Below 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 Ouachita Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Respiratory care was not provided in accordance with policy for three residents. Two residents ordered continuous O2 had tubing and humidifier issues, including an empty or undated humidifier bottle and tubing not changed on schedule, while another resident’s BiPAP nasal prongs were left out of a bag when not in use. The DON confirmed the equipment concerns.
Improper Food Storage and Kitchen Sanitation: The facility failed to store and handle food in accordance with professional standards. Kitchen observations found opened food items left exposed to air without proper sealing or dating, a sauce bottle with spills and splatters on the outside, and grease buildup on two fryers. The ADM confirmed the issues during interview, and the DON was later notified.
Failure to Use EBP During Resident Care: The facility failed to consistently implement EBP for two residents with indwelling devices and other clinical needs. A CNA emptied a resident’s urinary catheter bag while wearing gloves but no gown, and two CNAs transferred another resident while wearing gloves without a gown. The DON confirmed the gown should have been worn for the catheter care and did not disagree that gowns should have been used during the transfer.
Wheelchair Was Damaged and Dirty: A resident who used a wheelchair for mobility was observed with cracked and torn arm padding exposing foam, and the wheelchair frame had dirt and debris on it. The S2DON confirmed the armrest was in need of replacement and the frame needed to be cleaned.
A resident with PTSD, anxiety, depression, personality disorders, and bi-polar disorder reported ongoing counseling and mental health clinic visits, but the care plan had no documentation of her mental health needs or these services. Staff confirmed the resident was attending counseling and a mental health clinic, and the DON verified that no care plan had been developed for those needs.
The facility failed to ensure call lights were within reach for three high-risk residents, leading to potential safety concerns. One resident in a wheelchair had their call light on the bed, while another in bed had it draped over a recliner. A third resident in a wheelchair also had their call light on the bed. All residents were at high risk for falls and dependent on staff for daily activities.
A resident's privacy was compromised when she was left exposed to the hallway during care. The incident occurred when a CNA left the room, and the door swung open, leaving the resident uncovered. The resident, who was cognitively intact and dependent on staff for daily living activities, expressed discomfort with being exposed. The DON was informed of the situation.
Two residents with cognitive and physical impairments did not receive necessary assistance with personal hygiene, as evidenced by untrimmed eyebrows and chin hair. Despite care plans indicating the need for staff assistance, observations confirmed the lack of grooming support, as acknowledged by the ADON and DON.
The facility failed to administer oxygen therapy as ordered for two residents. One resident, with a history of subdural hemorrhage and other conditions, had their oxygen set at 2 liters instead of the prescribed 3 liters. Another resident, with chronic obstructive pulmonary disease, had their oxygen set at 3.5 liters instead of the prescribed 2 liters. These discrepancies were confirmed by staff, indicating a failure to follow physician orders.
The facility did not follow the prescribed menu for residents on pureed diets, affecting seven individuals. The menu required pureed cornbread, but the facility served regular cornbread instead. This issue was observed on two consecutive days, and the Dietary Manager confirmed the oversight.
The facility failed to maintain food safety standards, with issues such as improper storage of personal items in the freezer, undated and uncovered food in the refrigerator, and improper handling of food with gloves. Staff were observed handling food after touching other items without changing gloves, and thawing meat improperly. These deficiencies were noted by the dietary manager.
The facility failed to maintain a manual can opener in safe operating condition, as it had a buildup of metal shavings. This was confirmed by a cook during an observation, affecting the preparation of 168 diets served from the kitchen.
The facility failed to maintain an effective pest control program, leading to an ant infestation in the kitchen's dry pantry area. Small black ants were observed on containers of grits and sugar, and a cook confirmed ongoing issues with ants. This deficiency had the potential to impact 168 residents receiving meals from the kitchen.
A facility failed to document a discharge summary for a resident with multiple health conditions, including cerebral infarction and diabetes, who required assistance with daily activities. The resident was discharged home without the necessary documentation, as confirmed by the DON.
The facility failed to provide dignified care and assistance to two residents. A resident with cognitive impairment was observed with a disposable brief used as a cushion in his wheelchair, while another resident with Parkinson's disease ate breakfast directly from the table without staff assistance, despite staff presence. The DON and ADON were informed of these incidents.
The facility failed to maintain a sanitary environment in the laundry department, as personal cell phones were placed on tables designated for folding clean clothing and linens, risking cross-contamination. This was confirmed by laundry workers and the supervisor, who acknowledged the breach in infection control protocols.
