Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Delta Grande Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Delayed GDR for antipsychotic medication. A resident with anxiety disorder, depressive episodes, psychotic disturbance, and moderate cognitive impairment was receiving an antipsychotic. The pharmacist recommended reducing the nightly Seroquel dose, and the MD agreed, but there was a 2-month delay in completing the GDR process, which the DON confirmed should not have occurred.
A resident with severe cognitive impairment, malnutrition, and dysphagia was ordered changed from a mechanical soft diet with ground meats to a regular diet after the resident and RP requested it, but the change was not implemented. Staff continued serving chopped meats, the resident became upset and often refused meals, and the DON confirmed the resident remained on the mechanical soft diet despite the verbal order.
A resident with CHF, DM, and severe cognitive impairment had frequent rejection of care documented in the MDS and progress notes, but the care plan did not address it. During observation, the resident’s fingernails were long and jagged, and the DON confirmed the resident frequently rejected care and that the plan of care did not include this issue.
A facility failed to follow its EBP policy during wound care for a resident with an unhealed stage 3 pressure ulcer, diabetes, and other chronic conditions. A CNA assisted the ADON with right heel wound care without donning the required gown and PPE, even though the resident met criteria for EBP. The CNA and ADON both confirmed that a gown should have been worn.
The facility failed to ensure proper use and monitoring of physical restraints for residents, as evidenced by the use of lap trays on wheelchairs without physician orders and monitoring. A resident with Alzheimer's and dementia was observed with a lap tray without proper documentation, while another resident with similar conditions had a verbal order but lacked monitoring records. Additionally, a resident with Parkinson's was placed in a geri-chair with a lap tray daily without a physician's order, and staff were unsure about the required release for range of motion exercises.
A facility failed to monitor a resident's oxygen saturation every shift as ordered by the physician. The resident, with a history of chronic respiratory failure and tracheostomy, required monitoring to ensure oxygen saturation remained above 92%. However, records from January and February 2025 showed no documentation of this monitoring, a deficiency confirmed by the Assistant Director of Nurses.
The facility failed to ensure nursing staff demonstrated necessary competencies, as evidenced by missing documentation for essential care procedures for two residents. One resident required Foley catheter and peg site care, but documentation was missing numerous times. Another resident required edema monitoring, which was not recorded 14 times. Observations confirmed the presence of edema, highlighting a deficiency in staff competency and documentation.
A facility failed to implement a gradual dose reduction for a resident prescribed Cymbalta for depression. Despite a Consultant Pharmacist's request to reduce the dosage from 90 mg to 30 mg, the Nurse Practitioner delayed addressing the request, and the dosage remained unchanged in the physician orders. The ADON confirmed the discrepancy, indicating a lapse in medication management.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring such measures due to medical conditions like tracheostomies, PEG tubes, and Foley catheters. Staff did not use gowns and gloves as required, and necessary signage was missing. Observations and staff interviews confirmed these lapses, indicating a deficiency in infection control practices.
A resident with severe cognitive impairment and dependence on staff for ADL care did not receive necessary nail care. Despite requests for assistance, the resident's fingernails and toenails were observed to be long and in need of trimming. The ADON confirmed the need for nail care upon observation.
A pharmacist failed to address a medication dosage discrepancy for a resident with depression, who was prescribed Cymbalta at 90 mg daily. Despite a request for dosage reduction and documentation by a Nurse Practitioner to reduce the dosage to 30 mg, the pharmacist did not ensure the physician orders were updated, resulting in the resident continuing to receive the higher dosage. This oversight was confirmed by the ADON, indicating a lapse in the facility's medication review process.
Two residents with severe cognitive impairments and indwelling urinary catheters did not have comprehensive care plans in place. Despite their complex medical conditions and dependency on staff for daily activities, the facility failed to develop and implement necessary care plans, as confirmed by the Assistant Director of Nurses.
A facility failed to notify a resident's responsible party of significant changes in the resident's wound care status. The resident, who was severely cognitively impaired and required assistance with daily activities, experienced wound deterioration and refused treatment on multiple occasions. Despite these changes, there was no documentation of communication with the responsible party, as confirmed by interviews with the wound care nurse and the DON.
