Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lawrenceville Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to properly dispose of refuse and maintain a clean dumpster area, resulting in food debris and trash being left exposed around and protruding from dumpsters. The facility's policy requiring waste to be kept in covered, leak-proof containers and deposited into sealed containers was not followed.
Staff did not update or revise care plans to reflect specialized diet orders, use of assistive devices during meals, or specific oxygen administration settings for several residents. Observations and record reviews showed that residents received food and care inconsistent with their physician orders, and staff interviews confirmed that care plans were not consistently updated to include these interventions.
Facility staff did not provide evidence of required physician visits at least every 60 days for five residents with complex medical needs. Documentation showed extended gaps between physician notes, and interviews revealed confusion among staff and the physician regarding visit tracking and documentation. The facility's own policy and federal regulations for physician visit frequency were not met, and no additional evidence was available to demonstrate compliance.
Several residents with dysphagia or special dietary needs were served food items that did not match their prescribed diet textures, such as being given regular rolls, cubed meats, and whole fruit slices instead of ground or chopped alternatives. Staff and dietary personnel confirmed that the meals did not conform to the required consistencies, and care plans lacked documentation of the altered diets, despite clear physician orders and facility policy.
Staff did not follow food safety protocols by storing an opened, undated bag of shredded cheese in the refrigerator and the dietary manager was observed with uncovered hair, both in violation of facility policy.
A resident with severe cognitive impairment who required assistance with eating was fed breakfast by a business office manager who stood over her, rather than sitting beside her and maintaining eye contact as per facility policy and staff practice. This action did not uphold the resident's dignity during mealtime.
Facility staff did not provide required physician documentation after a resident, who was moderately cognitively impaired and dependent for care, was transferred to the hospital following an incident involving hip pain. Although the transfer was communicated and carried out, there was no evidence of a post-hospital physician or NP note in the clinical record, contrary to facility policy.
Facility staff failed to accurately complete an MDS assessment for a resident, incorrectly coding the individual as physically restrained due to the use of a wheelchair seatbelt, even though the resident could independently release it and was not restricted. Observations and interviews confirmed the resident was not restrained, but the MDS correction process had not been completed as required by facility policy.
Three residents with physician-ordered modified diets for dysphagia were not provided with comprehensive care plans addressing their dietary needs. Staff served meals inconsistent with prescribed diets, and care plans lacked specific information about required dietary modifications. Interviews confirmed that care plans did not reflect these needs, despite facility policy requiring such documentation.
Facility staff did not clarify conflicting physician orders for oxygen administration for a resident with acute respiratory failure, COPD, and myocardial infarction. Both 2L and 4L oxygen rates were documented as administered on the MAR, despite the lack of clarification. An LPN confirmed that the professional standard would have been to clarify the order, but this was not done.
Staff did not clarify conflicting physician orders for oxygen therapy for a resident with acute respiratory failure and COPD, resulting in documentation that both 2L and 4L oxygen rates were administered. An LPN acknowledged the orders were conflicting and should have been clarified, but this was not done, contrary to facility policy.
A resident with a history of gout and a recent hip fracture received PRN pain medications without documented evidence that non-pharmacological interventions were attempted beforehand, as required by facility policy. Despite staff statements that such interventions should be tried and documented prior to medication administration, the eMAR and progress notes lacked this documentation for multiple instances.
The facility did not ensure that the DON refrained from serving as a charge nurse, as required. On one reviewed day, the DON was assigned as the nurse on a unit and confirmed working as a charge nurse and handling the medication cart, despite facility census and regulatory requirements.
The facility did not ensure that monthly medication regimen reviews were completed by a pharmacist for several residents, and failed to ensure that physicians responded to pharmacist recommendations for medication changes. For multiple residents, there was missing documentation of required reviews and unaddressed pharmacy recommendations for dose reductions of psychoactive and anticonvulsant medications, contrary to facility policy.
Facility staff did not ensure two residents' drug regimens were free from unnecessary medications by failing to act on pharmacist recommendations for dose reductions and not monitoring anticoagulant therapy as ordered. One resident's medication changes were not considered or documented by the physician, and another resident's required monitoring for anticoagulant side effects was not recorded on the MAR as per facility policy.
Facility staff did not ensure timely physician review and response to pharmacy recommendations for gradual dose reductions of psychotropic medications for two residents. Pharmacist suggestions to reduce or reassess antianxiety and anticonvulsant medications were not addressed or documented, and required monthly medication regimen reviews were missing from the clinical records.
