Landmark Medical Center

In the surveyor’s words

From the most serious findings on record at Landmark Medical Center, in the surveyor’s own words.

• Immediate jeopardy, patternF755Aug 9, 2024

  Based on observation, interview, and record review, the facility failed to have a system in place to ensure safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for 17 of 17 Resident (Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150, and 151) by failing to: 1. Maintain accountability records for all controlled substances/medications that were disposed of or destroyed with the unused supply between 1/1/2024 through 8/8/2024 and ensure each resident's individual controlled drug record (CDR, any Schedule 2 through Schedule 5 controlled drugs [potential for abuse and/or addiction] received or supplied by a pharmacy) for each controlled medication was used for accurate accountability of controlled… […]

• Immediate jeopardy, patternF600Jul 15, 2021

  Based on observation, interview, and record review the facility failed to ensure one of two sampled Residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type with a resident). On 6/16/2021 at 5:45 pm, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) found Resident 1 and Resident 2 partially naked inside Resident 1's room having sex. The facility did not protect Resident 1 from further abuse by failing to conduct a thorough investigation to identify whether it was consensual, and report the incident to the police, the Department of Public Health, and the Ombudsman (an official appointed to investigate individuals' complaints against maladministration). […]

• Immediate jeopardy, patternF607Jul 15, 2021

  Based on observation, interview, and record review, the facility failed to implement and develop a policy on sexual abuse (is non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) by failing to: 1. Report and investigate the sexual act between Resident 1 and Resident 2 that was witnessed by Licensed Vocational Nurse 1 (LVN1) and Certified Nursing Assistant 1 (CNA 1) on 6/16/2021 at 5:45 pm. 2. Protect Resident 1 from further sexual abuse that led Resident 1 to request to have a room change to a different unit in the facility. 3. Prevent Resident 1 from being sexually abused and afraid of Resident 2. 4. […]

• Immediate jeopardy, patternF609Jul 15, 2021

  Based on observation, interview, and record review the facility failed to report a sexual abuse (non-consensual sexual contact of any type with a resident) allegation for one of two sampled residents (Resident 1) to the California Department of Public Health (CDPH) within a two hour time frame as indicated in their Abuse Prevention Policy. On 6/16/2021 at 5:45 pm, Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) found Resident 1 and Resident 2 partially naked inside Resident 1's room having sex and the facility did not conduct an investigation, did not report the incident to the police, the Department and the Ombudsman (an official appointed to investigate individuals' complaints against maladministration) and did not protect Resident 1 from further abuse. […]

• Immediate jeopardy, isolatedF678Sep 24, 2024

  Based on observation, interview, and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breathe], performed when the heart stops beating or beats ineffectively to restore breathing) to one of two sampled residents (Resident 1), who was a full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or their representative's wishes to perform all lifesaving procedures to keep the resident alive, a full code is the default status for all patients unless they have explicitly discussed other wishes with their medical provider). […]