Delayed GDR for antipsychotic medication
Penalty
Summary
The facility failed to ensure that Resident #8, who had diagnoses including anxiety disorder, depressive episodes, and psychotic disturbance and a BIMS score of 9 indicating moderate cognitive impairment, received a timely gradual dose reduction for an antipsychotic medication. Record review showed the resident was taking antipsychotics, with a current order for Seroquel 100 mg nightly starting 02/06/2026. The pharmacist completed a GDR on 11/28/2025 and recommended reducing the nightly Seroquel dose from 150 mg to 100 mg, and the physician agreed to the reduction and signed the GDR on 01/08/2026. During an interview on 04/08/2026, the DON confirmed there should not have been a 2 month delay in completing the GDR process for Resident #8.
Failure to Implement Ordered Diet Change
Penalty
Summary
The facility failed to ensure Resident #41 received his diet as ordered. The resident was admitted with Alzheimer’s disease, Parkinson’s disease, folate and vitamin B-12 deficiency anemia, moderate protein-calorie malnutrition, and dysphagia. His MDS showed a BIMS score of 4, indicating severe cognitive impairment, and he required substantial to maximal assistance with eating. His care plan identified a nutritional problem related to malnutrition, vitamin deficiency, and a mechanical soft diet, with dietician review as needed. Records also showed an AMA Speech Pathology Report indicating his recommended diet was mechanical soft with ground meats, but the resident and responsible party requested a regular diet, and on 12/22/2025 a verbal order was obtained to change the diet to regular with signatures from the responsible party and S2DON. Despite that order, there was no documentation that the diet change was implemented, and the resident continued to receive a mechanical soft diet with ground meats. During observation, his dietary card still read Regular/Mechanical Soft Diet with ground meats, and he became upset when served chopped meats instead of the regular consistency he wanted. On one occasion he refused the chopped pork and accepted baked chicken instead, eating 50% of the meal; on another, he refused chopped chicken and only ate a regular corndog, consuming 25% of the meal. Staff interviews confirmed he often refused meals and asked for something different, and the DON confirmed the resident’s diet had not been changed to regular as ordered and had remained mechanical soft with ground meats from 12/22/2025 to the present.
Failure to Address Frequent Rejection of Care in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered plan of care for Resident #24 by not including rejection of care in the resident’s plan of care. Resident #24 was admitted on 07/31/2025 with diagnoses of congestive heart failure and diabetes. Review of the 01/28/2026 quarterly MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment, and also indicated that the resident rejected care frequently, 4-6 days weekly. Review of March and April 2026 progress notes also documented that Resident #24 frequently rejected care. On 04/08/2026 at 1:30 p.m., observation showed the resident’s fingernails were long and jagged. During interview on 04/08/2026 at 11:55 a.m., the S2DON confirmed that Resident #24 frequently rejected care and that the plan of care did not address rejection of care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when 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 facility failed to implement its Enhanced Barrier Precautions policy for Resident #4, who was admitted with diagnoses including polyosteoarthritis, a stage 3 pressure ulcer of the right heel, type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, dementia, and bipolar disorder. The quarterly MDS indicated a BIMS score of 13, showing the resident was cognitively intact with daily decision making, and also documented an unhealed stage 3 pressure ulcer. During wound care to the resident’s right heel, a CNA assisted the ADON without donning PPE, even though the resident required EBP and a gown was indicated for wound care. The CNA confirmed the resident required EBP and that a gown was required, and the ADON also confirmed the CNA should have donned a gown while assisting with wound care.