A resident with severe cognitive impairment and nutritional risks was not provided with a divided plate during meals as ordered by the physician. Despite facility policy and a documented recommendation from a speech language pathologist, staff did not consistently supply the required assistive device, and the care plan lacked documentation of its use.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Facility staff failed to properly dispose of refuse and maintain a clean dumpster area, as observed during a kitchen task. During an observation outside the main kitchen, one dumpster had an open seam at the bottom with tin foil containing food debris and a trash bag protruding from it, while food waste such as a half sandwich and citrus peel were found in front of the dumpster. Another dumpster had its bifold lid fully open on one side. Staff interviews confirmed that the area had not been cleaned after trash pickup and that responsibility for the dumpster area was shared between maintenance and dietary staff. The facility's Waste Disposal policy requires all waste to be kept in leak-proof, covered containers and deposited into sealed containers outside, which was not followed in this instance.
Failure to Revise Care Plans for Specialized Diets, Assistive Devices, and Oxygen Administration
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans for several residents, resulting in deficiencies related to specialized diet orders, use of assistive devices during meals, and oxygen administration. For multiple residents with physician orders for dysphagia-advanced diets, care plans did not include information about the altered diet, despite meal tickets and prescriber orders specifying the need for modified food textures. Observations confirmed that residents were served food inconsistent with their prescribed diets, and staff interviews revealed a lack of consistent care plan updates to reflect these dietary needs. In another instance, a resident with a physician order for a divided/sectional plate at all meals did not have this intervention documented in the care plan. Observations showed inconsistent use of the divided plate, and staff interviews confirmed that the care plan did not reflect the assistive device order. The speech language pathologist had recommended the divided plate to decrease spillage and increase oral intake, but this was not incorporated into the care plan until after the deficiency was identified. Additionally, a resident with orders for oxygen therapy had conflicting orders for different oxygen flow rates, and the care plan did not specify the correct oxygen setting. Medication administration records showed both rates being documented as administered, and staff acknowledged that the care plan should have been reviewed and revised to clarify the correct oxygen administration. Facility policy required care plans to incorporate all identified problems and interventions, but this was not consistently followed for the residents involved.
Failure to Document Timely Physician Visits
Penalty
Summary
Facility staff failed to provide evidence that physician visits occurred at least every 60 days for five residents, as required by federal and facility policy. Documentation review revealed significant gaps between physician notes for these residents, with intervals ranging from 80 to 112 days between visits. The facility's own policy mandates that the attending physician or designee must visit each resident at least every 30 days for the first 90 days after admission, and at least every 60 days thereafter, but this standard was not met for the identified residents. The affected residents had complex medical histories, including diagnoses such as acute respiratory failure, COPD, CHF, multiple sclerosis, diabetes mellitus, encephalopathy, dysphagia, CVA, hemiplegia, and Alzheimer's disease. Their care plans reflected the need for ongoing monitoring and interventions related to their conditions, such as supervision for activities of daily living, observation for cardiac complications, and monitoring for adverse reactions to medications. Despite these needs, the clinical records did not contain timely physician progress notes to demonstrate that required face-to-face visits were occurring. Interviews with staff and the physician indicated a lack of clarity and consistency in the process for tracking and documenting physician visits. The physician reported visiting the facility multiple times per month but cited a lack of remote access to the documentation system for several months, which contributed to the absence of timely notes. Nursing staff were unsure about the timing of physician documentation, and administrative staff confirmed that no additional evidence could be provided to support compliance with visit frequency requirements.