A resident received an incorrect dosage of Nifedipine ER due to an LPN's failure to verify the medication card label against the e-MAR before administration. The error was traced back to a nurse sending in a label from a previously discontinued dosage, leading to the pharmacy filling the wrong dosage.
A resident with multiple medical conditions was administered Nifedipine ER 30 mg instead of the prescribed 90 mg due to a labeling error by a nurse, which was confirmed by the DON.
The facility failed to follow dietary orders for two residents who were prescribed mighty shakes and did not adhere to a resident's preference for wheat bread. Despite the availability of the required items, the dietary staff did not place them on meal carts, and CNAs did not provide them to the residents.
The facility failed to maintain sanitary conditions in the kitchen, with grease build-up in fryers, old food particles on a toaster and microwaves, and unlabeled opened bags of pasta. The Culinary Supervisor confirmed these issues.
The facility failed to ensure consistent documentation of a resident's code status, resulting in a discrepancy between the paper and electronic medical records. The resident's paper record indicated Full Code, while the electronic record and a physician's order indicated DNR. The DON was unaware of this inconsistency.
The facility failed to ensure a resident received appropriate treatment and care according to professional standards and the care plan. The resident, with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia, was frequently observed in a high back wheelchair with a tilted lap tray and unsupported feet. Staff confirmed ongoing issues with the wheelchair and lap tray positioning, and the DON acknowledged the facility's failure to address these concerns in a timely manner.
A resident with moderate cognitive impairment and multiple serious health conditions was found with a cup of pills left at the bedside. An LPN confirmed the medications were administered before her arrival and should not have been left there. The DON also confirmed this practice was incorrect.
A resident with Parkinson's disease and dementia had an ongoing issue with a tilted wheelchair lap tray that was not repaired in a timely manner. The tray had a tear causing a rough edge and a blue substance that the resident was picking at. The LPN was unsure if maintenance was aware of the issue, and the DON confirmed that the concerns should have been addressed.
Respiratory Equipment Not Maintained or Stored per Policy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for 3 residents reviewed for respiratory care. The facility’s Oxygen Concentrator Cleaning Policy and Procedure required oxygen tubing, cannula, and mask to be stored in a plastic bag when not in use and changed weekly and as needed, and required the oxygen concentrator filter to be cleaned or changed weekly and as needed. For Resident #36, who had diagnoses including acute and chronic respiratory failure with hypoxia and COPD and was ordered oxygen at 2 liters per nasal cannula continuously with tubing and humidifier changes every Monday night shift, the resident was observed on 04/13/2026 with the humidifier water bottle empty and dated 03/03/2026. For Resident #84, who had diagnoses including obstructive sleep apnea, chronic respiratory failure with hypoxia, CHF, and COPD and was ordered oxygen tubing and humidifier changes every Monday night shift and as needed, the resident was observed on 04/13/2026 with oxygen at 4 liters per nasal cannula, with undated tubing and a humidifier dated 03/31/2026. For Resident #169, who had diagnoses including dementia, disorders of the lung, interstitial pulmonary disease, pleural effusion, and shortness of breath and was ordered BiPAP at bedtime, the resident was observed on 04/13/2026 with the BiPAP not in use and the nasal prongs not stored in a bag. The DON confirmed the oxygen tubing and humidifier for Resident #84 were not changed in a timely manner, and confirmed the BiPAP nasal prongs should be stored in a bag when not in use.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During an early morning kitchen observation, the storage pantry contained a large bottle of browning serving sauce with spills and splatters on the outside, and a bag of miniature marshmallows was open to air without an open date. In the freezer, a bag of meat pies was open to air and not sealed properly. In the refrigerator, a large ziplock bag of cheese was open to air and an opened bag of turkey was open to air and not sealed properly. Two large fryers also had grease buildup on the inside compartments and on the outside surfaces. An interview with the Assistant Dietary Manager confirmed these kitchen issues, and the Dietary Manager was later notified of the observed conditions.
