Lawson Manor & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawson, Missouri.
- Location
- 210 West 8th Terrace, Lawson, Missouri 64062
- CMS Provider Number
- 265666
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lawson Manor & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, chronic pain, and multiple comorbidities had PRN oxycodone ordered for pain management. An RN removed three oxycodone tablets from the emergency kit, documented that they were for the resident, but only one dose was recorded as administered and there was no documentation for the remaining two tablets. Later, the RN admitted to taking a full card of the resident’s oxycodone and manipulating the narcotic count sheet to make it appear the medication was gone. Staff interviews and record review showed that three cards of oxycodone had been delivered and that one card went missing without proper documentation, while the NP reported never authorizing an increased dosing frequency or being notified of uncontrolled pain. This sequence of events demonstrated a failure to protect the resident’s narcotic medication from misappropriation.
A resident with multiple conditions, including a femur fracture, cognitive impairment, depression, osteoarthritis, seizure disorder, and chronic pain, had PRN oxycodone ordered for pain control. An RN removed three oxycodone tablets from the emergency kit but documented administration of only one tablet, with no record of the disposition of the remaining two. Later, an LPN discovered that one of three oxycodone cards for the resident was missing, with the narcotic count sheet page folded over and no documentation of destruction or return, and reported this to the ADON. Pharmacy records confirmed delivery of three oxycodone cards, and the NP was not notified of the missing medication until much later. Despite a policy requiring prompt reporting of alleged misappropriation to the state survey agency within specified timeframes, the facility did not report the missing narcotic medication when it was first identified as missing, resulting in a deficiency for failure to timely report suspected misappropriation.
The facility failed to maintain a safe and effective system for handling controlled substances when staff did not follow policies for counting, documenting, and removing oxycodone. A resident with severe cognitive impairment, multiple comorbidities, and chronic pain had PRN oxycodone ordered, and an RN removed three tablets from the emergency kit but documented administration of only one, with no record of the disposition of the remaining two tablets. Staff interviews and record review showed that nurses routinely signed narcotic count and audit sheets without actually performing counts, failed to initial or clearly document card additions or destructions, and removed multiple doses of oxycodone from the emergency kit at one time, contrary to policy requiring single-dose removal. Leadership confirmed that these practices did not meet facility expectations for controlled substance reconciliation and emergency kit use, and an entire card of oxycodone for the resident was later found to be missing with no supporting documentation.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that six nurse aides completed a state-approved competency evaluation program within four months of hire, as identified through interviews and record reviews. The facility census was 46.
The facility did not administer the required two-step TB screening test upon hire for six newly hired employees, compromising the infection prevention and control program. This deficiency was identified during a record review, with the facility census at 46.
The facility's Administrator and DON did not investigate when a resident was found without a fentanyl patch on two occasions. Despite reports from LPNs, no investigation was conducted, affecting one resident in a facility with 46 residents.
The facility failed to ensure six nurse aides completed a state-approved competency evaluation program within four months of hire. Despite being employed for four to ten months, the aides were not enrolled in any CNA classes, and the facility lacked a certification policy. The DON cited operational changes for the delay, and the Administrator expected the DON to ensure competency. CNA training was available at a sister facility, but none of the aides were enrolled, leading to concerns about the limited number of CNAs.
The facility failed to administer the required TB screening for six newly hired employees, as per its infection prevention and control program. The Director of Nursing was unable to locate TB test records for these employees, and both the DON and Administrator acknowledged the oversight in ensuring TB testing was completed and documented before employment began.
A resident's visitation rights were violated when a former employee, who was a friend of the resident, was denied access to visit. The resident, capable of making their own decisions, was upset by the denial. Despite facility policies allowing residents to choose their visitors, the visitor was turned away multiple times by the BOM and Administrator, citing the visitor's status on a do-not-rehire list.
A resident with severe cognitive impairment was found without a fentanyl patch on two occasions, and the facility's Administrator and DON failed to investigate the missing patches. Despite reports from LPNs, no investigation was conducted, and discrepancies were noted in the medication records. The DON was aware of the issue but did not document any findings or notify the physician, leading to a deficiency in the facility's compliance with its abuse investigation policy.