Failure to Provide Diet-Appropriate Food Consistencies for Residents with Dysphagia
Penalty
Summary
Facility staff failed to provide food in the prescribed texture and consistency for five residents with dysphagia or other dietary needs. Multiple observations revealed that residents on mechanical soft or advanced dysphagia diets were served regular rolls, peach cobbler with crust, cubed chicken, and whole pineapple slices, instead of the required ground or chopped meats, pureed bread, and appropriately prepared fruits and desserts. In one instance, a resident with a mechanical soft, nectar thick liquid order was observed consuming an unthickened beverage with a straw, contrary to physician orders and dietary guidelines. Meal tickets for these residents clearly indicated the required diet modifications, such as mechanical soft or advanced dysphagia textures, and specified items like ground chicken nuggets, pureed bread, and chopped fruit. However, the food served did not match these specifications. Staff interviews confirmed that the food items provided did not conform to the required consistencies, and the dietary manager acknowledged that the kitchen failed to check and prepare certain items as needed. Additionally, the care plans for these residents did not contain information about their altered diets, despite existing prescriber orders. Staff, including CNAs and dietary personnel, described their roles in ensuring that food served matches the meal ticket and diet orders. Despite these protocols, the observed discrepancies indicate that the process for preparing and verifying diet-appropriate meals was not consistently followed. The facility's policy requires individualized diet modifications based on interdisciplinary input and written orders, but these were not implemented as required for the affected residents.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
Facility staff failed to maintain the kitchen in a sanitary manner as evidenced by an opened five-pound bag of shredded sharp cheese found in the refrigerator without a date label, contrary to facility policy requiring opened food items to be marked with the open date. Additionally, the dietary manager was observed in the kitchen with the back of her hair not covered by a hair net, despite facility policy mandating that hair restraints cover all hair on the head. These deficiencies were confirmed through staff interviews and review of the facility's Food Safety and Sanitation policy.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
Facility staff failed to treat a resident with dignity during feeding assistance at breakfast. A resident with severe cognitive impairment, as indicated by a BIMS score of 3 out of 15 and requiring supervision or touching assistance for eating, was observed being fed by the business office manager, who stood beside and over the resident while feeding her. This method of feeding did not align with the facility's policy, which requires that residents who cannot feed themselves be assisted with attention to safety, comfort, and dignity. A CNA interviewed stated that proper feeding assistance involves sitting beside the resident and maintaining eye contact, rather than standing over them. The incident was brought to the attention of facility leadership, and no additional information was provided prior to the survey exit.
Lack of Required Physician Documentation After Resident Hospital Transfer
Penalty
Summary
Facility staff failed to provide required physician documentation following the transfer of a resident to the hospital. The resident, who had diagnoses including transient ischemic attack (TIA), dysphagia, and cognitive communication deficit, was moderately cognitively impaired and dependent on staff for most activities of daily living. After an incident where the resident complained of right hip pain and a bulge was observed, the resident was assessed and subsequently transferred to the hospital. Although the physician was contacted and the transfer was carried out, there was no evidence of a post-hospital physician or nurse practitioner transfer note in the clinical record. Interviews with staff revealed uncertainty about when physicians document after a resident is transferred, and the physician confirmed that documentation was done in the electronic medical record system but did not specify the timing. Review of the facility's policy indicated that physician progress notes must be timely, accurate, and maintained for each resident, but in this case, the required documentation was not present following the resident's hospital transfer.
Inaccurate MDS Assessment Due to Misclassification of Physical Restraint
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. On the resident's most recent annual MDS, the assessment reference date indicated that the resident was coded as having no cognitive impairment and as being physically restrained when in a chair or out of bed. However, multiple observations of the resident revealed that he was not physically restrained at any time. The resident himself stated that he had never been physically restrained and always had free and independent movement in bed and in a chair. The LPN responsible for MDS coordination reported that she had initially coded the resident as physically restrained due to the use of a seatbelt in the wheelchair. She later learned that the seatbelt did not qualify as a restraint because the resident could release it independently and it did not restrict his movement. Despite this realization, the correction process for the MDS had not been completed or submitted at the time of the survey. Facility policy requires that errors in MDS records be corrected within 14 days of discovery, but this had not occurred.
Failure to Develop Comprehensive Care Plans for Residents with Modified Diets
Penalty
Summary
Facility staff failed to develop comprehensive care plans addressing the dietary needs of three residents with physician-ordered modified diets for dysphagia. Observations revealed that these residents were served meals inconsistent with their prescribed diets, such as regular rolls and peach cobbler instead of mechanical soft or pureed options, and cubed chicken instead of ground or pureed meat. Meal tickets and prescriber orders clearly specified the required dietary modifications, including mechanical soft textures, nectar thick liquids, and restrictions such as no straws, but these were not reflected in the residents' care plans. Interviews with staff, including LPNs and the MDS coordinator, confirmed that care plans did not include specific information about the residents' altered diets. The MDS coordinator stated that she typically documents "Diet as ordered" rather than specifying the type of diet, and acknowledged that she had not been able to locate dietary information in any of the care plans. She also noted that floor nurses have the ability to update care plans but generally do not do so. The lack of dietary information in the care plans was recognized as an issue by the staff during the survey. Facility policy requires that person-centered comprehensive care plans include measurable objectives and timetables to meet each resident's medical, nursing, mental, and psychosocial needs, and that all services and interventions required by the resident be described. Despite this policy, the care plans for the three residents did not address their dietary modifications, and no additional information was provided by the facility prior to the survey exit.