Failure to Use EBP During Resident Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not consistently using Enhanced Barrier Precautions (EBP) during high-contact resident care activities for 2 residents reviewed. The facility’s EBP policy stated that gown and glove use is required during high-contact care activities, including transferring and device care or use such as urinary catheters. Resident #9 was admitted with diagnoses including Parkinson’s disease, urinary retention, malignant neuroendocrine tumors, and benign neoplasm of the prostate, and had an indwelling urinary catheter with an order for EBP due to chronic wounds or indwelling medical devices. On observation, EBP signage was posted on the door, and a CNA entered the room, donned gloves, and emptied the urinary catheter bag but did not don a gown. The CNA stated she was not sure when to wear a gown with residents on EBP, and the DON confirmed the CNA should have worn both gloves and a gown when emptying the catheter bag. Resident #13 was admitted with diagnoses including multiple sclerosis, type 2 diabetes mellitus, protein calorie malnutrition, stage 4 sacral pressure ulcer, dysphagia following CVA, neuromuscular dysfunction of the bladder, and hypertension, and had a BIMS score indicating moderate cognitive impairment, an indwelling catheter, and an unhealed pressure ulcer. EBP signage was posted on the resident’s door, and the resident also had a left arm midline IV access. During an observed transfer, two CNAs wore gloves but did not wear a gown. Both CNAs later confirmed that EBP precautions were not implemented appropriately because a gown was not donned during the transfer, and the DON did not disagree that gowns should have been worn.
Wheelchair Was Damaged and Dirty
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for Resident #106, who was admitted on 08/02/2024 with diagnoses including bilateral primary osteoarthritis of the hip, muscle wasting and atrophy, unspecified lower leg weakness, and spondylosis of the lumbar region. The quarterly MDS documented that the resident used a wheelchair for mobility. On observations made on 04/13/2026, 04/14/2026, and 04/15/2026, the resident's wheelchair arm padding was found to be cracked and torn with foam exposed, and the wheelchair frame had dirt and debris on it. During an observation and interview on 04/15/2026, the S2DON confirmed that the wheelchair armrest was cracked, torn, and needed replacement, and that the wheelchair frame had dirt and debris and needed to be cleaned.
Failure to Care Plan Counseling and Mental Health Services
Penalty
Summary
The facility failed to develop a comprehensive care plan related to Resident #3’s need for counseling and mental health services. Resident #3 stated that she has PTSD related to an incident that occurred when she was eight years old and reported that she goes to a counselor about every 3 weeks and to a mental health clinic. Record review showed diagnoses including anxiety disorder, personality disorders, depression, PTSD, and bi-polar disorder. The social history and assessment indicated the resident was alert and oriented, and the BIMS score of 14 indicated cognitive intactness. Staff interviews confirmed that Resident #3 had recently been admitted from another nursing home and was attending counseling and a mental health clinic, but review of the care plan showed no documentation of her mental health needs or her attendance at counseling and the mental health clinic. The DON confirmed that no care plan had been developed for counseling and mental health services for Resident #3.
Call Lights Out of Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, all of whom were at high risk for falls. During observations, it was noted that Resident #102, who was in a wheelchair, had their call light placed on the bed, making it inaccessible. This resident was cognitively intact with a BIMS score of 15 and had multiple diagnoses, including cerebral infarction and vascular dementia. Resident #141 was observed lying in bed with the call light draped over a recliner, out of reach, and was unable to call for assistance when needed. This resident had significant cognitive impairment with a BIMS score of 2 and was diagnosed with conditions such as metabolic encephalopathy and chronic atrial fibrillation. Similarly, Resident #143, who was sitting in a high-back wheelchair, had their call light placed on the bed, out of reach. This resident had moderate cognitive impairment with a BIMS score of 11 and was diagnosed with Parkinson's disease and coronary artery disease. All three residents were dependent on staff for activities of daily living and were always incontinent of bladder and bowel. The Director of Nursing was informed of the situation, highlighting the facility's failure to accommodate the residents' needs and preferences by ensuring call lights were accessible.
