Landmark South Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Landmark South Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Nov 14, 2024

  Based on record review and interviews, the facility failed to follow its policy regarding advance directives by failing to ensure all medical records consistently reflected the resident's current wishes for code status for 1 (#27) of 32 residents reviewed for advanced directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE], when Resident #27's Advance Directive consent form was signed to indicate the resident wished to have a code status of DNR and the facility inaccurately entered a status of Cardiopulmonary Resuscitation (CPR) into the resident's clinical records. On [DATE], Resident #27 verbalized she wished to have a code status of DNR. […]

• Actual harm, isolatedF600Oct 7, 2021

  Based on observation, interviews, and record review, the facility failed to protect a cognitively impaired resident from physical and verbal abuse by a staff member, for 1 (Resident #1) of 1 resident reviewed for abuse out of a total sample of 35 residents reviewed. The deficient practice resulted in an actual harm on 8/15/2021 at 9:30 a.m., when S2CNA was observed throwing cold water on Resident #1 while she was unclothed and aggressively pushing Resident #1 across her bed while attempting to clothe the resident. Resident #1 grimaced at the force and was witnessed by staff telling S2CNA to leave her alone. S2CNA continued aggressively providing care while using profane and derogatory language. Soon after, S2CNA was witnessed slapping Resident #1 three times on her mouth with her hand. […]

• No harm, potential for more than minimal, patternF641Jan 14, 2026

  Based on interviews and record review, the facility failed to accurately code PASRR Level IIs on the residents' MDS assessments for 3 of 3 (#15, #101, and #128) residents reviewed with Level II PASRRs.Resident #15 Review of Resident #15's Clinical Record revealed an admission date of 05/05/2023 and diagnoses, which included Bipolar Disorder, Current Episode, Depressed, Severe, With Psychotic Features, and Personal History of Suicidal Behavior. Review of Resident #15's Form 142s revealed Resident #15 was approved for admission by Level II authority for temporary periods effective 10/24/2024 through 10/23/2025 and 10/24/2025 through 10/23/2026. […]

• No harm, potential for more than minimal, patternF812Nov 14, 2024

  Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was dated after opening; 2. Ice machine was properly cleaned and sanitized; and 3. Ice machine rolling table was properly cleaned and sanitized. This deficient practice had the potential to affect 137 out of 142 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility's undated policy titled, Storage Of Refrigerated Food revealed the following, in part; Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. […]

• No harm, potential for more than minimal, patternF812Nov 18, 2022

  Based on observation and interview, the facility failed to store food in accordance with professional standards for food safety by failing to ensure: 1. Canned goods did not have a compromised seal; and 2. Food products had not exceeded their expiration date. This deficient practice had the potential to affect any of the 135 residents who consumed meals prepared in the facility's kitchen. Findings: An observation was conducted on [DATE] at 8:45 a.m. during the initial kitchen tour with S1DM revealed the following: 1 black Pepper seasoning container with an expiration date of [DATE] 3 loaves of bread with green fuzzy substance 1 can of pinto beans with dents 1 can of vanilla pudding with dents 2 cans of mandarin oranges with dents An interview was conducted on [DATE] at 9:00 a.m. […]