Failure to Clarify Conflicting Oxygen Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not clarifying conflicting physician orders for oxygen administration for one resident. The resident, who had diagnoses including acute respiratory failure, COPD, and myocardial infarction, was assessed as not cognitively impaired but required maximal assistance for most activities of daily living. The care plan identified a risk for respiratory complications and required oxygen to be administered as ordered. However, a review of the physician's orders revealed two conflicting directives: one for oxygen at 4 liters via nasal cannula and another for 2 liters, both to be administered continuously. The medication administration record (MAR) showed that both oxygen rates were documented as administered. During staff interviews, an LPN acknowledged the presence of conflicting orders and stated that the professional standard would have been to clarify the physician's order rather than document that both rates were administered. The facility's policy required nursing staff to perform duties in accordance with professional standards, but this was not followed in this instance. The deficiency was identified through staff interview, clinical record review, and facility document review.
Failure to Clarify and Follow Physician Orders for Oxygen Administration
Penalty
Summary
Facility staff failed to provide respiratory therapy services as ordered by the physician for one resident with a history of acute respiratory failure, COPD, and myocardial infarction. The resident required maximal assistance for mobility and was at risk for respiratory complications, with a care plan indicating a need for supplemental oxygen. Physician orders specified oxygen administration at both 2 liters and 4 liters via nasal cannula, but these orders were conflicting and not clarified by staff. Review of the medication administration record showed documentation that both oxygen rates were administered, despite the conflict. During an interview, an LPN acknowledged the presence of conflicting orders and stated that clarification should have been sought from the physician, rather than documenting that both rates were given. The facility's policy required verification and adherence to physician orders for oxygen administration, but this was not followed in this case.
Failure to Document and Implement Non-Pharmacological Pain Interventions Prior to PRN Medication
Penalty
Summary
Facility staff failed to provide a complete pain management program for one resident, as they did not implement or document non-pharmacological interventions prior to administering as needed (PRN) pain medications on multiple occasions. The resident, who had a history of a gout flare-up and a recent hip fracture from a fall, was assessed as moderately impaired in decision-making and reported experiencing almost constant pain. The resident received both acetaminophen and oxycodone for pain, but the electronic medication administration records (eMAR) and progress notes did not show evidence that non-pharmacological interventions were attempted before medication administration, as required by facility policy. Interviews with the resident indicated uncertainty about the use of non-pharmacological interventions, and staff interviews revealed that such interventions were supposed to be attempted and documented prior to giving PRN pain medications unless refused. Despite this, documentation was lacking for several instances where pain medication was administered. The facility's pain management policy outlined various non-pharmacological strategies, but there was no evidence these were consistently implemented or recorded for the resident in question.
DON Served as Charge Nurse in Violation of Staffing Requirements
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse for one of the days reviewed. Specifically, on 3/1/25, staffing records showed that the DON was assigned as the nurse working on the west wing while the resident census was 72. During an interview, the DON confirmed that she worked as a charge nurse on the floor and managed the medication cart on that day. The executive director and the DON were informed of this concern, and no specific policy addressing this issue was provided by the facility. No additional information was presented prior to the survey exit. No details regarding individual residents, their medical history, or their condition at the time of the deficiency were included in the report.
Failure to Complete and Act Upon Monthly Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews for all residents as required, and did not ensure that physicians responded to pharmacist recommendations in a timely manner. For one resident, there was no evidence of monthly medication regimen reviews by the pharmacist in two separate months, and the attending physician did not respond to pharmacist recommendations regarding dose reductions for multiple medications across several months. The director of nursing reported that the pharmacist reviews residents deemed necessary and communicates urgent concerns, but there was no established process to ensure all required reviews were completed or that physician responses were documented and followed up. Another resident's clinical record also lacked evidence of monthly medication regimen reviews for two months. The director of nursing confirmed that there was no process in place to ensure completion of all required reviews. Additionally, for a third resident, the facility staff failed to act upon pharmacy recommendations for gradual dose reductions of antianxiety and anticonvulsant medications. The clinical record did not contain documentation of monthly pharmacy reviews for the past year, and recommendations made by the pharmacist were not addressed or documented by the physician, with some recommendations left blank and progress notes predating the recommendations. Facility policy requires the consultant pharmacist to perform monthly medication regimen reviews for every resident and to report irregularities to the attending physician, medical director, and director of nursing. The policy also requires that these reports be acted upon and that the physician document their review and any actions taken in the resident's medical record. However, the facility did not provide evidence that these requirements were consistently met for the residents reviewed during the survey.