Resident Privacy Not Maintained During Care
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during care. On March 9, 2025, at 1:45 p.m., a resident was observed lying on the bed with no sheets covering her, and her brief was exposed to the hallway. This occurred when a CNA left the room to get a gown for the resident, and the door swung open, leaving the resident exposed. The resident, who was cognitively intact with a BIMS score of 15, expressed discomfort with being exposed during care. The resident had diagnoses including cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, and vascular dementia with behavioral disturbances. She was always incontinent of bladder and bowel and dependent on staff for all activities of daily living. The Director of Nursing was notified of the incident on March 11, 2025.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for two residents who were unable to perform activities of daily living independently. Resident #14, who was admitted with Parkinson's disease and had moderate cognitive impairment, required partial to moderate assistance with personal hygiene, including shaving. Observations revealed that the resident had long, untrimmed eyebrows, indicating a lack of assistance in maintaining personal hygiene. Despite being care planned to receive one staff assistance for personal hygiene, the resident's needs were not adequately met, as confirmed by the Assistant Director of Nursing and the Director of Nursing. Similarly, Resident #63, who was admitted with hemiplegia, hemiparesis, and severe cognitive impairment, was dependent on staff for personal hygiene due to a self-care deficit. Observations showed that the resident had a large amount of long, untrimmed chin hair, suggesting a failure to provide necessary grooming assistance. The resident's care plan included staff assistance with hygiene and grooming tasks, but this was not effectively implemented, as confirmed by the Assistant Director of Nursing. Both cases highlight the facility's failure to ensure residents received the required assistance with personal hygiene, as documented in their care plans.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for two residents receiving oxygen therapy. Resident #138, who has a history of subdural hemorrhage, insomnia, and other health conditions, was observed with an oxygen concentrator set at 2 liters per minute, despite a physician's order for 3 liters per minute. This discrepancy was confirmed by both the LPN and the Director of Nurses during interviews, indicating a failure to adhere to the prescribed oxygen administration. Similarly, resident #48, with a history of cerebrovascular disease and chronic obstructive pulmonary disease, was found with an oxygen concentrator set at 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. The resident, who is cognitively intact, confirmed that she does not adjust her oxygen settings. This was corroborated by an LPN and the Director of Nurses, highlighting a failure to maintain the correct oxygen flow as ordered by the physician.
Failure to Serve Pureed Cornbread as Per Menu
Penalty
Summary
The facility failed to adhere to the prescribed menus for residents on pureed diets, affecting seven residents. The lunch menu for pureed diets indicated that residents were to receive pureed cornbread, but instead, the facility substituted cornbread without pureeing it. This discrepancy was observed on two consecutive days, where residents did not receive the pureed cornbread as specified in their dietary plan. The Dietary Manager confirmed in an interview that the pureed diets were not served the appropriate cornbread, indicating a failure to follow the planned menu and meet the nutritional needs of the residents as required.
Food Safety and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations and interviews. A personal drink was found in the reach-in freezer, which was confirmed by the dietary staff as inappropriate. In the walk-in refrigerator, a pan of pureed rib meat was not fully covered or dated, and a pan of taco soup was available for consumption despite being dated 02/27/2025. Additionally, large containers of powdered mashed potatoes were found with scoops and handles improperly stored inside. Dishes were stored in an upright position rather than inverted, which was noted by the dietary manager. Further deficiencies were observed during meal service. Dietary staff were seen handling food with gloved hands after touching various items without changing gloves. A bag of chips that fell on the floor was picked up and handled without changing gloves, and the same gloves were used to continue food preparation. During lunch service, cornbread was served with gloved hands that had touched other items, and a dietary staff member continued to serve food after cleaning a spill without changing gloves. Additionally, hamburger meat was observed thawing improperly in standing water without cold water running over it. These findings were communicated to the dietary manager.
Unsafe Mechanical Equipment in Kitchen
Penalty
Summary
The facility failed to ensure that mechanical equipment was in safe operating condition, specifically a manual can opener in the kitchen. During an observation on March 9, 2025, at 8:00 a.m., it was noted that there was a buildup of metal shavings on the large mechanical can opener. An interview with a cook confirmed the presence of these metal shavings. This deficiency affected the preparation of 168 diets served from the kitchen.
Ant Infestation in Kitchen's Dry Pantry Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in the dry pantry area. During an observation on March 9, 2025, at 7:45 a.m., small black ants were found on large containers of grits and sugar in the kitchen's dry food storage area. S5Cook confirmed the presence of the ants and acknowledged that the facility had been experiencing issues with them. This deficiency had the potential to affect the 168 residents receiving meals from the kitchen.
