Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 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.
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Illustrative
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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.
Illustrative
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Nursing homes near West Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgecrest Community Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| The Oaks | 2.6 mi | ★★★★★ | 2 | 0 |
| Mary Goss Nursing Home | 5 mi | ★★★★★ | 12 | 0 |
| St Joseph Skilled Nursing And Rehabilitation | 5.1 mi | ★★★★★ | 11 | 0 |
| Delta Grande Skilled Nursing And Rehabilitation | 5.7 mi | ★★★★★ | 5 | 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.