Misappropriation of a Resident’s Narcotic Medication by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically narcotic pain medication, from misappropriation by staff. The facility had a policy stating residents have the right to be free from misappropriation of property and that the facility would develop and implement policies and protocols to prevent and identify theft or misappropriation. Despite this, an RN removed three 5 mg oxycodone tablets from the emergency medication kit for a resident and documented that the medication was to be given to the resident, but only one tablet was recorded as administered on the Medication Administration Record, with no documentation of the disposition of the other two tablets. Later, the RN admitted to taking an entire card of the resident’s oxycodone and folding over the narcotic count page to make it appear the medication was gone. The resident involved had multiple medical conditions, including a right femur fracture, cognitive communication deficit, major depressive disorder, osteoarthritis of the knee, seizure disorder, and chronic pain. The admission MDS showed the resident had severely impaired cognition (BIMS score of 7), limitations in all extremities, used a wheelchair, was dependent on staff for ADLs, and reported moderately rated pain. Hospital discharge orders included oxycodone 5 mg every eight hours as needed for moderate to severe pain, and the facility’s POS later reflected an order for oxycodone 5 mg every four hours as needed. Progress notes by the RN documented the resident yelling out in pain and receiving oxycodone, and referenced contacting the NP for an increased frequency order; however, the NP later stated that no such order to increase the frequency of oxycodone was given and that he/she was never notified of uncontrolled pain or yelling out in pain. The facility’s investigation found that three cards (180 tablets) of 5 mg oxycodone had been delivered for the resident and signed for by an LPN. An LPN reported that on a prior shift there had been three cards of oxycodone for the resident, but when returning to work, only two cards remained, and the narcotic count sheet page for the missing card was folded over without documentation of destruction or return. The DON stated that controlled substances were to be counted at each shift change by oncoming and off-going nurses, that counts should match the narcotic count sheets, and that staff were expected not to misappropriate resident medications. Despite these expectations and procedures, the RN’s admission to taking the resident’s oxycodone and the lack of proper documentation for removed doses demonstrated that the facility failed to protect the resident from misappropriation of property.
Failure to Timely Report Suspected Misappropriation of Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report a suspected misappropriation of a resident’s narcotic medication to the state survey agency as required by regulation and facility policy. The facility’s Abuse Investigation and Reporting policy required that all alleged violations, including misappropriation of property, be promptly reported to local, state, and federal agencies, with alleged misappropriation reported immediately but not later than two hours if involving abuse or serious bodily injury, or within 24 hours if not. The policy also required a written report of investigative findings within five working days. Despite these requirements, the facility did not report a missing card of oxycodone, a highly addictive pain medication, within the required timeframe after it was identified as missing. The resident involved had multiple medical conditions, including a right femur fracture, cognitive communication deficit, major depressive disorder, osteoarthritis of the knee, seizure disorder, and chronic pain, and was dependent on staff for ADLs and used a wheelchair. Hospital discharge orders included oxycodone 5 mg every eight hours as needed, and the physician order sheet later reflected oxycodone 5 mg every four hours as needed. On one occasion, an RN removed three 5 mg oxycodone tablets from the emergency kit for the resident and documented administration of only one tablet on the MAR, with no documentation in the record regarding the disposition of the other two tablets. Pharmacy records showed three cards (180 tablets) of oxycodone had been delivered for the resident. On a later date, an LPN, during narcotic count, noticed that one of three oxycodone cards for the resident was missing and that the narcotic count sheet page for that card was folded over, a practice used when a card is empty or destroyed, but with no documentation indicating destruction or return. The LPN reported the missing card to the ADON, and the DON confirmed with the pharmacy that three cards had been delivered. The Administrator later stated that missing medications should be reported to the state survey agency within two hours of being noted missing and acknowledged that the missing medications should have been reported when they were first identified as missing. The NP reported not being notified of the missing medication until weeks later. The facility’s failure to report the suspected misappropriation of the resident’s oxycodone to the state survey agency within the required timeframe constituted the cited deficiency.
