Landmark of Itasca Rehabilitation and Nursing Cent

In the surveyor’s words

From the most serious findings on record at Landmark of Itasca Rehabilitation and Nursing Cent, in the surveyor’s own words.

• Immediate jeopardy, widespreadF800Jun 1, 2026

  Based on observation, interview, and record review, the facility failed to have a system in place to provide sufficient food to meet the daily nutritional requirements of residents and serve the facility planned/approved menu.This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/18/26 at 11:58 AM when the facility failed to maintain two days' worth of food supplies on hand, failed to purchase food in quantities/quality to be able to serve all residents the planned, palatable menu, and failed to have sufficient food to serve double portions and dietary supplements to residents with recent significant weight loss.This applies to 14 of 14 residents (R11, R15, R16, R21, R22, R23, R24, R25, R27, R28, R30, R31, R32, and R33) reviewed for residents with significant weight… […]

• Immediate jeopardy, widespreadF600Jan 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for a resident (R1) with a known history of physical aggression. This failure resulted in (R1) grabbing (R4) around the neck, throwing him to the ground, and R4 hitting his head on the floor. (R4) was transferred to a local hospital for evaluation of a head injury. This failure has the potential to affect all residents in the building as R1 is ambulatory throughout all units of facility and accesses the elevator independently. The findings include: The Immediate Jeopardy began on 12/30/23 when R1 grabbed R4 around the neck and threw R4 on the floor, resulting in R4 being sent to the hospital for evaluation of head injury. […]

• Immediate jeopardy, patternF689Nov 17, 2025

  Based on observation, interview and record review the facility failed to ensure a resident with a history of elopement was appropriately assessed and/or monitored to prevent elopement, failed to identify and assess residents who actively seek exits or display elopement behaviors, failed to ensure all exit doors/windows were secured/monitored, failed to promptly/effectively respond to triggered door alarms and perform a resident head count, and failed to maintain a current list of residents at risk for elopement at the front door exit per facility policy and resident care plans. […]

• Immediate jeopardy, isolatedF689Nov 4, 2025

  Based on interview and record review the facility failed to provide the necessary monitoring and supervision for a resident with a history of suicidal ideation and a history of obtaining knives. The facility also failed to have a system in place to accurately screen residents for suicide risk in a timely manner, and ensure residents with suicide risk were identified, and interventions were put in place. This failure resulted in R1 sustaining self-inflicted stab wounds and expiring at the facility from apparent suicide. This failure resulted in Immediate Jeopardy when the facility lacked interventions and processes to protect a resident with a history of suicidal ideation from keeping sharp knives in his room and sustaining self-inflicted stab wounds and expiring from apparent suicide. […]

• Immediate jeopardy, isolatedF600Aug 14, 2023

  Based on observation, interview and record review, the facility failed to ensure a resident, R1 was free from physical abuse from another resident, R11. The facility failed to implement interventions to keep R1 free from further abuse by R11 and the facility failed to implement a treatment plan to keep other residents safe from R11's behaviors. This applies to one (R1) of seven residents reviewed for physical abuse in a sample of 16. This failure has the potential to affect the other 24 residents residing in this unit with R11. This unit is the facility's Dementia Unit cares for residents at risk for abuse related to their cognitive impairment and inability to verbalize needs. The Immediate Jeopardy began on July 14, 2023, at 7:00 A.M. […]