Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawrence County Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiplegia, and total dependence for ADLs alleged that a CNA punched them during incontinence care after the CNA was later seen with a bloody nose and lip. A CNA reported the resident’s allegation to an LPN, who documented the staff injury and notified the DON and physician by text but did not document the resident’s abuse allegation in the progress note and did not ensure immediate administrative or state notification. Administration did not learn of the allegation until the next day, and the self-report to the State Survey Agency occurred about 16 hours after the initial report to the charge nurse, exceeding the facility’s policy requirement to report abuse allegations within two hours.
A resident with severe cognitive impairment, hemiplegia, and total ADL dependence alleged that a CNA punched them during care after the CNA was seen leaving the room with a bloody nose. The resident told staff they no longer wanted that CNA in the room and reported being hit in the stomach, ribs, and leg. An LPN was informed and notified the DON and physician but only documented the CNA’s bloody nose and the notification, omitting the resident’s abuse allegation, any initiation of an investigation, or immediate protective actions. The CNA was allowed to continue working independently on another hall for the rest of the shift, and administration did not become aware of the abuse allegation or begin the formal investigation until the following day.
Eight cards of narcotic medications for multiple residents were found unsecured in the former DON's office desk, contrary to facility policy requiring double-locked storage and proper accounting. Staff interviews confirmed that narcotics should only be stored in locked medication carts or rooms, and the police removed the medications for investigation.
Two residents experienced misappropriation of property when a staff member used a resident's credit card without permission for vending machine purchases, and another staff member, along with the DON, was involved in the handling and subsequent loss of a large sum of cash belonging to a resident. Both incidents involved residents with cognitive or psychiatric diagnoses and resulted in unauthorized use or loss of their funds.
Staff, including the DON, made demeaning and upsetting comments to a resident in front of others, discussed the resident's behaviors and health status publicly, and threatened to revoke smoking privileges for two residents if they shared cigarettes. These actions led to feelings of humiliation, fear, and self-isolation among residents, and were acknowledged by staff as inappropriate and contrary to facility policy.
A resident with chronic pain and metastatic cancer did not receive consistent and appropriate pain management due to staff failing to accurately document pain levels, interventions, and physician notifications. Staff restricted access to narcotic pain medications without a physician order, and communicated to the ED that the resident could not receive narcotics or return if prescribed, despite the resident's diagnosis. Facility staff prioritized non-narcotic interventions based on the resident's history of substance abuse, leading to inadequate pain control and the resident's dissatisfaction with care.
A resident with severe cognitive impairment and high fall risk was injured during a Hoyer lift transfer when a CNA left the resident unsupervised, resulting in a tibial fracture. Facility policy required two staff members for such transfers, but one CNA stepped away, leading to the incident.
Failure to Timely Report Allegation of Staff-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of possible physical abuse was reported immediately to management and within two hours to the State Survey Agency, as required by facility policy. The facility’s abuse policy states that every staff member must immediately report any observed or suspected abuse and that the DON will ensure all alleged violations involving abuse are reported not later than two hours after the allegation is made. In this case, staff became aware of an allegation of possible staff-to-resident physical abuse on the evening of 01/27/26, but administration and the Department of Health and Senior Services (DHSS) were not notified until the following day, approximately 16 hours after the initial report to the charge nurse. The resident involved had severe cognitive impairment, hemiplegia of the left side, diabetes mellitus, and high blood pressure, and was dependent on staff for all ADLs, using a wheelchair. The resident’s care plan noted that the resident could be resistive to care at times and that staff should provide clear explanations of care activities. On the evening of 01/27/26, a CNA responded to the resident’s call light for incontinence care. Shortly afterward, another CNA observed this CNA running down the hall with blood on the CNA’s face. The resident later stated that the CNA had punched the resident in the stomach and leg, and that the resident did not want that CNA in the room anymore. The CNA who heard this allegation reported it to the charge nurse (LPN A), who then questioned the resident. LPN A documented in a progress note that the CNA reported having a bloody nose and lip after the resident allegedly hit the CNA, and that the DON and physician were notified. However, the progress note did not document the resident’s allegation that the CNA had punched the resident. During interview, LPN A stated that the resident reported the CNA had punched the resident in the right leg, and that LPN A texted the DON and physician about the incident but received no response and was unsure what to do next. Administration did not become aware of the allegation until late morning on 01/28/26, and the self-report to DHSS was submitted shortly thereafter, 16 hours after the incident was initially reported to the charge nurse, contrary to the policy requirement for reporting within two hours of an abuse allegation.