Failure to Safely Manage and Reconcile Controlled Substances, Including Oxycodone
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system for controlled substances, specifically oxycodone, by not following its own policies and procedures for counting, documenting, and removing narcotic medications. The facility’s written policy required controlled substances to be counted upon delivery, jointly verified and signed by the receiving nurse and the delivery person, stored in separately locked compartments, and reconciled at each shift change by the oncoming and offgoing nurses. The policy also required that only one dose at a time be removed from the emergency medication kit as needed, with proper documentation and reconciliation of all controlled substances, including waste and destruction. Surveyor review showed that these procedures were not consistently followed, leading to an unaccounted-for card of oxycodone and undocumented doses removed from the emergency medication kit. The resident involved had multiple medical conditions, including a fracture of the lower end of the right femur, cognitive communication deficit, major depressive disorder, osteoarthritis of the knee, seizure disorder, chronic pain, and severe cognitive impairment as indicated by a BIMS score of 7. The resident used a wheelchair, had limitations in both arms and legs, was dependent on staff for ADLs, and reported moderately rated pain. Hospital discharge orders included oxycodone 5 mg every eight hours as needed for moderate to severe pain, and the facility’s physician orders later reflected oxycodone 5 mg every four hours as needed for pain. On one occasion, an RN documented that after giving scheduled pain medication, the resident continued to experience significant pain, including yelling and screaming during care and dressing changes, and the RN removed three oxycodone 5 mg tablets from the emergency kit, administering one dose but not documenting the disposition of the remaining two tablets. Record review and staff interviews revealed systemic failures in controlled substance handling and documentation. The facility’s investigation showed that nurses could not consistently recall how many oxycodone cards were present for the resident, and the DON found that none of the interviewed nurses had signed the Controlled Drug Count sheet for the relevant dates, despite their statements that counts were done at shift change. The Daily Controlled Substances Audit form showed nurses were signing to verify card counts without actually performing the required counts. When medication cards were destroyed, nurses documented changes such as +1 or -2 without initials or clear indication of which card was added or subtracted. One LPN reported that on a later date he/she observed that a previously present third card of oxycodone was missing, with the corresponding narcotic count sheet page folded over as if for destruction or return, but with no documentation. Multiple nurses, including LPNs and RNs, stated they routinely removed multiple doses (e.g., several tablets at once) from the emergency medication kit, sometimes eight or nine tablets, and then included any unused tablets in the narcotic count, explaining that they had been trained by other nurses to do this, even though the DON and Administrator stated staff were expected to remove and document only one dose at a time from the emergency kit. These actions and inactions resulted in an unaccounted-for card of oxycodone and undocumented controlled substance doses, in violation of the facility’s controlled substance policy. Additional interviews with leadership confirmed the expectations that were not met. The DON stated that controlled substances should be counted at each shift change by both oncoming and offgoing nurses, that each medication cart and each card’s pill count should match the narcotic count sheets, and that staff should sign the narcotic count book and count medications each time the medication room keys changed hands. The DON also stated that staff should remove only one dose at a time from the emergency medication kit and document removals in the emergency kit carbon notebook for communication with the pharmacy. The Administrator similarly stated that staff were expected to follow the facility’s policy on counting controlled substances and to remove only one dose at a time from the emergency medication kit. Despite these stated expectations, the documented practices and staff interviews showed that counts were not reliably performed or reconciled, documentation was incomplete or inaccurate, and multiple doses were removed from the emergency kit at once without proper tracking, leading to the identified deficiency in the facility’s medication management system for controlled substances.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Nurse Aide Competency
Penalty
Summary
The facility failed to ensure that six nurse aides completed a competency evaluation program approved by the state within four months of their hire. This deficiency was identified through interviews and record reviews conducted by surveyors. The facility had a census of 46 residents at the time of the survey. The report does not provide specific details about the residents' conditions or the direct impact of this deficiency on their care.
Failure to Administer TB Screening for New Hires
Penalty
Summary
The facility failed to ensure the required two-step tuberculosis (TB) screening test was administered upon hire for six newly hired employees. This oversight in the infection prevention and control program was identified during a record review. The facility census at the time was 46, indicating that the deficiency affected a significant portion of the staff responsible for resident care.
Failure to Investigate Missing Fentanyl Patch
Penalty
Summary
The facility Administrator and Director of Nurses (DON) failed to investigate the misappropriation of resident property when a resident was found without a fentanyl patch on two separate occasions. The first incident was reported by an LPN on 11/11/24, and the second was reported by another LPN to the DON on 11/13/24. Despite these reports, no investigation was conducted by the facility's administration. This deficiency affected one resident in a facility with a census of 46.