Failure to Ensure Proper Use and Monitoring of Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints unless medically necessary, as evidenced by the use of lap trays on wheelchairs without proper physician orders and monitoring. Resident #61, who was admitted with Alzheimer's disease, heart disease, and dementia, was observed with a lap tray on his wheelchair on multiple occasions. Despite having an informed consent and pre-restraining evaluation for the lap tray, there was no physician order or documentation of monitoring the release of the lap tray every two hours, as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident #38, diagnosed with Alzheimer's, anxiety disorder, and dementia, was observed with a lap tray on his wheelchair. Although there was a verbal order for the lap tray, there was no documented evidence of monitoring the release of the lap tray every two hours. The ADON confirmed the lack of documentation for monitoring, which is a requirement according to the facility's policy on the use of restraints. Resident #23, with a diagnosis of Parkinson's disease and cognitive impairment, was also observed with a lap tray attached to a geri-chair without a physician's order. Staff interviews revealed that the resident was placed in the chair with the lap tray daily, but there was uncertainty about whether the tray was released every two hours for range of motion exercises. The ADON confirmed the absence of an active physician's order and monitoring documentation for the lap tray, indicating a failure to comply with the facility's restraint policy.
Failure to Monitor Oxygen Saturation as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's oxygen saturation levels as ordered by the physician. The resident, who had a complex medical history including non-traumatic acute subdural hemorrhage, chronic respiratory failure, and tracheostomy status, was supposed to have their oxygen saturation monitored every shift. The physician's orders specified that if the oxygen saturation fell below 92%, the physician and respiratory therapist should be notified. However, a review of the medication administration records for January and February 2025 revealed that the nurses did not document checking the resident's oxygen saturation every shift as required. This deficiency was confirmed during an interview with the Assistant Director of Nurses, who acknowledged the failure to monitor the resident's oxygen saturation as ordered.
Deficiency in Nursing Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary competencies and skills to care for residents' needs, as evidenced by the lack of documentation for essential care procedures for two residents. Resident #2, who has multiple diagnoses including Parkinson's disease, vascular dementia, and profound intellectual disabilities, required Foley catheter care every shift and peg site care. However, there was no documented evidence of peg site care 87 times in January 2025 and 55 times in February 2025, and Foley catheter care was not documented 10 times in January 2025 and 4 times in February 2025. Interviews with the LPN and ADON confirmed the absence of documentation and the lack of an order for peg site care. Resident #41, diagnosed with hemiplegia following cerebral infarct, hypertensive heart disease with heart failure, diabetes mellitus, and chronic kidney disease, had an active physician order for edema monitoring every shift. Despite this, edema monitoring was not recorded 14 times in February 2025. Observations revealed that the resident had 2 plus edema in the right lower leg, which was confirmed by the ADON. The failure to document these care procedures indicates a deficiency in the facility's ability to ensure that nursing staff possess the necessary competencies to meet residents' care needs.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) for a resident who was prescribed Cymbalta for depression. The resident had multiple diagnoses, including acute respiratory failure, anxiety disorder, and depression. A Consultant Pharmacist requested a dosage reduction from 90 mg to 30 mg in October 2024, but this request was not addressed by the Nurse Practitioner until December 2024. Despite the Nurse Practitioner documenting that the Cymbalta dosage had been reduced to 30 mg, the physician orders for December 2024, January 2025, and February 2025 continued to reflect a dosage of 90 mg. The Assistant Director of Nurses (ADON) confirmed during a review that the Cymbalta dosage remained at 90 mg and was never decreased as documented. This oversight indicates a failure in the medication management process, as the facility did not implement the requested dosage reduction, potentially exposing the resident to unnecessary medication levels. The deficiency was identified through record review and interviews, highlighting a lapse in following through with the Consultant Pharmacist's recommendation for a dosage reduction.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy and procedures for six residents who required such precautions due to their medical conditions. The EBP policy, dated April 1, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not adhere to these requirements, as they only wore gloves and did not don gowns during procedures such as changing dressings and briefs for residents with tracheostomies, PEG tubes, and other indwelling medical devices. For instance, Resident #7, who had a tracheostomy and PEG tube, was observed receiving care without the staff donning the required gowns, despite the resident's door indicating the need for EBP. Similarly, Resident #19, who had a Foley catheter, and Resident #21, with a colostomy, Foley catheter, and PEG tube, did not have the necessary EBP signage outside their rooms, and staff did not use the required PPE during care activities. These lapses were confirmed through interviews with staff, who acknowledged the absence of PPE supplies and signage. Additionally, Residents #25, #42, and #60, who had various medical conditions necessitating EBP, also lacked proper signage and PPE usage during care. Observations and staff interviews confirmed that these residents, who had conditions such as Tessio catheters, arterial ulcers, and indwelling urinary catheters, were not provided with the required EBP measures. The facility's failure to implement its EBP policy and procedures for these residents highlights a significant deficiency in infection prevention and control practices.
