Landmark of Desoto

In the surveyor’s words

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

• Actual harm, isolatedF656Oct 30, 2024

  Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with pressure ulcers for two (2) of 20 sampled residents. Resident # 28 and Resident # 209 Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 8/17 revealed, .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24 revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. […]

• Actual harm, isolatedF686Oct 30, 2024

  Based on observation, record review, resident and staff interview the facility failed to provide treatment and services to prevent pressure ulcers for two (2) of five (5) residents observed with pressure ulcers. Resident #28 and Resident # 209 Findings Included: Record review of facility policy Pressure Ulcer Prevention and Treatment Intervention Guidelines, revised 10/22, revealed C. Protection from Fiction or Shear .4. Provide padding for casts, braces, splints, oxygen tubing, shoes etc. as needed to prevent friction. 5. Remove orthotics on a regular basis for skin inspection .Therapy Department Interventions .3. Explore possible therapy interventions for .c. Splinting/orthotic modifications . 1. […]

• No harm, potential for more than minimal, widespreadF552Mar 19, 2026

  Based on staff interview, record review and facility policy review the facility failed to ensure informed consent was obtained prior to the initiation of psychotropic medications for 5 (five) of 5 residents reviewed for unnecessary medications. Resident #1, Resident #3, Resident #6, Resident #12, and Resident #38. Findings Include: Facility policy titled Psychotropic Medications, dated 02/25, stated, Consent for Anti-psychotic Medication Treatment shall be completed for new order of or increasing the dose of an anti-psychotic, psychoactive, or neuroleptic medication. The prescribing physician, or facility medical director shall complete Section I providing indications for use, diagnosis, risks, benefits, alternatives and course of therapy. […]

• No harm, potential for more than minimal, widespreadF851Oct 30, 2024

  Based on staff interviews and record reviews, the facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required for the third quarter (Q3) of fiscal year (FY) 2024 (April 1-June 30). Findings include: Record review of a letter, on facility letter head, signed by the Administrator, revealed that the facility does not have a policy related to Payroll Based Journal (PBJ) submission. A record review of the facility's PBJ Staffing Data Report for Q3 FY 2024 revealed that the facility triggered for excessively low weekend staffing. In an interview on 10/29/24 at 12:45 PM, the Administrator stated that the facility had not submitted accurate PBJ staffing data to CMS for the third quarter of FY 2024. […]

• No harm, potential for more than minimal, widespreadF888Apr 28, 2022

  Based on staff interviews, record reviews, and facility policy review, the facility failed to implement the facility policy to ensure all staff are fully vaccinated for COVID-19 for three (3) of 43 staff employed by the facility. Findings include: Record review of policy titled, Mandatory COVID-19 Vaccination Policy and Procedure, with the latest revision date of 04/22, revealed, .Purpose: Vaccination is a vital tool to reduce the presence and severity of COVID-19 cases in the workplace, in communities, and in the nation as a whole. This facility has adopted this policy on mandatory vaccination to safeguard the health of our staff and residents from the hazards of COVID-19 Scope: . […]