Failure to Ensure Nurse Aide Competency Evaluation
Penalty
Summary
The facility failed to ensure that six nurse aides completed a competency evaluation program approved by the state within four months of hire. The facility census was 46, and the nurse aides in question had been employed for varying lengths of time, ranging from four to ten months. Interviews with the nurse aides revealed that they were not enrolled in any Certified Nurse Aide (CNA) classes despite being promised enrollment. The facility did not provide a policy regarding NA certification, and the Director of Nursing (DON) acknowledged responsibility for ensuring nurse aide competencies but cited operational changes as a reason for the delay in enrollment. The Administrator expected the DON to ensure the competency of facility nurse aides, and it was noted that CNA training was available at a sister facility. However, none of the nurse aides had been enrolled in the class, although plans were made to schedule them for a class in January 2025. A Licensed Practical Nurse (LPN) expressed concern about the limited number of CNAs, indicating that the facility often relied on nurse aides who had not completed the required training. This situation highlights a significant deficiency in the facility's compliance with state requirements for nurse aide training and competency evaluation.
Failure to Administer TB Screening for New Hires
Penalty
Summary
The facility failed to ensure that the required two-step tuberculosis (TB) screening test was administered upon hire for six newly hired employees. The facility's policy, revised in March 2021, mandates that all employees be screened for latent tuberculosis infection and active TB disease using a tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening before beginning employment. However, during an observation on December 4, 2024, the Director of Nursing (DON) was unable to locate the TB test records for six employees hired between October and November 2024. In interviews conducted on the same day, the DON admitted that the TB testing process was neglected when he/she stopped handling the hiring process and did not follow up to ensure that TB testing was completed for all new hires. The Administrator also confirmed that TB testing was expected to be completed before employees started their employment and that documentation of the TB testing should be maintained by the facility. This oversight resulted in a failure to adhere to the facility's infection prevention and control program, potentially compromising the health and safety of both staff and residents.
Violation of Resident's Visitation Rights
Penalty
Summary
The facility failed to uphold a resident's visitation rights when a visitor, who was a former employee, was denied access to visit a resident. The resident, who was cognitively intact and capable of making their own decisions, expressed distress over the situation, stating that they wanted to maintain their friendship with the visitor. The facility's policy allows residents to receive visitors of their choosing, and the resident had no guardian, indicating they were their own responsible party. Interviews with facility staff revealed conflicting accounts regarding the denial of visitation. The Business Office Manager (BOM) claimed they had never denied visits, while a Licensed Practical Nurse (LPN) confirmed that the BOM had indeed turned away the visitor on two occasions. The Director of Nursing (DON) mentioned that a former employee had been escorted out due to making staff uncomfortable, but there was no indication that this was related to the resident's visitor. The visitor, who had voluntarily left the facility on good terms, attempted to visit the resident multiple times but was denied access by the BOM and the Administrator. The Administrator stated that the visitor was on a do-not-rehire list, yet also acknowledged that residents with capacity should be allowed to have visitors of their choosing. This inconsistency in enforcing visitation rights led to the deficiency noted in the report.
Failure to Investigate Missing Fentanyl Patches
Penalty
Summary
The facility Administrator and Director of Nurses (DON) failed to investigate the misappropriation of a resident's property when a resident was found without a fentanyl patch on two separate occasions. The first incident occurred when an LPN reported the missing patch on November 11, and the second incident was reported by another LPN on November 13. Despite these reports, no investigation was conducted by the facility management, which is a violation of the facility's policy on abuse investigation and reporting. The resident involved had severe cognitive impairment and was dependent on staff for personal care and mobility. The resident was on a scheduled pain medication regimen, including a fentanyl patch, which is a high-risk opioid medication. The facility's records showed discrepancies in the administration and documentation of the fentanyl patches, with missing entries and incorrect balances noted in the controlled medication sheets. Interviews with facility staff revealed that the DON was aware of the missing patches but did not conduct a thorough investigation or document any findings. The Administrator was not informed of the missing patches until much later. The lack of investigation and documentation, as well as the failure to notify the physician, contributed to the deficiency identified in the report.
Latest citations in Missouri
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A resident with Alzheimer’s disease, severe cognitive impairment, and identified elopement risk was housed on a secured unit but was able to leave the building unnoticed when a floor tech exited through a coded door without ensuring it closed and no one followed. Staff last observed the resident near the nurses’ station and dining room, and when a CMT attempted to pass medications later, the resident could not be found, triggering a Code Pink and search. Multiple staff reported that the door alarm did not sound that night and that the door could be opened by pushing on it for several seconds or by using a code without an alarm. The facility’s investigation determined the door between the rehab and secured units was not securely closed after staff use, allowing the resident to elope and later be found in the community by EMS and transported to the ER without documented injury.