Failure to Timely Investigate Abuse Allegation and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of staff physical abuse and to immediately protect residents after the allegation was made. Facility policy required that the DON immediately initiate an abuse incident report, begin an investigation, and prevent further potential abuse, including reassigning or suspending the involved employee. However, after an evening incident in which a CNA reported being hit by a resident and the resident alleged the CNA had punched them, the investigation was not initiated until the following day, and there was no immediate documentation of protective measures for residents. Resident #1, who had severe cognitive impairment, hemiplegia, diabetes, high blood pressure, and was dependent on staff for all ADLs, allegedly told staff that a CNA punched them in the stomach, leg, and ribs during in-room care. The resident was known to be resistive to care at times and required clear explanations of care activities. On the evening of the incident, a CNA observed the accused CNA running down the hall with blood on their face after answering the resident’s call light. The resident then stated they did not want that staff member in the room anymore and alleged that the CNA had punched them, which the CNA reported to the charge nurse. The charge nurse (LPN) documented only that the resident had needed changing, that the CNA reported a bloody nose and lip, and that the DON and physician were notified, but did not document the resident’s allegation, initiation of an investigation, or steps taken to protect residents. The LPN stated the resident reported the CNA had punched them, and that the CNA continued to work the remainder of the shift on another hall, with no immediate suspension or reassignment documented. Administration did not become aware of the abuse allegation until late the following morning, at which time interviews and a physical assessment were conducted. The record and interviews showed that staff did not document or implement immediate protective measures for all residents at the time the allegation was made, and the accused CNA continued to work independently with residents until the next day.
Narcotics Improperly Stored in Unsecured Office Desk
Penalty
Summary
The facility failed to provide proper pharmaceutical services to ensure the accurate acquiring, receiving, and accounting of all drugs, specifically narcotics, for eight residents. Eight cards of narcotic medications, including oxycodone, hydrocodone-acetaminophen, oxycodone-acetaminophen, and tramadol, were found unsecured in the former Director of Nursing's (DON) office desk drawer, which was not locked. Facility policy requires that narcotics be stored under a double lock system, counted at the beginning and end of each shift, and that discontinued narcotics be placed in a locked box in the medication room with their narcotic sheets attached. The medications found included various quantities of narcotic pain relievers for eight different residents, all with original order or fill dates documented. Interviews with staff, including an LPN, a Certified Medication Technician (CMT), the interim DON, and the Administrator, confirmed that narcotics are to be stored in a locked medication cart or medication room, always behind two locks, and never in an office or desk. Staff were unaware of why the narcotics were found in the former DON's office and reiterated that this was not in accordance with facility policy. The police were involved and confirmed the discovery and removal of the medications for investigation. The facility census at the time was 64.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
The facility failed to ensure that all residents were free from misappropriation of property, as evidenced by two separate incidents involving staff and residents' funds. In the first incident, a resident with diagnoses including non-Alzheimer's dementia, schizophrenia, depression, and moderately impaired cognition reported that their billfold and credit card went missing. Subsequent review of bank records revealed multiple unauthorized charges at the facility's vending machine, totaling approximately $55.40. The facility's administrator confirmed that the former Director of Nursing (DON) was present at the facility on each day a charge was made, and video evidence later captured the former DON using the resident's credit card at the vending machine. The police were notified, and the resident's credit card was found in the former DON's possession, leading to their arrest. In the second incident, another resident, who was cognitively intact and diagnosed with psychosis, reported approximately $16,000 in cash missing. The resident had received life insurance payouts and, lacking a bank account, sought assistance from the former DON, who arranged for the facility's IT Person to help cash the checks. The IT Person deposited the checks into their own account, withheld $1,500 as a fee, and delivered the remaining cash to the resident, who then directed significant amounts to be given to the former DON for safekeeping. The facility's investigation could not confirm how much money was given to the former DON or how many times cash was handed over, and no safe or cash was found in the former DON's office after their arrest. Both incidents demonstrate a failure by the facility to protect residents from misappropriation and exploitation, as defined in the facility's own abuse policy. The actions of the former DON and the IT Person resulted in unauthorized use and loss of residents' funds, with the facility unable to account for the missing money or prevent staff from taking advantage of residents' trust and vulnerabilities.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
