Landmark at 95th Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Landmark at 95th Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 1, 2024

  Based on interviews and record reviews the facility [ A] failed to monitor and recognize change in condition for one resident [R3]out of 4 residents with known history of chronic kidney disease fluid volume status, [B] failed review and address diagnostic test results, and [C] failed to follow physician orders to schedule nephrology, cardiology, and pulmonary consultant appointments. These failures resulted in R3 being sent to the emergency department very weak, massive volume overload, worsening kidney function, pulmonary edema, respiratory failure, hypotension, and diagnosed with cardiorenal syndrome, in acute renal failure, admitted to intensive care unit to place line for emergent dialysis. The facility's immediate jeopardy began on [DATE]. […]

• Immediate jeopardy, isolatedF684Jun 14, 2022

  Based on interviews and record review the facility failed to ensure (R3) one of five sampled residents received medication for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, on 5/02/2022 R3 was found unconscious experiencing seizures. According to R3's death certificate the [CONDITION(S)] activity contributed to R3's death. This was identified as an immediate jeopardy situation which began on 04/02/2022. On 06/09/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 06/10/2022. […]

• Actual harm, patternF689Feb 24, 2023

  Based on observations, interviews and record reviews, the facility failed to follow their Fall Prevention and Management Program by (a) not implementing a comprehensive resident centered care plan with goals and interventions to prevent falls, (b) not providing supervision for a wandering resident, and (c) not providing fall prevention interventions for 5 (R7, R8, R15, R16, R11) of 5 in a sample of 28 residents reviewed for falls. These failures resulted in R11 sustaining a right femoral neck fracture. These failures also resulted in R15 falling on the floor directly on her face and sustaining a nasal bone fracture. R7 sustained a left hip (femur) fracture. R8 sustained a scalp hematoma, forehead laceration that required stitching, and multiple acute pelvic and sacral fractures. […]

• Actual harm, isolatedF600Jun 18, 2026

  Based on interview and record review the facility failed to protect one resident (R2) out of four residents who were reviewed for abuse and the facility failed to report a suspicion of abuse and/or unknown injury to the abuse coordinator. Subsequently the resident sustained multiple bruises and trauma.Findings Include:R2's Progress note dated 06/03/26 19:48 document in part reads: Nursing Progress Note Text: Resident observed with discoloration to the forehead and discoloration to the right side of his face. Further skin assessment revealed discoloration to the right hip area. Attending physician notified and gave orders to send resident to hospital for evaluation.On 06/17/26 at 03:05 PM V21 (Certified Nurse Assistant) stated I did not witness R2 and R24 altercation. […]

• Actual harm, isolatedF684Jun 18, 2026

  Based on interview and record review the facility to seek medical attention right away for one resident (R2) who was on anti-coagulant medications after the resident told the nurse he was in an incident with another resident and an injury was noted to his face. Subsequently the resident was not sent to the hospital until a day later after a mark was noted and where resident required hospitalization for a Intracranial Hemorrhage and Hematomas to other parts of his body. Findings Include:R2 has diagnosis not limited to Seizures, Anemias, Transient Ischemic Attack (Tia), and Cerebral Infarction, Abnormalities of Gait and Mobility, Major Depressive Disorder, Epilepsy, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, Schizophrenia, Bipolar Disorder, Hemiplegia and Hemiparesis… […]