Inspection Reports for
Landmark Nursing & Rehabilitation Ctr of West Mon

The facility failed to complete Minimum Data Set (MDS) assessments at least every 3 months for 4 residents, did not implement comprehensive care plans for residents with constipation and smoking needs, and failed to obtain ordered lipid lab levels for one resident on medication for hyperlipidemia.

The complaint investigation was substantiated. Resident #1 fell out of bed on 08/22/2024 while left unattended during a bed bath by S4 CNA, who failed to follow the care plan requiring two-person assist and bed lock precautions. Resident #1 sustained bilateral supracondylar femur fractures requiring surgery. The CNA was suspended and in-serviced, and the facility implemented corrective actions prior to the survey.

The facility failed to ensure adequate supervision and competency of staff in providing care to Resident #1, resulting in an actual harm fall with bilateral femur fractures. The responsible CNA did not follow the two-person assist requirement and failed to ensure the bed was locked before leaving the resident unattended. Corrective actions were implemented prior to the investigation.

The complaint investigation was substantiated. Resident #1 was physically and verbally abused by staff on 05/19/2024, as evidenced by video footage and physical examination showing bruises. Staff failed to maintain privacy during care and did not report the abuse. Multiple staff were suspended and terminated. The facility implemented corrective actions and was found in compliance as of 05/23/2024.

The facility failed to provide personal privacy during incontinent care and failed to protect resident #1 from physical and verbal abuse by staff. Multiple staff members were suspended and terminated following the investigation. The facility implemented corrective actions including staff in-services and Quality Assurance Performance Improvement (QAPI) monitoring.

The visit was complaint-related, focusing on medication administration errors and failure to report abnormal blood sugars. Substantiation status is not explicitly stated.

The facility failed to ensure residents received treatment and care according to professional standards and care plans for medication administration. Nurses did not follow insulin sliding scale orders for resident #32 and failed to notify the physician of high blood sugar readings. Nursing staff also failed to report abnormal blood sugars and update care plans for resident #4. Additionally, the medication room was found unlocked, allowing unauthorized access to medications.

The complaint investigation involved two resident investigations (#3 and #5), with substantiation that the facility failed to report injuries of unknown origin immediately to the state agency, specifically for resident #5 who had a fractured clavicle and bruising. The incident was discovered on 09/18/2023 but was not reported within 2 hours as required.

The facility failed to ensure that alleged violations involving injuries of unknown source were reported to the state agency within the required 2-hour timeframe. Resident #5 had bruises and a fracture of the distal clavicle of indeterminate age, and the incident report was not submitted timely. The investigation was ongoing at the time of the report.

The facility failed to maintain an effective infection prevention and control program by not ensuring all staff wore KN95 masks correctly during the outbreak, allowing personal items including cat food in the clean laundry room, and permitting staff to store personal items in resident restorative therapy areas and hallways.

The facility failed to maintain proper infection prevention and control practices as a student trainee did not change gloves, apply hand sanitizer, or wash hands after providing pericare to resident #1, resulting in potential cross contamination with clean supplies and resident personal items.

The facility was found deficient in multiple areas including environmental safety, timely transmission of resident assessments, proper administration of tube feeding, respiratory care, medication administration errors, and failure to provide therapeutic diets as ordered. Several residents were affected by these deficiencies.