Lawrence County Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible physical abuse by staff involving one resident (Resident #1). Management and DHSS were not made aware of the allegation until the following day. The facility census was 66. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely investigate an allegation of abuse and ensure protection of all residents during the investigation when after receiving an allegation of possible staff physical abuse involving one resident (Resident #1) the staff did not begin an investigation until the next day and allowed the staff member to continue to work with residents independently. The facility had a census of 66. Review of the facility policy titled Abuse, undated, showed the following:-The facility will ensure each resident is free from abuse, neglect, misappropriation of resident property, and exploitation;-The facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;-The facility will ensure that all alleged violations are thoroughly investigated; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and accounting of all drugs when eight cards of narcotics for eight residents (Resident #3, #4, #5, #6, #7, #8, #9 and #10) were found in the former Director of Nursing's (DON's) office desk. The facility census was 64. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from misappropriation of property when staff used one resident's (Resident #1) credit card without resident permission and when staff took money from one resident (Resident #2). The facility census was 64. Record review of the facility's policy titled Abuse, undated, defined exploitation as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. The same facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents' environments were free of accident hazards when the facility failed to implement a process to ensure resident accessible hot water temperatures in all resident access areas were maintained at a safe temperature resulting in the hot water in 12 residents rooms (Resident #2, #12, #24, #25, #6, #68, #36, #34, #15, #44, #55, and #38) and a common bath/shower room to measure between 125.6 to 138 degrees Fahrenheit (F). The facility census was 70. The Administrator was notified on 08/08/25, at 1:55 P.M., of an Immediate Jeopardy (IJ) which began on 08/05/25. The IJ was removed on 08/09/25 as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and distribute and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to ensure all food items were properly labeled and sealed, failed to ensure expired foods were discarded, and failed to ensure the dishwasher washed and rinsed the dishes at the recommended temperatures. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 70 residents.1. Review of the 2022 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination. Review of the facility policy titled, Date Marking and Food Storage Policy and Procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse and neglect prevention policies, when they failed to complete an employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) check and a check of the Nurse Aide (NA) Registry (a list checking for a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) for four staff members (Housekeeper (HK) S, Certified Nurse Aide (CNA) T, Dietary Aide (DA) U, and Dietary [NAME] (DC) N) of ten sampled records. The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were appropriately screened prior to placement in a nursing home when the facility failed to obtain documentation of Preadmission Screenings and Resident Reviews (PASARR) for two residents (Resident #2 and #69). The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to prepare pureed diets per approved recipes and failed to provide the approved serving size for pureed meals. The facility census was 70. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standard and the resident's choices when the facility failed to follow-up regarding a cardiology referral for one resident (Resident #40), who had a pacemaker, in a timely manner. This would place the resident at an increased risk for a cardiac incident due to lack of oversite on his/her pacemaker. The facility census was 70. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence possible when staff failed to provide restorative nursing services three times weekly per the restorative therapy program for one resident (Resident #52). The facility census was 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct installation and maintenance of bed rails when the bed rail of one resident (Resident #11) was loose and improperly secured. The facility census was 70. Review of the facility policy titled, Bed Rail Policy, dated 2017, showed the following:-It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use;-A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenance and individual bed rail evaluations;-In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was treated with respect and dignity at all times when the facility staff made harsh and upsetting comments to one resident (Resident #1) in front of other residents; when staff threatened two resident's (Resident #1 and #3) smoking rights if they shared cigarettes with one resident (Resident #1); and when staff talked with one resident (Resident #4) regarding being friends with one resident (Resident #1). A sample of six residents was reviewed in a facility with a census of 65. Review of the facility's policy titled Dignity, revised February 2021, showed the following information: -Residents are treated with dignity and respect at all times; -Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person, or entity associated with the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective pain management for all residents when staff failed to accurately and consistently document pain levels and steps taken to address pain, failed to document timely physician notification of pain, and restricted a resident's access to certain medications without a physician order for one resident (Resident #1) out of six sampled residents. The facility census was 65. Review of the facility's policy titled Pain Care, undated, showed the following information: -The effectiveness of the facility's pain care program will