Landmark Nursing & Rehabilitation Ctr Of West Mon
Inspection history, citations, penalties and survey trends for this long-term care facility in West Monroe, Louisiana.
- Location
- 1611 Wellerman Road, West Monroe, Louisiana 71291
- CMS Provider Number
- 195438
- Inspections on file
- 32
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Landmark Nursing & Rehabilitation Ctr Of West Mon during CMS and state inspections, most recent first.
The facility failed to maintain infection control precautions for three residents. A resident with a sacral wound infection and antibiotic-resistant organisms did not have contact precautions implemented, and two residents who met criteria for EBP due to an indwelling catheter and chronic wounds did not have EBP signage posted outside their rooms. The DON and Infection Preventionist confirmed the missing precautions.
A resident with multiple chronic conditions, including DM2, COPD, a stage 2 sacral pressure ulcer, heart failure, and documented need for assistance with personal care, had a physician order for one-person assist with ADLs but no corresponding ADL-focused care plan. Surveyors observed the resident on more than one occasion with long fingernails and dark brown grimy material under the nails on both hands. During observation and interview, the DON acknowledged the nails needed cleaning and trimming and confirmed there was no care plan addressing ADL needs or specifying responsibility and frequency for nail care.
A resident with multiple chronic conditions, including DM2, COPD, a stage 2 sacral pressure ulcer, peripheral vascular disease, hypertensive heart disease with HF, and documented need for assistance with personal care and ADLs, was observed on multiple occasions with long fingernails and a dark brown grimy substance under the nails on both hands. Despite a physician order for one-person assist with ADLs, staff did not ensure timely cleaning and trimming of the resident’s fingernails, and the DON later confirmed that the nails needed to be cleaned and trimmed.
A resident with depression, schizophrenia, cognitive communication deficit, hemiplegia, and presbyopia had a BIMS score indicating intact cognition, yet Zaditor eye drops were observed on the bedside table and no physician order was documented for the medication. The resident stated she used the drops herself when her eyes felt dry, and the DON confirmed the resident should not have medications at the bedside.
Dirty Overbed Tables and Unsecured Air Conditioner Unit: Two residents had overbed tables with spills and splatters observed on repeated checks, and the Housekeeping Supervisor confirmed the tables were dirty and needed cleaning. Another resident had an AC unit that was not secured to the wall with gaps on both sides, and the Maintenance Supervisor confirmed the condition.
MDS Assessments Not Completed and Submitted Timely: The facility failed to complete and transmit MDS assessments within required timeframes for three residents. One resident’s discharge MDS after death in the facility was late, another resident had no documented discharge MDS, and a third resident’s annual MDS was transmitted late; an LPN and the DON confirmed the delays.
Failure to Administer PRN BP Medication as Ordered: Nursing staff failed to give a resident’s PRN Clonidine HCL for hypertension on multiple occasions when the resident’s diastolic BP was above the ordered parameter. The resident had CHF, AFib, angina, HTN, and moderate cognitive impairment, and both an LPN and the DON confirmed the missed administrations.
A resident with edema, Parkinson's disease, and dementia received Lasix 20 mg daily for edema, but the MAR and nurses notes showed no documented monitoring for edema while the diuretic was being given. An LPN and the DON confirmed there was no documented evidence of edema monitoring.
The facility failed to complete the Minimum Data Set (MDS) assessments for four residents within the required three-month timeframe, as mandated by CMS. The last assessments for these residents were dated several months prior to the survey. This deficiency was confirmed by the Clinical Care Coordinator.
The facility failed to implement comprehensive care plans for a resident with constipation and two residents who were smokers. The resident with constipation had inconsistent documentation of bowel status, while the two smokers did not receive required quarterly Safe Smoking Assessments. These deficiencies were confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not collecting lipid levels as ordered. The resident, diagnosed with hyperlipidemia, was prescribed Rosuvastatin 20 mg at bedtime. Despite a physician's order to obtain lipid levels every six months, the facility did not conduct these tests. The DON confirmed the oversight.
