkup. The note stated the skin around the pacemaker site was clean, dry, and intact with no redness, discoloration, edema, or drainage. The physician order summary showed a cardiologist referral order on the same date. However, the medical record did not show documentation about the referral being acted on or an appointment being scheduled. During interviews, the resident stated he/she had repeatedly told staff and the person who made appointments that he/she wanted to see the heart doctor and had difficulty getting appointments scheduled and attended. An LPN stated he/she did not recall the resident mentioning the need to see a cardiologist and was not aware of the referral order, and said the issue occurred because no one knew the referral was there. The Medical Records staff member stated he/she had not seen the order and was not aware of the nurse’s note or referral, and explained that appointment orders needed to be placed in the box at the nurses’ station for scheduling. The DON stated the resident needed a cardiology appointment early in the stay, that an agency nurse messaged the Medical Director about the request, and that the facility did not know who had placed the pacemaker. The Medical Director stated that if a cardiology referral had been ordered in March, he/she would have expected the appointment to have been scheduled before then. The Administrator stated all appointments go to Medical Records for scheduling and staff were expected to place referral paperwork on the Medical Records staff member’s desk.
Restorative Nursing Services Not Provided as Planned
Penalty
Summary
The facility failed to ensure a resident with limited mobility received restorative nursing services at the planned frequency to maintain or improve mobility with maximum practicable independence. Resident #52 was admitted on 04/28/25 with diagnoses including congestive heart failure, morbid obesity, and chronic obstructive pulmonary disease. The resident’s PPS Part A discharge MDS dated 06/10/25 showed the resident was cognitively intact and required partial/moderate staff assistance with most ADLs, including transfers, bed mobility, and walking 10 feet. The care plan identified an ADL self-care performance deficit related to weakness and stated the resident’s goal was to rehab to home. The resident’s restorative nursing program, effective 06/06/25, required restorative services three times weekly for 90 days and included bilateral upper extremity AROM exercises, resistance band exercises, arm bike use, sit-to-stands at the grab bar, and functional ambulation with assistance. Review of nursing notes showed restorative therapy was provided only on 06/08/25, 06/12/25, 06/17/25, 06/21/25, 06/26/25, and 06/30/25 in June, and on 07/04/25, 07/14/25, 07/18/25, 07/19/25, 07/23/24, and 07/24/25 in July. The record did not show resident refusals for the June sessions, and the resident declined therapy only once in July. During interview, the resident stated restorative therapy had been provided about once per week and that more was needed because the resident wanted to ambulate again and return home. The restorative aide stated all residents were planned for restorative therapy three times per week but that sessions could not always be completed because the aide was often pulled to work the floor due to staffing issues. The DON and Administrator confirmed residents were typically planned for restorative therapy three times per week, that the resident was supposed to receive therapy three times weekly, and that residents were not receiving 100% of planned restorative sessions because of short staffing and the restorative aide being reassigned to the floor.
Loose Bed Rail Not Properly Secured
Penalty
Summary
The facility failed to ensure correct installation and maintenance of bed rails when the bed rail for one resident was loose and improperly secured. The resident was admitted with diagnoses including a left femur fracture, cognitive symptoms and signs, anxiety, and depressed mood. The admission MDS showed the resident was cognitively intact but dependent on staff for transfers, bed mobility, and wheelchair use, with a history of falling in the month before admission. The resident’s care conference documented that the family requested quarter bed rails for bed mobility because the resident had used them at home, and the team explained the risks and the family accepted them. A side rail assessment indicated bilateral assist bars were appropriate, and the physician ordered bilateral half side rails for increased independence with bed mobility, repositioning, and safety. The care plan included side rails for safety during care provision and to assist with bed mobility. Facility weekly bed rail audits documented changing rail sizes over time, but some weekly audit periods were not documented. During observation, the resident’s right upper bed rail was found loose, and the resident demonstrated that it wiggled. On a later interview and observation, the resident said the right bed rail was loose, difficult to use for getting up and turning in bed, and unsafe, and stated that staff and maintenance had been told but it had not been fixed. Staff interviews showed inconsistent understanding of who was responsible for checking bed rails, whether loose rails were being checked, and how often inspections occurred. The RA stated weekly audits were not always completed when pulled to the floor, the maintenance assistant was not aware of the loose rail, and the DON and Administrator stated there was no scheduled timeframe for checking loose bed rails.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
Facility staff failed to ensure residents were treated with dignity and respect at all times, as evidenced by multiple incidents involving the Director of Nursing (DON) making harsh and upsetting comments to a resident in front of others. The DON discussed a resident's behaviors and questioned their mental health in the presence of other residents, accused the resident of lying and being sneaky, and made demeaning remarks about the resident's cancer diagnosis and smoking habits. These interactions were observed and corroborated by resident interviews, with the affected resident reporting feelings of humiliation, fear of homelessness, and self-isolation as a result of the DON's comments. Additionally, the DON threatened to revoke the smoking privileges of two residents if they continued to share cigarettes with the resident in question. Residents expressed confusion and distress over these threats, stating that their cigarettes were their own property and money. The DON also approached another resident to warn them about being friends with the resident, labeling the individual as manipulative and potentially exploitative, which led to further feelings of being singled out and treated differently due to the resident's past. Staff interviews confirmed that such behavior was inappropriate and not in line with facility policy, which mandates treating residents with dignity and respect and prohibits demeaning practices. The DON acknowledged making the statements and justified them as attempts to educate the resident, but admitted that her comments were inappropriate. The administrator was made aware of the situation, and staff members indicated they would report similar incidents if observed.