be examined monthly; -Pain assessments should include the location, description, frequency, level, what alleviates or exacerbates the pain, history and effectiveness of pain medications, and the residents desires about future pain care; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to follow proper technique during a mechanical lift transfer of one resident (Resident #1). The facility census was 68. The Director of Nursing (DON) was notified by facility staff on 04/24/24 of the noncompliance that occurred on 04/24/24. The DON and Administrator made an online self-report to the Department of Health and Senior Services, began an investigation, and began in-servicing with all nursing staff regarding transfers on 04/24/24. The facility implemented monitoring of the resident involved and all residents who required a two person assistance transfer assistance with a Hoyer lift (mechanical lift normally used to transfer non-weight bearing residents) to ensure transfers were completed safely and as required with two staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were immediately reported to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed one resident (Resident #1) touch another resident (Resident #2) in a sexual manner and the nurse failed to report the allegation to management or the SSA. The facility census was 62. Review of the facility's policy titled Abuse Reporting, revised 03/15/18, showed the following: -It is the policy of the facility that all personnel promptly report any incident or suspected incident of resident abuse; -The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends or other individuals; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents when Certified Nurse Aide (CNA) B alleged one resident (Resident #1) was observed to touch another resident (Resident #2) in a sexual manner. The facility census was 62. Review of the facility policy titled Abuse Investigating, revised 03/15/18, showed the following: -It is the policy of the facility that reports of abuse will be promptly and thoroughly investigated; -The administrator will provide to the person in charge of the investigation a copy of the Resident Abuse Report Form and any supporting documents relative to the investigation: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to clean the hand washing sink, sink in the food preparation area, floor under the three vat sink, the area between the wall and the stove, fryer, and warming cart, the vent above the ice machine, and failed to repair the walls behind the dishwasher and in the beverage room and tiles and wall under the three vat sink to ensure they were washable surfaces; staff failed wear hair nets appropriately to prevent contamination of food; staff failed to regularly test and have knowledge of the correct temperatures of the dishwashing machines; and the drain from the ice machine had no air gap between it and the drain. The facility census was 60. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for four residents (Resident #16, #25, #29, and #31). The facility census was 60. Review of the facility's policy titled, Advance Directives, revised [DATE], showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Review of Resident #'16's face sheet (admission data) showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to document a full discharge summary with information regarding discharge for one resident (Resident #59). The facility census was 60. Review of the facility's policy titled, Discharge Procedure, revised 04/26/00, showed the following: -To assist family and resident to continue care if returning home; -To advise other departments promptly of dismissal; -To facilitate proper closing of records and collection of personal belongings; -Upon notification of dismissal, the records will be completed as quickly as possible assuring an organized dismissal. 1. Review of Resident #59's face sheet (admission data) showed the following information: -re-admission date of 04/14/18; -Diagnoses included unspecified dementia, obesity, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and routine assessments, failed to consistently provide physician ordered treatment and antibiotic, and failed to develop a baseline and comprehensive care plan for one resident (Resident #61) with a right heel pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three sample of three closed record (discharged ) residents. The facility census was 60. Review of the facility policy, Decub (pressure ulcer) Care Protocol, dated 02/01/07, showed staff to assess the resident at least weekly and document the assessment in the skin book and nurses notes. Review of the facility policy, Pressure Ulcers/Injuries Overview, revised July 2017, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician orders for the care and treatment of one resident's (Resident #3's) colostomy (a surgical opening on the outside of the body called a stoma. The opening creates a passage from the large intestine to the outside of the body for passage of feces.) out of two sampled residents with stomas. The facility census was 60. Review of the facility policy titled, Colostomy/Ileostomy Care/Irrigation, undated, showed the following: -Goal to promote positive self-image and comfort by maintaining clean, odor-free environment without peristomal (around the stoma) skin excoriation. Prevent constipation or bowel obstruction and establish bowel regularity by cleansing intestinal tract of fecal material; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received assistance to maintain proper nutrition and hydration unless unavoidable when staff failed to ensure one resident (Resident #6) received his/her ordered house shakes two times daily and failed to ensure a physician order was appropriately received when a staff member placed a nothing by mouth (NPO) sign on the outside of one resident's door (Resident #41). A sample of two residents were reviewed in a facility with a census of 60. Review of the facility's policy titled Weight Assessment and Intervention, revised 03/22, showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Interventions for undesirable weight loss are based on careful consideration of the following: resident choice and preferences; [...]

