Inspection Reports for
Landmark of DeSoto
3068 Nail Road West, Horn Lake, MS, 38637
Back to Facility Profile3 Reports
Inspection Report — Oct 30, 2024
Routine CMS
Date: Oct 30, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, honoring resident rights regarding healthcare decisions, care planning for pressure ulcers, pressure ulcer prevention and treatment, catheter care, medication record reconciliation, medication storage, and accurate staffing data submission to CMS.
Deficiencies (8)
F 0550: The facility failed to provide privacy for Resident #17 who was left uncovered and visible from the hallway, violating dignity and respect policies.
F 0578: The facility failed to honor Resident #58's right to make healthcare decisions related to CPR, as the resident was not consulted and a family member signed the consent.
F 0656: The facility failed to develop a comprehensive care plan for Residents #28 and #209 with pressure ulcers, lacking measurable objectives and interventions.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents #28 and #209, including lack of pressure relief devices and inadequate skin monitoring under immobilizer.
F 0690: The facility failed to provide appropriate catheter care for Resident #57, including improper cleaning technique leading to cross contamination risk.
F 0755: The facility failed to maintain accurate medication records for controlled substances, specifically Lorazepam in the medication room refrigerator, which was not reconciled every shift.
F 0761: The facility failed to ensure medications were stored securely, as Resident #58 had unsecured medications at bedside without physician orders or staff monitoring.
F 0851: The facility failed to submit accurate direct care staffing data to CMS for Q3 FY 2024, lacking a policy for Payroll Based Journal submission and resulting in reporting errors.
Report Facts
Residents reviewed: 20
Narcotic vials: 4
PBJ quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Confirmed Resident #17 privacy issue and medication reconciliation issues | |
| Director of Nursing (DON) | Confirmed privacy and dignity concerns, medication reconciliation, and staffing data submission issues | |
| Wound Treatment Nurse | Interviewed regarding pressure ulcer care deficiencies for Residents #28 and #209 | |
| MDS Nurse #1 and MDS Nurse #2 | Confirmed lack of care plan for pressure ulcers | |
| Rehabilitation Director | Confirmed pressure ulcer prevention interventions and wound care issues | |
| Certified Nurse Assistants (CNA) #1 and #2 | Observed and interviewed regarding improper catheter care for Resident #57 | |
| Pharmacy Consultant | Confirmed medication reconciliation deficiencies for controlled substances | |
| Administrator | Confirmed medication storage and staffing data submission deficiencies | |
| Therapy Rehab Director | Reported on Resident #209's immobilizer issues and wound care |
Inspection Report — Aug 17, 2023
Routine CMS
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess compliance with care plan implementation, personal hygiene assistance, and infection prevention and control practices at the nursing home.
Findings
The facility failed to implement comprehensive care plans for residents requiring oral and nail care, failed to provide adequate personal hygiene assistance as evidenced by residents with long nails, dry cracked lips, and yellow substance on teeth, and failed to properly clean multi-resident use vital sign equipment between residents, increasing infection risk.
Deficiencies (3)
F 0656: The facility failed to develop and implement complete care plans for residents #23 and #39, specifically for oral and nail care needs.
F 0677: The facility failed to provide personal hygiene assistance, resulting in chapped peeling lips, long nails with brown substance, and yellow substance on teeth for residents #23 and #39.
F 0880: The facility failed to prevent infection spread by not cleaning multi-resident use vital sign equipment between residents during medication administration.
Report Facts
Residents sampled for ADLs: 18
Survey days observed for infection control: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed deficiencies in care plan implementation, oral and nail care, and infection control practices. | |
| Minimum Data Set (MDS) Nurse | Responsible for developing comprehensive care plans; confirmed care plans were not followed. | |
| Licensed Practical Nurse (LPN) #1 | Observed not cleaning vital sign equipment between residents. | |
| Certified Nursing Assistant (CNA) #1 | Reported on resident #39's dry, cracked lips and oral care practices. | |
| Certified Nurse Aide (CNA) #4 | Confirmed resident #23's long nails and oral hygiene practices. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed resident #23's long nails and oral care practices. | |
| Licensed Practical Nurse (LPN) #1 | Assigned to resident #39 and observed dry, cracked lips. | |
| Certified Nursing Assistant (CNA) #2 | Assigned to resident #39; confirmed oral care omissions. |
Inspection Report — Apr 28, 2022
Routine CMS
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments and staff COVID-19 vaccination status.
Findings
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident by not indicating dialysis treatment. Additionally, the facility did not ensure that three staff members were fully vaccinated for COVID-19 by the required deadline, resulting in noncompliance with the facility's vaccination policy.
Deficiencies (2)
F 0641: The facility failed to accurately complete the Minimum Data Set assessment for Resident #50 by not indicating dialysis treatment on the 4/3/22 assessment.
F 0888: The facility failed to ensure three staff members were fully vaccinated for COVID-19 by March 15, 2022, violating the mandatory vaccination policy.
Report Facts
Residents reviewed for MDS accuracy: 13
Staff employed: 43
Unvaccinated staff members: 3
Resident's BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) Nurse | Interviewed regarding inaccurate MDS assessment for Resident #50 | |
| Director of Nursing (DON) | Confirmed dialysis omission in MDS and staff vaccination noncompliance | |
| Administrator | Interviewed about staff vaccination status and policy enforcement | |
| Dietary Staff Member #1 (Dietary Manager) | Unvaccinated staff member interviewed about vaccination status and work restrictions | |
| CNA #2 | Unvaccinated staff member interviewed about vaccination status and work restrictions | |
| CNA #1 | Unvaccinated staff member with unsuccessful telephone interview attempt |
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