Landmark Care And Rehabilitation

In the surveyor’s words

From the most serious findings on record at Landmark Care And Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Mar 12, 2024

  Based on observation, interview and record review the facility failed to provide the vital services needed for wound healing and treatment of serious infection by consistently providing dressing changes and initiating antibiotics timely for 3 of 3 residents (Resident's 1, 2 and 8) reviewed for pressure injuries (wounds over a bone caused by pressure). Resident 1 experienced harm when the Stage 4 pressure injury (a wound with full tissue loss and exposed bone, tendon and muscle) that was acquired at the facility worsened, they experienced pain and the osteomelitis (a high risk infection in the bone that can lead to full body system wide infection) was not treated timely. […]

• Actual harm, patternF689Jun 13, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision, assess, monitor, and revise care plan interventions for efficacy, and ensure care planned interventions were consistently followed to prevent avoidable repeated falls for 4 of 5 residents (Residents 21,19, 41, and 29) reviewed for falls. Resident 21 who had 14 falls between 04/13/2025 and 05/23/2025, experienced harm when they had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back) and required a back brace that supports and stabilizes the spine. […]

• Actual harm, isolatedF686Jun 13, 2025

  Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development of pressure injuries and to implement wound treatment measures consistently to avoid worsening of pressure injuries for 1 of 3 residents, (Resident 46) reviewed for pressure injuries. Resident 46 experienced harm when they developed a pressure related fluid filled blister to the left heel and a pressure injury to their right lateral malleolus (the bony prominence on the outside of the ankle joint) that had both slough and eschar present in the wound. These failures also placed the resident at risk for pain, infection, and other medical complications. […]

• Actual harm, isolatedF686May 22, 2024

  Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) and to implement wound treatments timely to avoid worsening of a PU/PI for 3 of 3 residents (Residents 20, 41, and 60), who had multiple co-morbidities with an increased risk for PU/PI, reviewed for PU/PI. Resident 20 experienced harm when they developed a Stage II PI (partial thickness skin loss with exposed top inner layers of skin) to their right buttock and an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their left buttock, and expressed significant pain and discomfort. […]

• Actual harm, isolatedF600Feb 16, 2024

  Based on observation, interview, and record review the facility failed to ensure goods and services were provided to avoid a decline in condition for 1 of 1 resident (Resident 1), reviewed for neglect. The facility did not follow through with a physician referral in a timely manner for a diagnostic test magnetic resonance imaging (MRI, an imaging examination to determine an extent of an injury) and a referral to a neurologist (a physician that specializes in the function and treatment of the neurological system). Resident 1 experienced harm when they had a decline in some of their fine motor skills, had increased pain, and anxiety. […]