Failure to Document Discharge Summary
Penalty
Summary
The facility failed to document a discharge summary for a resident who was discharged from the facility. The resident, who had a history of cerebral infarction, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, morbid obesity, epilepsy, and type 2 diabetes mellitus, required partial to moderate assistance with activities of daily living according to their Admission Minimum Data Set (MDS) assessment. The resident was discharged home, but the facility did not complete the necessary discharge summary documentation. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Provide Dignified Care and Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life. Resident #143, who has moderate cognitive impairment and is dependent on staff for activities of daily living, was observed sitting in a high back wheelchair with a disposable brief used as a cushion behind his head. This observation was made on 03/09/2025, and the Director of Nursing was informed of this inappropriate use of a disposable brief on 03/11/2025. Resident #14, also with moderate cognitive impairment and a self-care deficit due to Parkinson's disease, was observed eating breakfast in the main dining room. Pieces of his meal were found on the table, and he was seen picking them up with his hands and eating directly from the table. Despite the presence of an LPN and two CNAs in the dining area, no assistance was offered to the resident. The Assistant Director of Nursing and the Director of Nursing were notified of this incident, confirming that staff should have assisted the resident with his meal.
Infection Control Breach in Laundry Department
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry department, which led to a deficiency in infection prevention and control. During an observation, two laundry workers were found in the clean laundry room, where one worker placed a personal cell phone directly on a table used for folding clean clothing and linen items. This action was confirmed by the worker, who acknowledged that the table was designated for clean items. A second table in the same room also had a cell phone lying on it, which was confirmed by another laundry worker to be used for folding resident items. The laundry supervisor was informed of these observations and confirmed that personal belongings should not be placed on these tables due to the risk of cross-contamination. The facility administrator was also notified of these findings.
Medication Administration Error
Penalty
Summary
The facility failed to provide services that met professional standards during medication administration for a resident. Specifically, a Licensed Practical Nurse (LPN) administered the incorrect dosage of Nifedipine Extended Release (ER) to a resident. The resident's physician's orders specified a dosage of 90 mg daily, but the LPN administered a 30 mg tablet. The LPN did not verify the medication card label against the Electronic-Medication Administration Record (e-MAR) before administration, leading to the error. The discrepancy was confirmed during a review of the resident's medication card and physician's orders, and the LPN acknowledged the mistake. Further investigation revealed that the incorrect dosage was filled by the pharmacy due to a nurse sending in a label from a previously discontinued dosage. The Director of Nursing (DON) confirmed that the LPN did not follow the facility's Medication Administration Policy and Procedure, which requires verifying that the medication selected matches the order and label, and ensuring the medication is administered at the prescribed dose. The resident involved had multiple diagnoses, including cerebral infarction, pressure ulcer, hemiplegia, type 2 diabetes mellitus, and hypertension.
Incorrect Medication Dosage Administered
Penalty
Summary
The facility failed to accurately obtain pharmaceutical services for a resident, resulting in the administration of an incorrect medication dosage. Resident #90, who has a medical history including cerebral infarction, dysphagia, pressure ulcer, hemiplegia, type 2 diabetes mellitus, and hypertension, was observed receiving Nifedipine ER 30 mg instead of the prescribed Nifedipine ER 90 mg. This error occurred because a nurse sent in a label from a previously discontinued dosage, leading the pharmacy to fill the incorrect medication. The Director of Nursing confirmed the error and acknowledged that the resident should have been receiving the correct dosage of 90 mg daily.
Failure to Follow Dietary Orders and Preferences
Penalty
Summary
The facility failed to ensure dietary orders were followed for two residents who had orders for mighty shakes and dietary preferences were followed for one resident. Resident #38, who had multiple diagnoses including end-stage renal disease and type 2 diabetes, did not receive the prescribed mighty shakes during observed meals. Despite the availability of mighty shakes in the refrigerator, the dietary staff did not place them on the meal carts, and the CNAs did not provide them to the resident, stating that the residents do not drink them anyway. Similarly, Resident #62, who had diagnoses including bilateral above-the-knee amputation and vascular dementia, also did not receive the prescribed mighty shakes during observed meals. The dietary card indicated that mighty shakes were to be served, but they were not included on the meal trays. The Culinary Supervisor confirmed that the dietary department should have placed the mighty shakes on the meal carts, but this was not done. Resident #73, who was cognitively intact and had a preference for wheat bread, was consistently served white bread instead. Despite the resident's repeated requests and the availability of wheat bread, the dietary staff continued to serve white bread. The Culinary Supervisor confirmed that the resident should have been served wheat bread according to her preference, but this was not followed during the observed meals.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, as observed during an initial tour and subsequent inspection of the kitchen. Observations included a large build-up of grease and grime in the lower compartments of small and large deep fryers, old food particles and sticky build-up on a large toaster, and unlabeled opened bags of pasta in the Dry Storage Area. Additionally, two small microwaves on top of covered dietary carts were found with old food particles on the bottom, top, and sides. The Culinary Supervisor confirmed the lack of labeling on the food items and the need for cleaning the kitchen appliances.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. The resident, who was admitted with diagnoses of unspecified dementia and cerebral infarction, had a severely impaired cognitive status and required supervision to moderate assistance for most activities of daily living. The paper medical record indicated that the resident's code status was Full Code, as signed by a family member, while the electronic medical record and a physician's order indicated a Do Not Resuscitate (DNR) status. This discrepancy was not known to the Director of Nursing (DON) until it was pointed out during the survey. The facility's Advance Directive Policy and Procedure required that any changes to an advance directive be communicated to the DON to ensure that physician orders are carried out and the resident's medical record is updated accordingly. However, in this case, the DON was unaware of the inconsistency between the paper and electronic records. This failure to maintain consistent and accurate records regarding the resident's code status led to a deficiency in honoring the resident's right to request, refuse, and/or discontinue treatment as per their advance directive.
