Landmark of Lancaster Rehabilitation and Nursing C

In the surveyor’s words

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

• Immediate jeopardy, patternF657Oct 28, 2021

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the person-centered comprehensive care plan for one (1) of fourteen (14) sampled residents (Resident #15). Staff interviews and record review revealed Resident #15 required one (1) staff assist for transfers and toileting; had frequent falls; and, attempted to toilet self without assistance. Review of Resident #15's incident reports, dated 02/18/2020 through 06/02/2021, revealed he/she had a total of sixteen (16) falls at the facility. Continued review revealed at least eleven (11) of the sixteen (16) falls occurred while the resident was attempting to toilet himself/herself. […]

• Immediate jeopardy, patternF689Oct 28, 2021

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible and the residents received adequate supervision and assistive devices to prevent accidents for eight (8) of fourteen (14) sampled residents (Residents #15, #16, #7, #3, #10, #17, #5, and #6 ). In addition, the facility failed to ensure staff utilized a mechanical lift for three (3) residents (Residents #7, #5, and #6). 1. The facility assessed Resident #15 to require the assistance of one (1) staff for transfers and toileting. Resident #15 sustained sixteen (16) falls from 02/18/2020 to 06/02/2021. […]

• Immediate jeopardy, isolatedF656Jun 7, 2022

  Based on interview, record review, review of the facility's policy, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated 10/01/2019, it was determined the facility failed to develop a person-centered comprehensive care plan (CCP), which included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs for one (1) of fourteen (14) sampled residents (Resident #1). Upon admission, on 04/18/2022, the facility assessed Resident #1 to be At risk for elopement. However, the facility failed to develop Resident #1's care plan to include person centered interventions that included supervision and monitoring. […]

• Immediate jeopardy, isolatedF689Jun 7, 2022

  Based on observation, interview, record review, review of the website World Weather Online, and review of the facility's policies, it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #1) was provided a safe environment. The facility also failed to ensure each resident received adequate supervision and monitoring to prevent elopement. Additionally, the facility did not follow their elopement policy by failing to call a Code 99 to ensure an accounting of all residents in response to the exit door alarm sounding on 05/04/2022. […]

• Immediate jeopardy, isolatedF656Oct 28, 2021

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement care plans for three (3) of fourteen (14) sampled residents (Residents #16, #7 and #6). On 03/18/2020, the facility placed Resident #16 in a bed with a bed rail designed to assist the resident with bed mobility. On 03/28/2020, the facility placed an alternating pressure relief air mattress (a mattress that inflates and deflates) to relieve pressure due to the resident's risk for skin breakdown. However, the facility failed to develop a plan of care addressing the use of the bed rails and the air mattress; and, failed to develop interventions to ensure the safety of Resident #16. On 08/28/2021, Resident #16 sustained a fall from the bed. […]