Facility staff did not fully develop or implement a comprehensive water management program to control Legionella and other waterborne pathogens. Although a written policy and an undated Water Management Plan existed, they lacked key elements such as a documented water management team, evidence of monthly monitoring review, documentation of baseline or annual Legionella testing, and specific guidance for identified high-risk areas like dead legs and unused bathrooms. Water temperature, pH, chlorine, and total dissolved solids were checked intermittently in random rooms without clearly identifying locations or consistently including all high-risk areas. The maintenance director reported flushing lines frequently but documenting checks only biweekly and not testing for Legionella, and was unfamiliar with the specific high-risk areas in the plan. Leadership, including the Regional Administrator, owner, and administrator, demonstrated limited knowledge of who performed Legionella testing, how the plan should be implemented, and the specific risk areas, control measures, and corrective actions required.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Failure to Secure Door and Supervise Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a secured unit door was properly secured and supervised, allowing an at-risk resident to exit the building unnoticed. The resident had Alzheimer’s disease, an anxiety disorder, hearing loss, and was assessed as severely cognitively impaired on the MDS. An Elopement Risk Evaluation identified the resident as ambulatory, wandering aimlessly, and at risk for elopement, and the care plan documented that the resident was on a secured unit with impaired cognitive function. Despite this, the resident was last seen around the nurses’ station and dining room in the early evening and was not continuously monitored in a way that prevented unsupervised access to an exit door. On the evening of the incident, staff reported seeing the resident around 8:00–8:10 p.m. near the nurses’ station and dining room. A CMT later attempted to pass medications to the resident at approximately 8:30 p.m. and discovered the resident was not in their room, prompting a Code Pink and an internal search of the unit and facility. Staff, including the CMT and CNA, reported that the door alarm did not sound the night the resident left, and that previously the door could be opened by pushing on it for several seconds, or by using a code, without an alarm sounding. The Administrator and DON stated that prior to the elopement, the doors were configured so that pushing and holding the bar for 15–20 seconds would open the door and trigger an alarm, but staff did not hear an alarm at the time of the incident. A floor tech working on the secured unit acknowledged exiting through the coded door between the rehab and secured units during the relevant time frame and not checking whether anyone was following or whether the door clicked shut behind them, despite prior training to watch the door for residents attempting to leave. The facility’s investigation concluded that the entry door to the facility was not securely closed after staff exited the unit, creating an opportunity for unauthorized egress, and determined that the resident exited through the door between the rehab and secured unit. The resident was later found by EMS approximately 1.5 miles from the facility, wandering and only alert to self, and was transported to the hospital, where no injuries were documented. The nurse practitioner noted the resident was a wanderer, fairly new to the facility, and expected staff to check on the resident every one to two hours.
Incomplete Legionella Water Management and Monitoring Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens, including Legionella. CMS guidance (QSO-17-30) requires certified healthcare facilities to have water management policies and procedures, including a facility risk assessment, a water management program aligned with ASHRAE standards and CDC toolkit, specified testing protocols with acceptable ranges and documentation of results and corrective actions, and compliance with applicable regulations. The facility’s Legionella Infection policy, dated 03/05/20, stated these requirements but the actual implementation and supporting documents did not meet them. Review of the facility’s Water Management Plan showed it included a risk assessment that identified several high-risk areas, such as dead legs in specific rooms and departments, empty resident room bathrooms, and low-rise floor sinks in housekeeping closets. The plan stated that environmental testing would be conducted if there was difficulty maintaining water systems within control limits or if a healthcare-associated Legionella case occurred, and it instructed staff to perform baseline Legionella testing at four specified sites. However, the plan lacked a list of designated water management team members, documentation of monthly review of scheduled monitoring, documentation of baseline or annual Legionella testing, and specific guidance related to the identified high-risk areas. The facility’s Infection Prevention and Control Program, dated 04/10/19, did not contain information related to Legionella. Record review of the Resident Room Water Temperature and Checklist for a three-month period showed staff tested water temperatures in random resident rooms on both wings and also tested water pH, chlorine, and total dissolved solids, but did not indicate the testing locations or include results for all identified high-risk areas. In interviews, the maintenance director reported flushing resident room water lines almost daily but only documenting water checks every two weeks, testing pH and chlorine every two