Inspectors wrote3. Review of the facility's policy titled Administering Medications, dated 04/2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing Services (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 60. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. 1. Observation on 09/20/23, at 9:15 A.M., showed the nurse staffing information posted on the wall behind the nurses' station above the printer. This was not in a prominent location for residents and visitors to readily view. The posting was dated 02/23/23. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent possible cross contamination of the residents' food during preparation and service when staff did not properly store and label food to prevent contamination or spoilage; did not perform proper food handling techniques; did not properly store clean dishware; and did not provide a require air gap for the drainage of the ice machine. The facility had a census of 49. 1. Record review of facility's policy on food storage, dated 10/26/12, showed the following: -Facility staff to label all food items held for more than 24 hours; -The label must include the name of the food and the date it should be consumed or discarded; -Facility staff to wrap food properly and never leave any food item uncovered or unlabeled. Observations starting on 1/13/20, at 9:40 A.M., in the dry storage area of the kitchen showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to respond, address and provide feedback regarding concerns expressed by multiple residents attending the resident council meetings. The facility census was 49. 1. During the Resident Council interview on 1/14/20 at 1:00 P.M., 8 residents attended the meeting and shared the following concerns: -During resident council meetings, the activity director (AD) took notes of the residents' concerns and gave the notes to the department heads; -At each meeting, the AD did not review the concerns from the previous month; -Staff did not resolve issues brought up in resident council, and staff gave no real rationale for not responding to requests. Sometimes the staff gave them was they would go over it or they were working on it. -Concerns included: Staff served meals late, food was cold; [...]

Inspectors wroteBased on observation and interview the facility failed to post the required abuse/neglect hotline information in a prominent location for residents, visitors, and staff to review. The facility census was 49. 1. Observation on 1/21/20 at 1:05 P.M., showed the facility posted the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information on the top left corner of a bulletin board located behind a water fountain in the main lobby. The posting measured approximately 8 inches x 10 inches, and was written in fine print which may not be visible to all residents and visitors. The facility did not have the DHSS Abuse and Neglect Hotline information posted in any other area of the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing program of meaningful activities based on their interests and abilities for four residents (Resident #8, #20, #28 and #43) residing in the Special Care Unit (SCU) out of a selected sample of 14 residents. The facility's census was 49. Record review of the facility's policy titled, Resident Activities showed the following: -A staff member is hired or designated as the Activity Director (AD) by the administrator; -This facility will provide an on-going program of meaningful activities appropriate to the needs and interests of the residents and designated to promote opportunities for engaging in normal pursuits of daily living including religious activities of their choice, if any; -Activities will be planned on a monthly basis and posted in an area easily accessible to all residents; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the residents' bathroom exhaust ventilation systems in proper working condition when 13 residents' bathrooms did not have functioning exhaust vents. The facility had census was 49. 1. Observation on 1/13/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following resident rooms did not have functioning exhaust ventilation system when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to utilize acceptable infection control practices while performing pressure ulcer care, failed to obtain treatment orders timely for new wounds, failed to care plan and implement pressure ulcer precautions, and failed to complete accurate and complete tracking of wounds for two residents (Resident #18 and #199). The facility census was 49. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to compete a side rail assessment, to include a risk/benefit review ad alternatives attempted prior to use, and failed to obtain informed consent for side rails for two residents (Residents #13 and #199). The facility census was 49. Record review of the facility's policy titled Side Rail Policy, dated 3/2015, showed the following: -Use of side rails can create accidents/falls with greater impact than if side rails were not used; -The facility will assess resident to eliminate unnecessary use of side rails; -Risks to side rails will be identified; -Alternatives to side rails will be considered; -The resident has the right to make choices regarding side rails; -An assessment will be completed at least quarterly to as assess the need for use of side rails. 1. [...]