Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawrence Co Nursing Center during CMS and state inspections, most recent first.
A resident with a suprapubic catheter was exposed during catheter care when an LPN reentered the room without knocking and did not drape the resident for privacy, leaving the vaginal area exposed. Another resident requested help drying beneath her breasts after a shower, but a CNA refused, saying it was a private area; the resident remained wet and later had a red, raised rash beneath her breast. Staff interviews confirmed residents should be assisted with needed personal care and that privacy and proper draping are expected during care.
Resident mail and packages were opened by staff without permission, despite the facility’s resident rights policy stating residents must receive unopened private mail. An Activities Director and an LPN said staff had been instructed to open mail or packages if they had concerns about the contents, and three cognitively intact residents reported that their mail had been opened before delivery, with one resident saying it made her feel her privacy was violated.
An LPN administered Vitamin D3 to a resident even though the physician order listed only one tablet daily and did not include a dosage strength. Two Vitamin D products were available on the cart, and the LPN chose the 125 mcg tablet even though another product contained Vitamin D3 at 25 mcg. The DON later stated the medication should have been held because the order was incomplete and staff should not independently determine the dose.
A resident with severe cognitive impairment and diagnoses including hemiplegia/hemiparesis and colostomy care received peri-care that did not follow policy. Two CNAs did not perform hand hygiene before or during care, did not use a basin, reused the same soapy washcloth without rinsing, did not rinse soap from the skin, and did not wear gowns despite an order for EBP during hygiene care. The LPN/IP and RN stated the care was not completed according to policy and placed the resident at risk for infection.
A resident with Type 2 DM, hyperglycemia, and morbid obesity requested specific breakfast items, including boiled eggs, bacon, and oatmeal, and the DM agreed to add them to the tray card. However, the resident repeatedly did not receive the requested items; trays contained other foods, and the DM stated the eggs were not provided because they were not prepared or the facility had run out. The DM acknowledged the resident should have received the boiled eggs when they were available, and the resident was cognitively intact with a BIMS of 14.
Infection control failed during peri-care for a resident with severe cognitive impairment and an order for EBP. Two CNAs did not perform hand hygiene before or during care, did not wear gowns, did not use a basin, reused the same soapy washcloth for multiple areas, and did not rinse soap from the resident’s skin before drying. Both CNAs acknowledged the care was not completed correctly, and the IP and RN stated the procedure did not follow facility policy.
Two residents with pressure ulcers did not receive wound care according to professional standards or physician orders, as an LPN failed to use proper cleansing technique and did not dry wounds before applying dressings. Both residents were also found double briefed, a practice acknowledged by staff as increasing the risk for skin breakdown and infection.
Staff did not follow care plan interventions during wound care for two residents with pressure ulcers. An LPN failed to pat wounds dry before applying prescribed treatments and dressings, as required by physician orders and care plans. Both residents were severely cognitively impaired, and the DON and RN confirmed that the care plans were not followed during the observed wound care.
An LPN failed to disinfect a bedside table before placing wound care supplies on it while treating a resident with a stage 2 sacral pressure ulcer. The LPN repeatedly retrieved gloves and sanitizer from the undisinfected surface during the procedure, contrary to facility infection control policy. Interviews with staff confirmed that the table should have been disinfected prior to use.
Failure to Maintain Privacy During Care and Assist With Personal Hygiene
Penalty
Summary
The facility failed to ensure residents were treated with dignity, respect, privacy, and received necessary assistance with personal care. The deficiency involved Resident #27, who had a suprapubic catheter and a BIMS score of 5 indicating severe cognitive impairment, and Resident #47, who had a BIMS score of 15 indicating cognitive intactness. Facility policy required residents to be treated courteously and with dignity, to have personal privacy respected, and for staff to knock before entering rooms; the suprapubic catheter care policy also required the resident to be draped for privacy during the procedure. For Resident #27, an LPN was observed providing suprapubic catheter care after initially knocking and explaining the procedure. The LPN left the room to gather supplies and reentered without knocking. During the care, the resident’s bed linens were pulled down to the knees, exposing the resident from beneath the breasts to the knees, including the vaginal area, and the resident was not draped for privacy. During interviews, the LPN gave conflicting statements about whether she knocked and whether the resident had been exposed. Another LPN and the RN/Case Manager stated the vaginal area should not have been exposed, that the resident should have been draped, and that staff should knock each time they enter a resident’s room. For Resident #47, the resident stated she needed help drying beneath her breasts after a shower and requested assistance from a CNA, who told her she could not help because it was a private area. The resident remained wet beneath her breasts and later reported a constant itchy, uncomfortable rash. The CNA stated assisting residents with showering included washing and drying all body areas when needed and said she reported the rash concern to an LPN. The resident was observed to have a red, raised rash beneath her left breast, and the NP stated moisture trapped beneath the breast can cause this type of rash and that thorough drying is important to prevent skin irritation and breakdown.
