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
- 30
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Landmark Nursing & Rehabilitation Ctr Of West Mon during CMS and state inspections, most recent first.
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.
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 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 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
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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