Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 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.
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 141 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 Lawson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Manor And Rehabilitation Center | 5.6 mi | ★★★★★ | 27 | 0 |
| Aspire Senior Living Excelsior Springs | 5.6 mi | ★★★★★ | 21 | 0 |
| Nick's Health Care Center | 15 mi | ★★★★★ | 13 | 1 |
| Oakridge Of Plattsburg | 15.3 mi | ★★★★★ | 16 | 0 |
| Liberty Health And Wellness | 16.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lawson Manor & Rehab.
100% money-back within 48 hours.
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.