Inspection Reports for
Lawson Manor &Amp; Rehab

The complaint involved allegations of misappropriation of a resident's narcotic medication by an employee. The investigation substantiated that RN A took the resident's oxycodone and was subsequently terminated. The facility also failed to report the missing medication to the state survey agency within the required two-hour timeframe.

The facility failed to protect one resident from misappropriation of narcotic medication by an employee who took the resident's oxycodone. Additionally, the facility failed to report the missing medication to the state survey agency within the required timeframe and did not follow proper medication counting and removal procedures for controlled substances.

The complaint investigation found that Resident #2 choked Resident #1, causing redness and fear. Resident #2 was observed with hands around Resident #1's neck multiple times. Resident #2 was relocated and placed on one-to-one supervision. The facility staff failed to provide adequate supervision and monitoring, contributing to the incident. Resident #2's legal guardian requested inpatient psychiatric care. Both residents expressed feeling safe after interventions.

The facility failed to protect Resident #1 from abuse by Resident #2, who choked Resident #1 causing redness and fear. Resident #2 was relocated to another room and placed on one-to-one supervision. Staff failed to adequately monitor Resident #2, leading to actual harm to Resident #1.

The complaint investigation found that Resident #2 pushed Resident #1 out of his/her room causing Resident #1 to fall and sustain a skin tear. Resident #2 had a history of aggressive behavior and was placed on 1:1 monitoring after the incident. The facility failed to adequately assess and care plan for Resident #2's behavioral risks. Police and guardians were notified. The abuse was substantiated.

The facility failed to protect Resident #1 from physical abuse by Resident #2, resulting in actual harm. The investigation revealed inadequate assessment, identification, and care planning for Resident #2's behavioral risks, leading to physical harm to another resident. Immediate corrective actions and staff training were implemented.

The facility was found deficient in multiple areas including failure to properly manage resident funds, inadequate surety bond coverage, inconsistent documentation of Do Not Resuscitate (DNR) orders, lack of trauma-informed care planning for a resident with PTSD, and unsanitary conditions in the memory care unit's dining and kitchen areas.

The visit was complaint-related, focusing on allegations of misappropriation of resident property and deficiencies in staff training and infection control. Substantiation status is not explicitly stated.

The facility failed to investigate the missing fentanyl patch for a resident, ensure six nurse aides completed competency evaluations within four months of hire, and provide required two-step tuberculosis screening for six newly hired employees. The facility census was 46.

The complaint investigation included allegations of visitation rights violations for Resident #6, missing fentanyl patches for Resident #1, nurse aide training deficiencies, and incomplete tuberculosis screening for new hires. The facility failed to fully investigate or document the missing fentanyl patches and did not ensure visitation rights were upheld for Resident #6. Nurse aides were not enrolled in required training timely, and TB screening documentation was missing for six employees.

The facility failed to ensure Resident #6's visitation rights were respected, failed to investigate missing fentanyl patches for Resident #1, did not ensure nurse aides completed competency evaluations or training within required timeframes, and failed to complete required two-step tuberculosis screening for six newly hired employees. Deficiencies were noted with minimal harm potential affecting few or some residents.

The facility failed to provide timely written notice of transfer or discharge to residents or their representatives, failed to notify the State Long-Term Care Ombudsman, and lacked policies regarding transfers, discharges, and bed holds. Additionally, the facility failed to ensure residents received adequate assistance with showers, grooming, incontinent care, and oral care.

The facility was found deficient in multiple areas including resident dignity and privacy, medication administration, care planning, infection control, food service safety, staff training, and environmental maintenance. Specific issues included failure to provide privacy during care, improper medication administration, inadequate care planning, poor infection control practices, unsafe food handling, and lack of a full-time Director of Nursing.

The complaint investigation was triggered by allegations of inadequate incontinence care, fall prevention failures, insufficient behavioral health staff training, and failure to provide protective oversight for a resident with self-harm behaviors who subsequently died. The investigation included interviews, record reviews, and observations confirming these issues.

The facility failed to provide appropriate incontinence care for two residents, failed to properly investigate falls and implement interventions for a resident with multiple falls, failed to train staff adequately for behavioral health care needs, and failed to provide protective oversight for a resident who displayed self-harm behaviors and died without timely physician notification. Staffing shortages and reliance on roommates for monitoring were noted.

The facility was found deficient in multiple areas including resident dignity and respect, call light accessibility, resident funds management, transfer notifications, care plan development and implementation, assistance with activities of daily living, provision of meaningful activities, nurse aide training, food preparation and safety, hospice care coordination, infection control related to water management, and quality assurance program documentation.