Lawrence Co Nursing Center: Wound Care Failures - MS
Both residents have lived with pressure ulcers for years. Both are severely cognitively impaired and cannot speak for themselves about the care they receive.
Resident #2 has been at the facility since December 2020, admitted with pressure ulcer diagnoses. By the summer of 2025, physicians had written orders for two separate wounds: an excoriated area on the right hip and a Stage 3 pressure ulcer on the sacrum, the bony area at the base of the spine. Stage 3 ulcers penetrate through the full thickness of skin into the tissue beneath. The orders for both wounds specified the same step: cleanse, pat dry, then apply the dressing materials.
On the morning of September 4, at 9:50 a.m., an inspector watched Licensed Practical Nurse #1 perform wound care on Resident #2. The nurse cleansed the right hip wound and the sacral wound. She did not pat either one dry. She applied Santyl ointment, gentamicin, nystatin powder, calcium alginate, and foam dressings directly to wet tissue.
Forty-five minutes later, at 10:35 a.m., the same nurse performed wound care on Resident #3, who has lived at the facility since March 2019. Resident #3 had a Stage 2 pressure ulcer on the sacrum, a shallower wound than Resident #2's but one with its own specific orders: cleanse, pat dry, then lightly pack calcium alginate and secure with foam. The nurse cleansed the wound with gauze soaked in wound cleanser, inserted gauze into the wound bed with a cotton swab, and applied the calcium alginate. She did not pat the wound dry.
The drying step is not incidental. Wound care products like calcium alginate interact with moisture to form a gel that promotes healing. Applied to a wound that hasn't been properly dried, the materials work against conditions the physician intended to create. The orders existed for a reason.
At 11:04 a.m., inspectors interviewed LPN #1. She acknowledged she had not patted the wounds dry before applying the dressings. She confirmed she had not followed the physician's orders. She confirmed she had not followed the care plans.
That was the whole interview, as far as the inspection report reflects. No explanation. No account of why the step was skipped, or whether it had been skipped before.
The Director of Nursing, interviewed that afternoon at 3:25 p.m., said LPN #1 did not follow the care plan and stated her expectation is that all staff follow care plans when providing care to residents. The MDS coordinator, a registered nurse interviewed at 4:34 p.m., confirmed the same thing: LPN #1 had not followed the care plan, and the care plan exists to direct staff on what residents need.
What neither interview addressed was how long this had been happening. The inspection was complaint-driven, triggered by someone reporting a problem at the facility. Inspectors observed wound care on September 4 and found the violations the same day. The records show Resident #2's sacral wound order dated to August 22, less than two weeks before the inspection. Resident #2's hip wound order dated to July 4. Resident #3's sacral wound order dated to June 20.
Weeks of orders. The nurse who performed the care knew what they said. She admitted as much.
Resident #2's cognitive assessment, completed in June 2025, placed them at a score of 3 on a mental status screening where scores below 8 indicate severe impairment. Resident #3 scored a 4 on a similar assessment in July 2025. Neither resident is in a position to tell a nurse she forgot a step, or to report afterward that something felt wrong, or to call anyone and describe what happened during wound care that morning.
The facility's own care plan policy describes the care plan as an interdisciplinary communication tool, something staff shall follow. The word is shall. The care plans for both residents listed patting the wounds dry as an intervention. The nurse who performed the care that morning did not follow it, and the only thing the record shows is that she knew it and said so.
The wounds remain. The residents remain. The nurse performed care on two people who could not correct her, and nobody in the room did either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lawrence Co Nursing Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
LAWRENCE CO NURSING CENTER in MONTICELLO, MS was cited for violations during a health inspection on September 4, 2025.
Both residents have lived with pressure ulcers for years.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.