Failure to Provide Nail Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate nail care, which is a part of activities of daily living (ADL) assistance. The resident, who was admitted with diagnoses including cerebral infarction, diabetes, and heart failure, was assessed with a severe cognitive impairment and was dependent on staff for ADL care. During observations and interviews, it was noted that the resident had long fingernails and toenails, which he reported had not been trimmed despite requesting assistance from the staff. The Assistant Director of Nurses confirmed the need for nail trimming upon observation.
Pharmacist Fails to Address Medication Dosage Discrepancy
Penalty
Summary
The pharmacist failed to identify and report irregularities in the medication regimen of a resident, leading to a deficiency in the facility's medication management. The resident, who had multiple diagnoses including depression, was prescribed Cymbalta at a dosage of 90 mg daily. A Consultant Pharmacist Communication to the Physician requested a dosage reduction on 10/23/2024, but this request was not addressed until 12/26/2024 by a Nurse Practitioner, who documented a reduction to 30 mg. Despite this documentation, the physician orders for December 2024, January 2024, and February 2024 continued to reflect the original 90 mg dosage. The pharmacist conducted monthly drug regimen reviews on November 29, 2024, and December 31, 2024, but failed to address the discrepancy between the documented dosage reduction and the physician orders. The Assistant Director of Nursing confirmed that the pharmacist did not follow up on the dosage reduction request or the subsequent documentation by the Nurse Practitioner, resulting in the resident continuing to receive the higher dosage of Cymbalta. This oversight highlights a lapse in the facility's medication review process, as the pharmacist did not ensure that the physician's orders were updated to reflect the correct dosage.
Lack of Comprehensive Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two residents with indwelling urinary catheters. Resident #1, who was admitted with multiple diagnoses including type 2 diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, and a history of urinary tract infections, was found to have an indwelling catheter without a corresponding care plan. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for assistance with all activities of daily living. Despite these needs, the medical record lacked a comprehensive care plan addressing the management of the indwelling catheter. Similarly, Resident #4, admitted with conditions such as convulsions, dementia, and major depressive disorder, also had an indwelling catheter without a comprehensive care plan. The MDS assessment for this resident also showed severe cognitive impairment and dependency on staff for all daily activities. The absence of a care plan for the indwelling catheter was confirmed by the Assistant Director of Nurses during an interview, highlighting a deficiency in the facility's care planning process for residents with specific medical needs.
Failure to Notify Responsible Party of Resident's Change in Status
Penalty
Summary
The facility failed to ensure proper communication of a resident's change in status to the responsible party. A resident with multiple diagnoses, including type 2 diabetes mellitus with a foot ulcer, chronic obstructive pulmonary disease, and pressure ulcer of the sacral region, was admitted to the facility. The resident was severely cognitively impaired, requiring assistance with all activities of daily living. Despite significant changes in the resident's wound care status, including deterioration of the wound and refusal of treatment, there was no documentation that the responsible party was notified of these changes. The wound care documentation revealed several instances where the responsible party was not informed of changes in the resident's condition or treatment plan. On multiple occasions, the resident's wound care orders were changed, the wound deteriorated, and the resident refused treatment, yet there was no record of communication with the responsible party. Interviews with the wound care nurse and the Director of Nursing confirmed that the responsible party was not notified, as there was no documentation to support such communication.
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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 Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Goss Nursing Home | 2.5 mi | ★★★★★ | 12 | 0 |
| Ouachita Healthcare And Rehabilitation Center | 3.3 mi | ★★★★★ | 5 | 0 |
| The Oaks | 3.6 mi | ★★★★★ | 2 | 0 |
| St Joseph Skilled Nursing And Rehabilitation | 4.1 mi | ★★★★★ | 11 | 0 |
| Landmark Nursing & Rehabilitation Ctr Of West Mon | 5.7 mi | ★★★★★ | 8 | 0 |
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