A resident with multiple medical conditions and cognitive impairment fell and sustained serious injuries after a CNA left them unattended during a bed bath. The resident required a two-person assist for bed mobility, which was not provided, and the bed was not locked, leading to the fall. The resident was hospitalized with bilateral femur fractures.
A CNA failed to provide the required two-person assistance and did not lock the bed while caring for a resident with multiple medical conditions, leading to the resident's fall and injuries. The CNA was unaware of the care plan requirements and left the resident unattended, resulting in fractures that required surgery.
A cognitively impaired resident in an LTC facility was physically and verbally abused by a CNA during incontinence care, resulting in bruises and potential psychosocial harm. The incident, captured on video, showed the CNA handling the resident roughly and using inappropriate language, while other staff present failed to report the abuse.
A resident with cognitive impairment did not receive personal privacy during incontinence care, as observed in a video. The resident was exposed with open blinds, an unpulled privacy curtain, and an open door, allowing view by a roommate and others. Multiple staff members were present, and the facility confirmed the lack of privacy.
A resident with cognitive impairment was roughly handled by a CNA during care, as captured on video by the family. Despite the presence of multiple staff members, the incident was not reported to the administration until the family provided the video evidence. The resident sustained bruises, and the staff involved were later suspended and terminated for failing to report the abuse.
Failure to Implement Contact Precautions and EBP
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The report identified that Resident #14 had a sacral wound infection with antibiotic resistant organisms detected on culture, received IV Meropenem for the wound infection, and had an unhealed stage 3 pressure ulcer and a PEG tube. Although the resident met criteria for infection control precautions, contact precautions were not implemented, and the Infection Preventionist confirmed that contact precautions had not been in place. The report also identified failures to implement Enhanced Barrier Precautions (EBP) for Resident #23 and Resident #94. Resident #23 had an indwelling urinary catheter with routine catheter care orders, and observation showed the catheter and drainage bag in place without EBP signage posted on the room door or outside the room. The DON confirmed the resident should have been on EBP related to the indwelling catheter and that signage should have been posted. Resident #94 was readmitted with multiple diagnoses and had several chronic arterial ulcers on the left shin, ankle, plantar foot, and dorsum of the second digit, with wound care orders in place. Observation showed dressings to the left ankle and foot, but no EBP signage was noted on the door or outside the room. The DON confirmed EBP precautions should have been in place for the resident due to the chronic arterial wounds, and that EBP signage was not observed.
Failure to Develop ADL Care Plan and Provide Nail Care
Penalty
Summary
The facility failed to develop a comprehensive, person-centered ADL care plan for one resident who required assistance with personal care. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus without complication, a stage 2 sacral pressure ulcer, COPD, need for assistance with personal care, lack of coordination, muscle wasting and atrophy of the right shoulder, major depressive disorder, generalized anxiety disorder, peripheral vascular disease, hypertensive heart disease with heart failure, personal history of venous thrombosis and embolism, obstructive sleep apnea, and obesity. Physician orders dated 12/24/2025 specified that the resident required one-person assistance with ADLs, but review of the comprehensive care plan showed no evidence that this ADL assistance need was addressed. On multiple observations, the resident’s fingernails were noted to be long with a dark brown grimy substance under the nails on both hands, and during an observation with the S2DON, the S2DON confirmed the fingernails needed to be cleaned and trimmed. In an interview, the S2DON confirmed that no ADL care plan had been developed for this resident and that there was no care plan specifying who would trim and clean the resident’s fingernails or how often nail care would be provided. This deficiency centers on the omission of an ADL-focused care plan despite documented orders for assistance and observable unmet personal care needs, specifically nail care, for a resident with significant medical and functional conditions.
