Landmark South Nursing & Rehabilitation Center

Based on interviews and record review, the facility failed to accurately code PASRR Level IIs on the residents' MDS assessments for 3 of 3 (#15, #101, and #128) residents reviewed with Level II PASRRs.Resident #15 Review of Resident #15's Clinical Record revealed an admission date of 05/05/2023 and diagnoses, which included Bipolar Disorder, Current Episode, Depressed, Severe, With Psychotic Features, and Personal History of Suicidal Behavior. Review of Resident #15's Form 142s revealed Resident #15 was approved for admission by Level II authority for temporary periods effective 10/24/2024 through 10/23/2025 and 10/24/2025 through 10/23/2026. Resident #15's Annual MDS with an ARD of 03/17/2025 revealed an answer of no to the following question: A1500 – Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? An interview was conducted with S3MDS on 01/14/2026 at 10:40 a.m. She stated she was responsible for completing MDS assessments for Resident #15. She stated when a resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was dated after opening; 2. Ice machine was properly cleaned and sanitized; and 3. Ice machine rolling table was properly cleaned and sanitized. This deficient practice had the potential to affect 137 out of 142 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility's undated policy titled, Storage Of Refrigerated Food revealed the following, in part; Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. Food taken out of original containers is put in a clean sanitized container with tight fitting lid. 5. All non-hazardous, opened food are labeled with name of food, date stored. 6. All hazardous foods are labeled with name of food and date stored. During the initial tour of the facility's kitchen on 11/07/2024 at 8:40 a.m. with S4DM, the following observations were made: Walk in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (#113) of 5 (#14, #20, #91, #113, and #119) residents reviewed for unnecessary medications by failing to ensure: 1. Resident #113 care plan addressed her use of antidepressant and psychotropic medications; and 2. Resident #113's care plan addressed her suicidal ideations. Findings: Review of Resident #113's clinical record revealed an admission date of 10/11/2024. Further review revealed Resident #113 had diagnoses, which included Alzheimer's Disease and Anxiety Disorder. Review of Resident #113's Medication Administration Records from 10/11/2024 to 11/14/2024 revealed the following, in part: Seroquel 25 mg Give 0.5 mg by mouth at bedtime was administered from 10/11/2024 to 10/31/2024; Seroquel 25 mg Give 1 tablet by mouth at bedtime was administered from 11/01/2024 to 11/11/2024; Seroquel 50 mg Give 1 tablet by mouth at bedtime was administered from 11/12/2024 to 11/13/2024; and Lexapro 20 mg Give 1 tablet by mouth in the morning was administered from 10/12/2024 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#80) of 6 (#4, #24, #33, #68, #80, and #84) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions, revised on 03/2024, revealed the following, in part: Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. indwelling medical devices). For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate monitoring for effectiveness and side effects of psychotropic medication was completed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Psychotropic Medications dated 10/2022 revealed the following: The use of PRN psychotropic medications require a screen pre and post administration. Documentation should include behavior the drug is intended to reduce, physiological, environmental and pharmacological interventions. As well as post administration behavior and side effects. A pre and post administration screen should be completed for each use of PRN Psychotropic medications. Residents that use psychotropic medications shall have side effect monitoring. Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: PRN medications will be documented on the MAR and the reason for giving as well as the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medication Carts were locked when unattended for 1 (Cart F) of 6 (Cart A, Cart B, Cart C, Cart D, Cart E, and Cart F) medication carts observed. Findings: Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: The medication cart is not to be taken into the resident's room, and therefore, is to be locked whenever unattended. On 07/17/2024 at 8:01 a.m., an observation was made of Cart F unlocked and unattended near room [ROOM NUMBER]. On 07/17/2024 at 10:15 a.m., an interview was conducted with S4LPN. She stated the medication cart should be locked at all times and confirmed Cart F was not locked when it was left unattended near room [ROOM NUMBER]. On 07/18/2024 at 11:35 a.m., an interview was conducted with S2DON. She stated medication carts should be locked when left unattended, and confirmed the surveyor should not have observed Cart F unlocked if it was left unattended.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (R1 and R2) of 5 (#1, #2, #3, R1, R2) residents reviewed. Findings: Review of the facilities policy, Call Light/Bell, dated 01/2024, revealed the following, in part: Purpose: To provide the resident a means of communication with staff members Procedure 1. Ensure resident has call light in reach when in resident room 7. Place the call light within the resident's reach before leaving the room. Resident R1 A review of Resident R1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Alzheimer's disease, Urinary Tract Infections, and Cognitive Communication Deficit. A review of Resident R1's current Care Plan revealed the following: Onset: 05/30/2019 Problem: Resident was at risk for injury from falls. Interventions: Place call light within reach. On 05/20/2024 at 9:40 a.m., an observation was conducted of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours after the incident, to the facility Administrator and to the State Survey Agency within the specified timeframe for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for accidents. Findings: Review of the facility's policy titled, Incident Investigation and Reporting, reviewed on 05/21/2024, dated 10/2022, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or reportable incidents as required by state and federal requirements. 2. Relevant Terms: Injury of unknown origin: a. Source of injury was not observed by any person and b. The source of injury could not be explained by the resident and c. The injury is suspicious due to the extent or location of the injury or the number of injuries at one time or the incidence of injury over time. 3. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to protect the residents' right to be free from physical abuse by Resident #39 for 1 (#17) of 3 (#17, #41 and #137) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Incident Investigation and Reporting revealed the following, in part: Purpose: 1. Each resident residing in this facility has the right to be free from any type of abuse including: physical abuse. Physical Abuse: this includes but is not limited to hitting, slapping, pinching and kicking. Resident #39 Review of Resident # 39's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebrovascular Disease, Traumatic Hemorrhage of Cerebrum without Loss of Consciousness, Lack of Coordination, Recurrent Depressive Disorders, Delusional Disorders, Bipolar…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.