weeks, and not testing for Legionella; the director was familiar with the water management plan only generally and was not familiar with the specific high-risk areas. The Regional Administrator stated the facility should have annual Legionella testing but did not know who conducted it. The owner indicated that corporate maintained a template Water Management Policy but that the facility administrator was responsible for developing and implementing a facility-specific plan. The administrator stated the water management plan should include how water is tested monthly, believed Legionella testing was only done if there was suspicion or a positive case, had not updated the plan since an earlier review, did not document the water management team membership, had not discussed the plan with the maintenance director, and was not familiar with specific risk areas, control measures, or corrective actions.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Monitor Bowel Function and Report Repeated Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders, facility bowel protocol, and the resident’s care needs, specifically related to bowel monitoring, constipation management, and medication refusals. The facility’s own Medication Monitoring policy required licensed nurses to report refusals of medications and to identify interventions on the care plan for systematic monitoring of high‑risk medications. The Bowel Protocol required routine monitoring and documentation of bowel movements (BMs), use of a stepwise regimen (milk of magnesia on day three without a BM, bisacodyl suppository on day four, and fleet enema on day five), and prompt provider notification of significant changes such as impaction. For one resident with significant GI history and prior constipation/impaction, staff did not consistently document BMs, did not follow the bowel protocol when BMs were absent for multiple days, and did not notify the physician in a timely manner. The resident had a history of chronic GI blood loss, recurrent constipation, large stool burden, and prior fecal impaction. In mid‑November, the resident was hospitalized for anemia, GI bleeding, and severe constipation with a large fecal impaction, during which a disimpaction was performed and the physician recommended keeping a record of BMs. After return, facility bowel elimination records showed multiple gaps in documentation and prolonged periods without recorded BMs. In early December, there were days with no documentation and no recorded BMs, and staff did not document physician notification or administration of bowel interventions from several consecutive days without BMs. Later in December, the record again showed multiple consecutive days with no BMs documented; staff did not administer bowel interventions until the sixth day and did not document physician notification until that time. A nurse’s note on that day described the resident having no BM for five to six days, vomiting coffee‑ground emesis, and being sent to the hospital, where hospital records documented stercoral colitis, fecal impaction, and a moderate to large amount of stool throughout the colon. Despite the resident’s history and the physician’s expectation for close monitoring, the February Treatment Administration Record showed an active order to monitor BMs daily with a requirement that the resident have a BM every other day and to give a Dulcolax suppository if no BM every other day, yet nursing staff failed to document monitoring on multiple shifts. The resident’s care plan did not reflect the increased BM monitoring ordered after the hospitalization for constipation/impaction. Interviews with RNs, LPNs, CNAs, the MDS coordinator, ADON, DON, and the physician showed inconsistent understanding and implementation of the bowel protocol and monitoring orders; staff acknowledged that monitoring had not been consistent and that the system for tracking BMs was not effective. The deficiency also includes failure to notify the physician of multiple medication refusals for this resident. Throughout February, the MAR showed repeated refusals of numerous ordered medications, including baclofen, bisacodyl, Carafate, Colace, Dexilant, ferrous sulfate, folic acid, metoprolol, Miralax, pravastatin, Remeron, and Senna‑S, often refused more than ten times in the month. The facility’s Medication Monitoring policy required nurses to report refusals of medications to the physician, but the medical record contained no documentation of physician notification regarding these repeated refusals. Nursing staff and the MDS coordinator acknowledged that the resident refused medications and that they used nursing judgment about when to notify the physician, but several staff did not know how many refusals should trigger notification, and some believed the physician was aware without recalling specific contacts or documentation. The physician stated that he knew the resident sometimes refused medications but was not aware of the high frequency of refusals in February and stated he wanted to know when refusals occurred so often. Overall, the actions and inactions leading to the deficiency included failure to consistently document and monitor BMs per order and protocol, failure to implement ordered bowel interventions when BMs were absent for multiple days, failure to update the care plan to reflect increased bowel monitoring after hospitalization for constipation/impaction, and failure to notify the physician of frequent medication refusals as required by facility policy. These failures occurred despite the resident’s known history of GI bleeding, recurrent constipation, fecal impaction, and prior hospitalizations for GI issues and constipation.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
