Landmark Nursing & Rehabilitation Ctr of West Mon

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to 1) Identify Resident #14 had a MDRO infection and implement contact precautions, and 2) implement EBP for Resident #23 and #94.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#51) of 1 sampled residents observed for medications available at the bedside.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents have the right to a clean, comfortable and homelike environment for 3 (#16, #29 and #51) of 3 residents reviewed for environment by 1) having unsanitary overbed tables for resident use (#16 and #29) and having an air conditioner unit in need of repair for resident #51.

Inspectors wroteBased on record reviews and interviews, the provider failed to ensure MDS assessments were completed and submitted timely for 3 (#3, #96, and #107) of 3 sampled residents reviewed for assessments.

Inspectors wroteBased on record review, observations, and interview, the facility failed to develop a comprehensive person-centered care plan for 1 (#99) of 2 sampled resident reviewed for ADLs. The provider failed to develop an ADLs care plan for Resident #99.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. The facility failed to ensure residents' fingernails were clean and trimmed in a timely manner for 1 (#99) of 2 residents reviewed for activities of daily living.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the nursing staff are able to demonstrate competency in skills necessary to care for the resident needs for 1 (#6) of 5 residents sampled for the unnecessary medication review. This was evidenced by the nurses failing to administer as needed blood pressure medication as ordered for Resident #6.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for edema while a resident was receiving a diuretic for 1 (#92) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure it assessed residents using the quarterly review instrument approved by Centers for Medicare & Medicaid Service (CMS) not less frequently than once every 3 months by failing to complete the Minimum Data Set (MDS) assessment at least every 3 months for 4 (#8, #15, #55, #63) of 4 sampled residents reviewed for timeliness of MDS assessments.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a comprehensive person centered care plan for 1 (#24) of 1 resident reviewed for constipation and 2 (#26, #60) of 2 residents reviewed for smoking.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure labs were collected as ordered for 1 (#84) of 5 (#9, #18, #42, #84, #94) residents reviewed for unneccessary medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 1 (#1) of 3 (#1, #2, #3) residents reviewed for accidents received the necessary supervision to prevent avoidable accidents including a fall. The deficient practice resulted in an actual harm for Resident #1 on 08/22/2024 at 12:25 p.m. when Resident #1 suffered major injuries from falling out of the bed to the floor while left unattended during a bed bath. S4 CNA (Certified Nursing Assistant) was providing a bed bath to Resident #1. S4 CNA left the room to get more supplies for the bath and Resident #1 rolled off the bed and to the floor. Resident #1 was sent to a local hospital ER (Emergency Room) on 08/22/2024. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (#1) of 3 (#1, #2, #3) residents reviewed. S4 CNA (Certified Nursing Assistant) failed to provide 2 person assistance during bed mobility for Resident #1 and failed to ensure the bed was in the locked position prior to exiting Resident #1's room. The facility implemented corrective actions prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. The Completion date was 08/26/2024.

Inspectors wroteBased on observation, record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired with communication deficits) on 05/19/2024 at 6:10 p.m. when S3CNA (Certified Nursing Assistant) physically and verbally abused resident #1 by forcefully grabbing resident #1's lower extremities, hands and arms in an attempt to reposition resident #1 and the resident sustained two red bruises that were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. S3CNA cursed resident #1 and expressed anger at resident #1. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to provide personal privacy during incontient care for 1 (#1) of 3 (#1,#2,#3) residents reviewed for incontinent care.

Inspectors wroteBased on record review and interview the facility failed to ensure an allegation of abuse by staff was reported immediately to the facility administrator no later than 2 hours after the allegation was made for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered careplan for 2 (#4, #32) of 6 (#4, #32, #51, #57, #111, #177) residents reviewed for medication administration. The facility failed to ensure: 1) nurses administered Insulin according to the residents sliding scale parameters, and report high blood surgars to the resident's physician as ordered (#32) 2) nursing staff reported abnormal blood sugars to the attending physician or nurse practioner and failed to update the plan of care to adress the abnormal blood sugars (#4)

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were accessible only to authorized personnel by failing to ensure the medication room remained locked.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that all alleged violations involving injuries of unknown source are reported immediately to the state agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation results in serious bodily injury for 1 (#5) of 2 (#3 and #5) resident investigations reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections. This deficient practice has the potential to affect all 117 residents who currently received care and services from the provider. 1) The provider failed to ensure all staff wore KN95 face masks during an outbreak status in accordance with facility's policies and procedures; 2) The provider failed to ensure staff's personal items, including cat food was not stored in the clean laundry room; and, 3) The provider failed to ensure staff's personal items were not stored in the hallway and near an area that was designated for resident restorative therapy.