Resident Mail Opened Without Permission
Penalty
Summary
The facility failed to ensure residents were permitted to receive unopened mail and packages and failed to protect residents’ privacy and confidentiality for three residents who were interviewed about mail receipt. The facility policy, Resident Rights Policy, stated that every resident has the right to be treated with consideration and respect for personal privacy and to receive unopened private mail. During interviews, the Activities Director stated she had opened mail addressed to residents in the past and had been instructed to do so to make sure residents were not ordering items that could be hazardous to their health. She also said nursing staff had been told it was acceptable to open resident mail at their discretion if they suspected a package contained something suspicious. LPN #3 acknowledged that staff opening resident mail was a facility practice and said the Social Services Director and other staff had been instructed to open resident packages if they had concerns about the contents. Resident #32, who had a BIMS score of 14 and was cognitively intact, reported that packages from her brother were sometimes opened before delivery and retaped, leaving her unsure whether items had been removed. Resident #3, who had a BIMS score of 15, stated staff opened his mail and told him they had always been told it was acceptable. Resident #9, who also had a BIMS score of 15, reported that some of her mail had been opened before delivery and said it made her feel terrible and violated her privacy. The Administrator stated he was unsure where staff got the idea they could open residents’ mail without permission and acknowledged that doing so violated residents’ privacy rights.
Incomplete Vitamin D Order Led to Medication Administration Error
Penalty
Summary
The facility failed to ensure physician orders contained complete and accurate medication dosage instructions for one resident reviewed for medication administration. During observation, an LPN administered Vitamin D3 to the resident even though the physician order directed staff to give one tablet daily without listing a dosage strength. The resident’s record showed the medication was ordered for Vitamin D deficiency, and the resident had a diagnosis of other paralytic syndrome following cerebral infarction affecting the left non-dominant side. The resident’s MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment. At the time of administration, two Vitamin D products were available on the medication cart: one labeled Vitamin D3 125 mcg and another labeled Vitamin D with Vitamin D3 as the active ingredient at 25 mcg. The LPN selected the product labeled Vitamin D3 and administered one 125 mcg tablet. During interview, the LPN stated both products contained Vitamin D3 and acknowledged the order required clarification to ensure the resident received the correct prescribed dose. The IDON stated the medication should have been held and the physician contacted because the order was incomplete and nurses should not independently determine which dosage to administer.
Improper Perineal Care and Failure to Follow Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate perineal care was provided for one resident during observed hygiene care. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side and an encounter for attention to colostomy. The resident’s MDS showed a BIMS score of 1, indicating severe cognitive impairment. The facility policy for perineal care required hand hygiene, use of clean portions of the washcloth or wipe for each stroke, rinsing soap from the genital area, drying front to back, and cleaning the anal area with a new washcloth or wipe. During observation, two CNAs provided peri-care without performing hand hygiene before or during the procedure. They obtained supplies from a hallway linen cart, but did not use a basin of clean water, did not rinse the washcloth between uses, and did not rinse soap from the resident’s skin before drying. One CNA cleansed the thigh and vaginal areas with the same soapy washcloth, then the other CNA turned the resident and used the same wet soapy washcloth to cleanse the buttocks area. The CNAs also did not wear gowns despite an active order for Enhanced Barrier Precautions during hygiene care and brief changes. After completing care, they removed gloves and performed hand hygiene in the hallway. During interviews, both CNAs confirmed the care was not completed correctly and stated they were nervous and forgot the proper procedure. They acknowledged the resident had a basin in the closet and that the care exposed the resident to cross contamination and infection. The LPN/Infection Preventionist and an RN both stated staff should have used a basin, rinsed soap from the resident’s skin, and performed hand hygiene before, during, and after care. They stated the CNAs failed to follow facility policy and that the resident was placed at risk for infection, including urinary tract infection, skin irritation, and skin breakdown.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of one resident who requested specific breakfast items, including two boiled eggs, two slices of bacon, and oatmeal. The resident stated she spoke with the Dietary Manager, who agreed to provide the requested breakfast items, but she only received the requested breakfast one time after making the request. During interviews and observation, the resident reported that her tray card had handwritten boiled eggs noted, yet the eggs were not included on her meal tray, and on another occasion her breakfast tray contained grits, scrambled eggs, sausage patty, and biscuits instead of the requested bacon, oatmeal, and boiled eggs. The Dietary Manager acknowledged that the resident had requested breakfast changes and that the items were added to the tray card. The Dietary Manager stated the resident did not receive boiled eggs on one occasion because the cook did not prepare them, and on another occasion because the facility had run out of eggs. The Dietary Manager further stated that eggs were delivered later and were available, but there was no reason the resident should not have received the requested boiled eggs when they were available. The resident’s record showed diagnoses including Type 2 Diabetes Mellitus Hyperglycemia and Morbid Obesity Due to Excess Calories, and her diet order was LCS/NSOT, regular texture, regular consistency. Her MDS indicated a BIMS score of 14, showing she was cognitively intact.
