Lansdowne Village

In the surveyor’s words

From the most serious findings on record at Lansdowne Village, in the surveyor’s own words.

• Immediate jeopardy, patternF760Apr 11, 2022

  Based on observation, interview, and record review, the facility failed to ensure there was a safe and effective medication system to ensure a newly admitted resident did not experience a significant medication error. The resident was admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As of the morning of [DATE], the resident had not received the ordered medications. This resulted in the resident experiencing an elevated blood pressure of ,d+[DATE] (Resident #369). In addition, the facility failed to ensure residents who admitted into the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #368). The facility also failed to provide an ordered gastrointestinal medication (Resident #365). The sample was 23. The census was 110. […]

• Immediate jeopardy, isolatedF678Feb 16, 2023

  Based on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest (cessation of respirations and/or pulse)) for one resident whose physician ordered him/her as a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and in accordance with the facility's policy (Resident #3). The resident expired. The sample size was 9. The census was 98. […]

• Actual harm, isolatedF689Mar 8, 2024

  Based on interview and record review, the facility failed to provide adequate supervision for one resident after an aide left the resident unattended in the bathroom during toileting (Resident #33). The resident was found in the hallway across the room, laying on their back on the floor, with a gash to the forehead. The resident was sent to the emergency room and returned with bruising to the head, face, and neck areas. The census was 113. The Administrator was notified on 3/8/24 of the past non-compliance. The nursing staff immediately assessed the resident and treated for injuries. Staff called 911 and reported the unwitnessed fall to the resident's next of kin and physician. The facility immediately in-serviced staff on toileting residents. […]

• Actual harm, isolatedF697Sep 7, 2023

  Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who require such services for one resident (Resident #5), who was placed on hospice and expressed pain. The facility failed to ensure the pain medication ordered by the hospice company was made available timely. This resulted in the resident expressing pain by yelling out with movement and care. In addition, staff completed wound care on the resident without waiting for pain medication to be administered. The census was 128. Review of the facility's Pain Management policy, dated 11/15/22, showed: -The facility will use a systematic approach to pain management, recognition, evaluation, treatment, and monitoring of pain. […]

• Actual harm, isolatedF686Apr 11, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing when facility staff did not provide wound treatments as ordered. This affected three residents (Residents #101, #86, and #92) of 23 sampled residents. The census was 110. Review of the facility's Skin Management Guidelines, revised July 2017, showed: -Purpose: -To identify at-risk residents for potential breakdown or ulcerations; -To prevent breakdown of tissue or ulcerations; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Risk factors: -Cognitive impairment; -Exposure of skin to urinary or fecal… […]