Failure to Provide Consistent and Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with a history of chronic pain, liver cancer, and past substance abuse. Staff inconsistently documented the resident's pain levels and did not consistently record the steps taken to address reported pain or whether the pain was relieved. There were multiple instances where staff failed to document timely physician notification when the resident reported significant pain, including pain rated as high as 10 out of 10. Additionally, pain assessments in the medical record and MAR did not always align with progress notes, and there were gaps in documentation regarding pain management interventions. The resident experienced frequent changes in pain medication regimens, including the discontinuation and initiation of various analgesics and opioids. Despite orders for pain medications, staff restricted the resident's access to certain medications, specifically narcotics, without a documented physician order prohibiting their use. When the resident was sent to the emergency department (ED) for pain management, facility staff communicated to the ED that the resident could not receive narcotic pain medications and could not return to the facility if such medications were prescribed, despite the resident's diagnosis of metastatic cancer. This restriction was not supported by a physician order in the resident's record. Interviews with staff revealed a facility-wide approach of prioritizing non-narcotic and non-pharmacological interventions due to the resident's history of substance abuse, even after the resident's diagnosis of terminal cancer. Staff and leadership cited the resident's past substance use as justification for withholding narcotics, but the on-call nurse practitioner stated that effective pain medication should not be withheld regardless of history. The resident reported feeling that pain was not being appropriately managed and expressed a desire to leave the facility due to these issues.
Failure to Ensure Safe Transfer with Hoyer Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards during a mechanical lift transfer involving a resident. The incident occurred when a certified nurse aide (CNA) stepped away from the resident during a transfer using a Hoyer lift, leaving the resident unsupervised. This resulted in the resident's right lower extremity becoming entangled and injured, leading to increased pain and a subsequent diagnosis of an acute midshaft tibial fracture. The resident involved had a history of severe cognitive impairment, was dependent on staff for transfers, and was at high risk for falls due to confusion and limited physical ability. The resident required maximum staff assistance for activities of daily living and was non-weight bearing. During the transfer, the CNA responsible for guiding the resident's legs and feet left the resident unattended to search for a slipper, while the other CNA continued to operate the lift, resulting in the injury. Interviews with staff, including nurse aides and nurses, confirmed that the facility's policy required two staff members to be present during Hoyer lift transfers, with one staff member operating the lift and the other ensuring the resident's safety. The staff acknowledged that stepping away from the resident during a transfer was against protocol and contributed to the incident. The facility's policy emphasized the importance of using appropriate techniques and devices to ensure resident safety during transfers.
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 19 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
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 Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Vernon Nursing | 0.4 mi | ★★★★★ | 0 | 0 |
| Ascend At Aurora | 11.5 mi | ★★★★★ | 4 | 0 |
| Ozarks Methodist Manor, The | 12.5 mi | ★★★★★ | 1 | 0 |
| Lacoba Homes Inc | 14.1 mi | ★★★★★ | 2 | 0 |
| Sarcoxie Health Care Center | 16.6 mi | ★★★★★ | 6 | 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.