Infection Control Failure During Peri-Care
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified during peri-care for one resident. During an observation, two CNAs assisted with peri-care for a resident and did not perform hand hygiene before starting care or during the procedure. They obtained supplies from a linen cart in the hallway, but did not wear gowns despite an active order for Enhanced Barrier Precautions during hygiene care and changing briefs. After care was completed, they removed their gloves and performed hand hygiene in the hallway. During the observed peri-care, one CNA turned on the faucet while wearing gloves, wet a hand towel, and applied soap. The other CNA lowered the bed linens and removed the resident’s brief. The resident’s thighs and vaginal area were cleansed with the same soapy washcloth without folding it or using a clean portion for each stroke. Soap was not rinsed from the resident’s skin before drying, and no basin of clean water was used. The same wet soapy washcloth was then used to cleanse the buttocks area before drying. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease and an order for Enhanced Barrier Precautions. The resident’s MDS showed a BIMS score of 1, indicating severe cognitive impairment. In interviews, both CNAs acknowledged the peri-care was not completed correctly and stated they forgot the proper procedure. The Infection Preventionist and RN stated staff should have used a basin, rinsed soap from the resident’s skin, performed hand hygiene before, during, and after care, and followed facility policy throughout the procedure.
Failure to Provide Proper Wound Care and Prevention of Skin Breakdown
Penalty
Summary
The facility failed to provide wound care in accordance with professional standards of practice and physician's orders for two residents with pressure ulcers. Observations revealed that a Licensed Practical Nurse (LPN) cleansed wounds by wiping back and forth across the wound bed multiple times with the same gauze, rather than discarding it after a single pass, and did not pat the wounds dry before applying prescribed treatments and dressings. This was observed during wound care for both the hip and sacral wounds of one resident, and the sacral wound of another resident. The facility's own policy required drying the skin by patting with a soft gauze, and physician orders specifically instructed to pat dry the wounds prior to dressing application. Additionally, both residents were found to be wearing two briefs at the time of care, a practice acknowledged by staff as contrary to their training and facility policy, and known to increase the risk of skin breakdown and infection. Interviews with staff, including the LPN and Director of Nursing (DON), confirmed that wounds were not dried as required and that double briefing should not occur. Both residents involved were severely cognitively impaired and had a history of pressure ulcers, as documented in their medical records.
Failure to Follow Wound Care Plan Interventions for Two Residents
Penalty
Summary
Facility staff failed to implement care plan interventions during wound care for two residents with pressure ulcers. For one resident, physician's orders and the care plan required cleansing and patting dry an excoriated area on the right hip and a stage 3 pressure ulcer on the sacrum before applying specific wound treatments and dressings. During observed wound care, the LPN did not pat either wound dry before applying the prescribed ointments, powders, and dressings, contrary to both the physician's orders and the care plan. The resident had a history of pressure ulcers and was severely cognitively impaired at the time of the incident. For the second resident, who also had a history of pressure ulcers and severe cognitive impairment, the care plan and physician's orders required cleansing and patting dry a stage 2 sacral pressure wound before applying calcium alginate and a foam dressing. During observed wound care, the LPN cleansed the wound but did not pat it dry before applying the dressing. The LPN acknowledged not following the care plan or physician's orders during interviews, and both the DON and RN confirmed that the care plan was not followed during these wound care procedures.
Failure to Disinfect Bedside Table During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during wound care for a resident with a stage 2 sacral pressure ulcer. During an observed wound care procedure, an LPN entered the resident's room carrying supplies on a disposable barrier, which was placed on the foot of the bed. However, the LPN placed a bottle of hand sanitizer and clean gloves directly onto the resident's bedside table without disinfecting the surface. Throughout the procedure, the LPN repeatedly retrieved gloves and sanitizer from the undisinfected bedside table, despite removing and reapplying gloves multiple times during the dressing change. Interviews with the LPN, the Director of Nursing, and the facility's Infection Preventionist confirmed that the bedside table should have been disinfected before placing any wound care supplies on it. The LPN acknowledged not cleaning the table and recognized this as a deviation from proper infection control protocol. The resident involved was severely cognitively impaired and had a physician's order for specific wound care to the sacral area. Facility policy required maintaining a sanitary environment to minimize infection risk, which was not followed in this instance.
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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 Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jefferson Davis Community Hospital Ecf | 14.1 mi | ★★★★★ | 7 | 0 |
| Haven Hall Health Care Center | 20 mi | ★★★★★ | 7 | 0 |
| Diversicare Of Brookhaven | 21 mi | ★★★★★ | 9 | 0 |
| Trend Health And Rehab Of Brookhaven | 21 mi | ★★★★★ | 6 | 0 |
| Silver Cross Health & Rehab | 21.1 mi | ★★★★★ | 11 | 0 |
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