Failure to Address Resident's Positioning Needs
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #69, who was admitted with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia, required staff assistance for all activities of daily living (ADLs). Despite the care plan being revised to include assistance with repositioning while in her wheelchair, multiple observations revealed that the resident's positioning needs were not addressed in a timely manner. The resident was frequently found in a high back wheelchair with a soft lap tray that was tilted to the right, and her feet were not supported by the wheelchair footrest. Additionally, the lap tray had a rough edge due to a tear, and the footrest was improperly positioned, causing discomfort and improper support for the resident's feet. Interviews with staff members, including a CNA and an LPN, confirmed ongoing issues with the resident's wheelchair and lap tray positioning. The CNA reported difficulty in adjusting the footrest, while the LPN acknowledged the persistent problem with the lap tray slanting and the footrest not providing adequate support. The Director of Nursing (DON) was informed of these concerns and confirmed that the facility had failed to address the resident's positioning needs in a timely manner. These findings indicate a deficiency in the facility's ability to provide appropriate treatment and care according to the resident's care plan and professional standards of practice.
Medications Left at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident and adhered to state and federal requirements. Specifically, medications were left at the bedside for a resident with moderate cognitive impairment. The resident, who had a Brief Interview Mental Status (BIMS) score of 10, was observed with a cup of pills on the bedside table while waiting for breakfast. The resident had multiple diagnoses, including cerebral infarct, type 2 diabetes, hypertension, chronic atrial fibrillation, end-stage renal disease requiring dialysis, systolic congestive heart failure, history of cardiac arrest, hypotension, chronic metabolic acidosis, and dysphagia. An LPN confirmed that the medications were administered at 6:00 a.m. before her arrival and should not have been left at the bedside. The Director of Nursing also confirmed that medications should not be left at the bedside.
Failure to Maintain Safe Operating Condition of Wheelchair Lap Tray
Penalty
Summary
The facility failed to ensure all patient care equipment was maintained in safe operating condition by not repairing a wheelchair lap tray in a timely manner for a resident with Parkinson's disease, cerebrovascular disease, and unspecified dementia. The resident required moderate to maximal assistance for most activities of daily living (ADLs) and had a care plan intervention for a wheelchair with a lap tray. Observations over two days revealed the lap tray was tilted to the right and had a tear in the right corner of the plastic overlay, causing a rough edge. Additionally, a blue substance was found under the torn area, which the resident was picking at with her right hand, resulting in the substance being on her fingers. An interview with an LPN revealed that the issue with the lap tray slanting had been ongoing, and the tear was noted on the Nurses' Report Form. However, the LPN was unsure if maintenance was aware of the need for repair or replacement. The Director of Nursing confirmed that the concerns with the lap tray, including the tear, the blue substance, and the tilting, should have been addressed and repaired. The failure to repair the lap tray in a timely manner compromised the safety and comfort of the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
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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) |
|---|---|---|---|---|
| Delta Grande Skilled Nursing And Rehabilitation | 3.3 mi | ★★★★★ | 5 | 0 |
| Mary Goss Nursing Home | 3.3 mi | ★★★★★ | 12 | 0 |
| St Joseph Skilled Nursing And Rehabilitation | 4.3 mi | ★★★★★ | 11 | 0 |
| The Oaks | 5.6 mi | ★★★★★ | 2 | 0 |
| Avalon Place | 5.9 mi | ★★★★★ | 9 | 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.