Failure to Provide Adequate Fingernail Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident who required assistance with activities of daily living received necessary services to maintain good personal hygiene, specifically related to fingernail care. The resident, admitted with multiple diagnoses including type 2 diabetes mellitus without complication, a stage 2 sacral pressure ulcer, COPD, need for assistance with personal care, lack of coordination, muscle wasting and atrophy of the right shoulder, major depressive disorder, generalized anxiety disorder, peripheral vascular disease, hypertensive heart disease with heart failure, personal history of venous thrombosis and embolism, obstructive sleep apnea, and obesity, had a physician order indicating the need for one-person assistance with ADLs. Observations on two consecutive mornings showed the resident’s fingernails were long with a dark brown grimy substance under the nails on both hands. During a subsequent observation with the DON present, the same condition of long, dirty fingernails was noted, and the DON confirmed the nails needed to be cleaned and trimmed. This deficiency centers on the facility’s failure to provide timely nail care and hygiene for a dependent resident, despite clear orders indicating the need for assistance with ADLs and repeated observable evidence of unclean, overgrown fingernails.
Failure to Assess Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications even though a bottle of Zaditor eye drops was observed at the bedside. Resident #51 was admitted on 01/28/2026 and had diagnoses including depression, schizophrenia, cognitive communication deficit, hemiplegia, and presbyopia. The admission MDS dated [DATE] showed a BIMS score of 13, indicating intact cognition for daily decision making. On 03/08/2026, surveyors observed the Zaditor eye drops on the resident’s bedside table during two separate room observations. Review of the March 2026 physician orders showed no documented order for Zaditor eye drops. During interview, the resident stated she used the eye drops in her eyes when they felt dry and administered them herself. Later that day, the DON confirmed the resident should not have medications for use at the bedside.
Dirty Overbed Tables and Unsecured Air Conditioner Unit
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents #16 and #29 by allowing their overbed tables to remain dirty. On 03/08/2026 at 11:15 a.m., 4:03 p.m., and on 03/09/2026 at 1:45 p.m., observations of both residents' overbed tables showed spills and splatters on the tops of the tables. During a 03/09/2026 observation with the Housekeeping Supervisor, the same condition was seen on both tables, and the Housekeeping Supervisor confirmed that the tables were dirty and needed to be cleaned. The facility also failed to maintain resident #51's air conditioner unit in proper condition. On 03/08/2026 at 3:53 p.m. and again on 03/09/2026 at 1:55 p.m., observations showed the air conditioner unit was not secured to the wall and had a gap on each side. During a 03/09/2026 observation with the Maintenance Supervisor, the same condition was confirmed, and the Maintenance Supervisor stated the unit should have been secured to the wall and that a gap was present on each side.
MDS Assessments Not Completed and Submitted Timely
Penalty
Summary
The provider failed to ensure MDS assessments were completed and submitted timely for 3 of 3 sampled residents reviewed for assessments. Resident #3 had an admission date and later expired in the facility, but the discharge (death in facility) MDS assessment was not completed and transmitted to CMS until after the 7-day timeframe. During interview, the S7 MDS/LPN confirmed the resident expired in the facility and acknowledged the discharge MDS was not completed and transmitted within 7 days. Resident #96 had an admission date and a discharge date, but there was no documented evidence that a discharge MDS assessment was completed or transmitted to CMS. The S7 MDS/LPN confirmed the resident was discharged from the facility and stated the discharge MDS was not completed and transmitted within 14 days. Resident #107 had an annual MDS assessment that was not completed and transmitted to CMS until after the required timeframe, and the S7 MDS/LPN confirmed the assessment should have been transmitted by the required date. The S2 DON also confirmed the MDS assessments were not completed and transmitted to CMS in a timely manner for Residents #3, #96, and #107.
