Landmark Nursing & Rehabilitation CTR of West Mon

In the surveyor’s words

From the most serious findings on record at Landmark Nursing & Rehabilitation CTR of West Mon, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 5, 2024

  Based on record review and interviews, the facility failed to ensure 1 (#1) of 3 (#1, #2, #3) residents reviewed for accidents received the necessary supervision to prevent avoidable accidents including a fall. The deficient practice resulted in an actual harm for Resident #1 on 08/22/2024 at 12:25 p.m. when Resident #1 suffered major injuries from falling out of the bed to the floor while left unattended during a bed bath. S4 CNA (Certified Nursing Assistant) was providing a bed bath to Resident #1. S4 CNA left the room to get more supplies for the bath and Resident #1 rolled off the bed and to the floor. Resident #1 was sent to a local hospital ER (emergency room ) on 08/22/2024. […]

• Actual harm, isolatedF600Jun 5, 2024

  Based on observation, record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired with communication deficits) on 05/19/2024 at 6:10 p.m. when S3CNA (Certified Nursing Assistant) physically and verbally abused resident #1 by forcefully grabbing resident #1's lower extremities, hands and arms in an attempt to reposition resident #1 and the resident sustained two red bruises that were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted… […]

• No harm, potential for more than minimal, patternF880Mar 10, 2026

  Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to 1) Identify Resident #14 had a MDRO infection and implement contact precautions, and 2) implement EBP for Resident #23 and #94.Findings:Resident #14 Review of the facility's undated Infection Control Precautions (Isolation) Policy revealed the following in part: Policy: Prevent the spread of infection Equipment: Provided by infection control coordinator Procedure: 5. […]

• No harm, potential for more than minimal, patternF638Jan 15, 2025

  Based on interview and record reviews, the facility failed to ensure it assessed residents using the quarterly review instrument approved by Centers for Medicare & Medicaid Service (CMS) not less frequently than once every 3 months by failing to complete the Minimum Data Set (MDS) assessment at least every 3 months for 4 (#8, #15, #55, #63) of 4 sampled residents reviewed for timeliness of MDS assessments. Findings: Review of the MDS for resident #8 revealed the last completed MDS assessment was dated 09/10/2024. Review of the MDS for resident #15 revealed the last completed MDS assessment was dated 08/02/2024. Review of the MDS for resident #55 revealed the last completed MDS assessment was dated 08/30/2024. […]

• No harm, potential for more than minimal, patternF656Jan 15, 2025

  Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person centered care plan for 1 (#24) of 1 resident reviewed for constipation and 2 (#26, #60) of 2 residents reviewed for smoking. Findings: Resident #24 0n 01/13/2025 at 9:06 a.m., interview with resident #24 revealed she had recurrent problems with constipation. Review of the medical record for resident #24 revealed she had a diagnosis of constipation. Review of the care plan revealed it addressed the constipation with an intervention to assess bowel patterns. Review of the January 2025 documentation for the resident's bowel status revealed it was not recorded for 13 of 13 day shifts, for 4 of 13 evening shifts, and for 7 of 13 night shifts. […]