Failure to Address Pharmacist Recommendations and Monitor Anticoagulant Therapy
Penalty
Summary
Facility staff failed to ensure that two residents' drug regimens were free from unnecessary medications. For one resident, staff did not respond to a pharmacist's recommendations to reduce the doses of Protonix and Trileptal, despite these recommendations being made in May, September, and October. The clinical record showed no evidence that the physician considered or responded to these recommendations in a timely manner. The director of nursing acknowledged that there was no established process to ensure physician follow-up on pharmacist recommendations, and that recommendations were not regularly scanned into the electronic medical record. For another resident, staff failed to monitor anticoagulant therapy as ordered. The resident, who had diagnoses including acute respiratory failure, COPD, and myocardial infarction, was prescribed Eliquis for heart health. The care plan required monitoring for signs and symptoms of abnormal bleeding or bruising, with documentation on the medication administration record (MAR) every shift. However, there was no evidence of this monitoring on the MAR until the night shift, despite the order being in place earlier that day. Interviews with staff confirmed that monitoring for anticoagulant side effects should be documented on the MAR, but this was not done as required. Facility policies reviewed indicated that medication regimen reviews and anticoagulant orders should include appropriate monitoring and documentation, but these procedures were not followed in the cases identified.
Failure to Implement and Document Pharmacy Recommendations for Psychotropic Medication Reduction
Penalty
Summary
Facility staff failed to implement appropriate interventions to prevent unnecessary administration of psychotropic medications for two residents. For one resident, staff did not respond to a pharmacist's recommendation to reduce the dose of Lorazepam, which was prescribed for anxiety. The pharmacist had recommended a dose reduction, but there was no evidence in the clinical record that the physician considered or responded to this recommendation in a timely manner. The director of nursing stated that while pharmacist recommendations were distributed to attending physicians, there was no established process to ensure physician follow-up or documentation of their responses in the electronic medical record. For another resident, staff did not respond to pharmacy recommendations regarding the use of antianxiety and anticonvulsant medications. The clinical record lacked documentation of monthly pharmacy medication regimen reviews for the past year. Pharmacy recommendations for gradual dose reductions of Depakote and Lorazepam were not addressed, and the associated physician responses were either missing or not documented. Psychiatric progress notes attached to the recommendations were dated prior to the recommendations and did not address the specific pharmacy suggestions. Facility policy required that medication regimen reviews be conducted to ensure residents receive only necessary medications, with recommendations provided to the attending physician, medical director, and director of nursing. The policy also required timely review and documentation of physician responses to pharmacist recommendations. However, the facility did not provide evidence that these procedures were followed for the two residents in question, resulting in a failure to prevent unnecessary psychotropic medication administration.
Failure to Provide Ordered Assistive Eating Device During Meals
Penalty
Summary
Facility staff failed to provide a divided plate as ordered for a resident during meals. The resident, who was severely cognitively impaired as indicated by a BIMS score of 3 out of 15, had a physician's order for a divided/sectional plate at all meals to decrease spillage and increase oral intake. Observations on two separate occasions showed the resident was served meals without the required divided plate, instead receiving food in separate bowls or on a regular plate. The care plan for the resident, which addressed nutritional risks related to chronic disease, cognitive impairment, and GERD, did not document the use of assistive devices during meals. Interviews with staff revealed a lack of awareness and recall regarding the use of the divided plate for the resident. The LPN supervising the resident during meals did not remember the resident using a divided plate, and the speech language pathologist who recommended the device had not worked with the resident since the previous year. Facility policy required that adaptive devices be provided for residents who need them and that assistance be given to ensure residents can use and benefit from such equipment. Despite these requirements and documented orders, the assistive device was not consistently provided.
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 13 citations issued within 25 miles in the last 12 months — 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 Lawrenceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Lakes Rehabilitation And Nursing | 16.5 mi | ★★★★★ | 0 | 0 |
| Greensville Health And Rehabilitation Center | 17.1 mi | ★★★★★ | 0 | 0 |
| Emporia Rehabilitation And Healthcare Center | 17.3 mi | ★★★★★ | 3 | 0 |
| Heritage Hall-blackstone | 23 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Roanoke Rapids | 24.1 mi | ★★★★★ | 10 | 0 |
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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.