Failure to Administer PRN Blood Pressure Medication as Ordered
Penalty
Summary
Nursing staff failed to demonstrate competency in administering as-needed blood pressure medication for Resident #6, who had diagnoses including chronic systolic congestive heart failure, shortness of breath, chest pain, angina pectoris, atrial fibrillation, and essential hypertension. The resident’s quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. A physician’s order dated 02/10/2026 directed staff to give Clonidine HCL 0.1 mg by mouth every 12 hours as needed for hypertension when systolic blood pressure was greater than 160 or diastolic blood pressure was greater than 90. Review of the February 2026 MAR showed 9 times when the resident’s diastolic blood pressure was greater than 90 and Clonidine HCL was not documented as administered as ordered. Review of the March 2026 MAR showed 3 additional times when the resident’s diastolic blood pressure was greater than 90 and Clonidine HCL was not documented as administered. During interview, an LPN confirmed that on 02/11/2026 the resident’s diastolic blood pressure was greater than 90 and Clonidine HCL was not given as ordered. The DON also confirmed that nurses failed to administer the PRN blood pressure medication 9 times in February 2026 and 3 times in March 2026 when the resident’s diastolic blood pressure was greater than 90.
Failure to Monitor Edema During Diuretic Therapy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring for edema while the resident was receiving Lasix 20 mg daily for edema. The resident was admitted on 10/22/2024 and had diagnoses including edema, Parkinson's disease, and dementia. The quarterly MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment and need for assistance with ADLs. Review of the March 2026 physician orders showed an order dated 03/04/2026 for Lasix 20 mg by mouth once daily related to edema, but review of the March 2026 MAR and nurses notes found no documented evidence that edema monitoring was performed. An LPN and the DON both confirmed there was no documented evidence that the resident was monitored for edema while taking Lasix.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that residents' assessments were updated at least once every three months, as required by the Centers for Medicare & Medicaid Services (CMS). Specifically, the facility did not complete the Minimum Data Set (MDS) assessments for four residents within the required timeframe. The last completed MDS assessments for these residents were dated several months prior to the survey, with dates ranging from August to September 2024. This deficiency was confirmed during an interview with the Clinical Care Coordinator, who acknowledged that the MDS assessments were not completed at least every three months for the affected residents.
Failure to Implement Comprehensive Care Plans for Constipation and Smoking
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with constipation and two residents who were smokers. For the resident with constipation, the care plan included an intervention to assess bowel patterns, but the facility did not consistently document the resident's bowel status. Specifically, there was no record of bowel status for 13 of 13 day shifts, 4 of 13 evening shifts, and 7 of 13 night shifts. This lack of documentation was confirmed by the Director of Nursing during an interview. For the two residents who were smokers, the facility did not conduct the required quarterly Safe Smoking Assessments. Both residents were moderately cognitively impaired and required limited assistance with activities of daily living. Despite having interventions in their care plans to assess safe smoking quarterly, the facility failed to perform these assessments since August 2024. This was confirmed by the Director of Nursing, indicating a lapse in following the care plan interventions for these residents.
Failure to Obtain Ordered Lab Tests for Medication Monitoring
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs by not collecting laboratory tests as ordered for a resident. The medical record review for a resident revealed that she was admitted with a diagnosis of hyperlipidemia and had a physician's order for Rosuvastatin 20 mg at bedtime to treat this condition. On March 1, 2024, the physician ordered lipid levels to be obtained every six months. However, the medical record showed that no lipid levels were done for the resident. An interview with the Director of Nursing confirmed that the facility had not obtained the required lipid levels for the resident.
Resident Falls Due to Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident, resulting in a fall and significant injuries. The incident occurred when a CNA left the resident unattended during a bed bath to gather additional supplies. The resident, who required a two-person assist for bed mobility and transfers, was left in an unsafe position, leading to a fall from the bed. The resident involved had a history of multiple medical conditions, including schizoaffective disorder, seizures, multiple sclerosis, and cognitive impairment. The resident was dependent on staff for bed mobility and was at risk for falls. Despite these needs, the CNA did not review the care plan, which indicated the requirement for a two-person assist, and left the resident alone in the room. The CNA did not ensure the bed was locked before leaving, and the resident fell, sustaining bilateral supracondylar fractures of the femurs. The resident was subsequently sent to the hospital for treatment. Interviews with staff confirmed that the CNA was not aware of the resident's care requirements and failed to follow proper procedures, contributing to the accident.