Facility staff failed to ensure residents were treated with dignity and respect at all times, as evidenced by multiple incidents involving the Director of Nursing (DON) making harsh and upsetting comments to a resident in front of others. The DON discussed a resident's behaviors and questioned their mental health in the presence of other residents, accused the resident of lying and being sneaky, and made demeaning remarks about the resident's cancer diagnosis and smoking habits. These interactions were observed and corroborated by resident interviews, with the affected resident reporting feelings of humiliation, fear of homelessness, and self-isolation as a result of the DON's comments. Additionally, the DON threatened to revoke the smoking privileges of two residents if they continued to share cigarettes with the resident in question. Residents expressed confusion and distress over these threats, stating that their cigarettes were their own property and money. The DON also approached another resident to warn them about being friends with the resident, labeling the individual as manipulative and potentially exploitative, which led to further feelings of being singled out and treated differently due to the resident's past. Staff interviews confirmed that such behavior was inappropriate and not in line with facility policy, which mandates treating residents with dignity and respect and prohibits demeaning practices. The DON acknowledged making the statements and justified them as attempts to educate the resident, but admitted that her comments were inappropriate. The administrator was made aware of the situation, and staff members indicated they would report similar incidents if observed.
Failure to Provide Consistent and Appropriate Pain Management
Penalty
Summary
Facility staff failed to provide safe and appropriate pain management for a resident with a history of chronic pain, liver cancer, and past substance abuse. Staff inconsistently documented the resident's pain levels and did not consistently record the steps taken to address reported pain or whether the pain was relieved. There were multiple instances where staff failed to document timely physician notification when the resident reported significant pain, including pain rated as high as 10 out of 10. Additionally, pain assessments in the medical record and MAR did not always align with progress notes, and there were gaps in documentation regarding pain management interventions. The resident experienced frequent changes in pain medication regimens, including the discontinuation and initiation of various analgesics and opioids. Despite orders for pain medications, staff restricted the resident's access to certain medications, specifically narcotics, without a documented physician order prohibiting their use. When the resident was sent to the emergency department (ED) for pain management, facility staff communicated to the ED that the resident could not receive narcotic pain medications and could not return to the facility if such medications were prescribed, despite the resident's diagnosis of metastatic cancer. This restriction was not supported by a physician order in the resident's record. Interviews with staff revealed a facility-wide approach of prioritizing non-narcotic and non-pharmacological interventions due to the resident's history of substance abuse, even after the resident's diagnosis of terminal cancer. Staff and leadership cited the resident's past substance use as justification for withholding narcotics, but the on-call nurse practitioner stated that effective pain medication should not be withheld regardless of history. The resident reported feeling that pain was not being appropriately managed and expressed a desire to leave the facility due to these issues.
Failure to Ensure Safe Transfer with Hoyer Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards during a mechanical lift transfer involving a resident. The incident occurred when a certified nurse aide (CNA) stepped away from the resident during a transfer using a Hoyer lift, leaving the resident unsupervised. This resulted in the resident's right lower extremity becoming entangled and injured, leading to increased pain and a subsequent diagnosis of an acute midshaft tibial fracture. The resident involved had a history of severe cognitive impairment, was dependent on staff for transfers, and was at high risk for falls due to confusion and limited physical ability. The resident required maximum staff assistance for activities of daily living and was non-weight bearing. During the transfer, the CNA responsible for guiding the resident's legs and feet left the resident unattended to search for a slipper, while the other CNA continued to operate the lift, resulting in the injury. Interviews with staff, including nurse aides and nurses, confirmed that the facility's policy required two staff members to be present during Hoyer lift transfers, with one staff member operating the lift and the other ensuring the resident's safety. The staff acknowledged that stepping away from the resident during a transfer was against protocol and contributed to the incident. The facility's policy emphasized the importance of using appropriate techniques and devices to ensure resident safety during transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Vernon Nursing | 0.4 mi | — | 0 | 0 |
| Ascend At Aurora | 11.5 mi | — | 4 | 0 |
| Ozarks Methodist Manor, The | 12.5 mi | — | 1 | 0 |
| Lacoba Homes Inc | 14.1 mi | — | 2 | 0 |
| Sarcoxie Health Care Center | 16.6 mi | — | 4 | 0 |
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