Failure to Ensure Competency in Resident Care
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated the necessary competencies to care for residents as outlined in their care plans. Specifically, a Certified Nursing Assistant (CNA) did not provide the required two-person assistance during bed mobility for a resident, nor did she ensure the bed was locked before leaving the room. This oversight occurred while the CNA was providing personal care to a resident who had multiple medical conditions, including schizoaffective disorder, seizures, multiple sclerosis, and cognitive impairments. The resident required total dependence for bed mobility with two-person assistance, as indicated in their care plan. During the incident, the CNA was assisting the resident alone, unaware of the two-person assistance requirement. While providing a bath, the resident had a bowel movement, prompting the CNA to leave the room to gather more supplies. The CNA did not check if the bed was locked before exiting. Upon hearing the resident yell, the CNA returned to find the resident on the floor, having fallen from the bed. The resident sustained injuries, including fractures in both legs, requiring surgical intervention. Interviews with facility staff confirmed that the CNA should not have been providing care alone and should have ensured the bed was locked. The incident report and subsequent interviews highlighted the CNA's lack of awareness regarding the resident's care plan and the necessary precautions to prevent such an incident. The failure to adhere to the care plan and ensure the resident's safety led to the resident's fall and subsequent injuries.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse, resulting in actual harm. The incident involved a cognitively impaired resident with communication deficits who was subjected to physical and verbal abuse by a Certified Nursing Assistant (CNA) during incontinence care. The abuse occurred when the CNA forcefully grabbed the resident's lower extremities, hands, and arms, causing multiple bruises. The CNA also cursed and expressed anger towards the resident, which would have caused severe psychosocial harm to a reasonable person. The resident, who had a history of encephalopathy, aphasia following cerebral infarction, abnormal weight loss, lack of coordination, muscle wasting, and Alzheimer's disease, was unable to make daily decisions and required assistance with all activities of daily living. The incident was captured on video by the resident's responsible party, showing the CNA handling the resident roughly and using inappropriate language. The video also revealed that other staff members were present during the incident but failed to report the abuse. The facility's investigation confirmed the abuse, and it was reported to law enforcement and the state agency. The video evidence showed the resident nearly falling off the bed due to the rough handling. Despite the presence of multiple staff members, none intervened or reported the incident, indicating a failure in the facility's abuse prevention and reporting protocols.
Failure to Maintain Resident Privacy During Incontinence Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during incontinence care, as observed in a video provided by the resident's responsible party. The resident, who was cognitively impaired with a BIMS score of 3 and required assistance with all activities of daily living, was left exposed during care. The video showed the resident undressed and lying in a fetal position with the window blinds open, the privacy curtain against the wall, and the door to the hallway open, allowing full view of the resident by the roommate and others. The incident involved multiple staff members, including CNAs and an LPN, who were present in the room or standing in the doorway during the care. The facility's administration confirmed that privacy was not maintained, as the staff failed to close the blinds, pull the privacy curtain, or shut the door. The staff involved were suspended and later terminated following the investigation of the reported abuse.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse by staff within the required timeframe, as evidenced by an incident involving a resident with significant cognitive impairment and physical dependencies. The resident, who was unable to make daily decisions due to conditions such as encephalopathy and Alzheimer's disease, was reportedly handled roughly by a CNA during incontinence care. The incident was captured on video by the resident's family, showing the CNA using force and inappropriate language while providing care. The video evidence revealed that the CNA was not alone; other staff members, including another CNA and several others, were present but failed to report the incident. The resident was found to have multiple bruises on her arms and hands following the incident. Despite the presence of multiple staff members, none reported the abuse to the administration, and the facility's leadership only became aware of the situation after the family provided the video evidence the following day. The facility's policy required immediate reporting of such incidents to the Director of Nurses and the Administrator, which did not occur in this case. The failure to report the abuse promptly led to a delay in addressing the resident's injuries and ensuring her safety. The staff involved were subsequently suspended and terminated, but the initial inaction highlighted a significant lapse in adherence to the facility's abuse reporting protocols.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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