Landmark of Desoto

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to ensure informed consent was obtained prior to the initiation of psychotropic medications for 5 (five) of 5 residents reviewed for unnecessary medications. Resident #1, Resident #3, Resident #6, Resident #12, and Resident #38. Findings Include: Facility policy titled Psychotropic Medications, dated 02/25, stated, Consent for Anti-psychotic Medication Treatment shall be completed for new order of or increasing the dose of an anti-psychotic, psychoactive, or neuroleptic medication. The prescribing physician, or facility medical director shall complete Section I providing indications for use, diagnosis, risks, benefits, alternatives and course of therapy. Section II shall be completed by resident or resident representative. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure that the physician reviewed and responded to pharmacy recommendations for gradual dose reduction (GDR) and failed to ensure as-needed (PRN) psychotropic medication orders included a stop date for four (4) of five (5) residents. (Residents #1, #6, #12, and #38) Findings Include: Review of the facility policy Gradual Dose Reduction (GDR) for Psychotropic Medications with revision date of 11/17 revealed A Gradual Dose Reduction (GDR) is a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Within 1st (first) year after admission on psychotropic or after initiation: GDR in 2 (two) separate quarters, with at least one month between attempts. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for six (6) of thirty-three medication opportunities. Medication error rate of 18.18%.Findings Include: Review of the facility policy titled Administration of Medications revised 3/25 revealed under, Procedure . 3. Drugs and biologics are administered no more than one hour before or no more than one hour after the dosage time on the order. Also revealed under, Oral Medication Administration Procedure: . 3. Verify the physicians order, comparing the medication label to the MAR (Medication Administration Record) to verify the following:a. Right medicationb. Right dosagec. Right routed. Right timee. Right resident. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have the call light accessible for Resident #30, this was for one (1) of 24 residents reviewed. Findings Include:Review of facility policy titled, Resident Call Light System, dated 07/25, revealed, A call light system is in place and operative in facility. This system allows individual residents to access a system that notifies nursing that the resident has a need . An observation and interview on 03/17/2026 at 10:50 AM observed Resident #30 lying in her bed and alert to name being called. A fall mat was on the floor next to the bed with bed in the lowest position. Observed a sign above the bed reminding resident to call for assistance, Please call, don't fall. Use the call button for assistance. Observed that call light was not within reach. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the accuracy of resident assessments by inaccurately completing section H (bowel and bladder) of the Minimum Data Set (MDS) for one (1) of 18 sampled residents. Resident #11. Findings Include: Review of the facility policy titled Resident Assessment, revised 9/19, revealed, An assessment will be completed on each resident utilizing the MDS (Minimum Data Set). The reason for the assessment, schedule, and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. An observation conducted on 3/17/26 at 11:29 AM revealed Resident #11 lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the interdisciplinary team (IDT) reviewed and revised the resident's comprehensive care plan to reflect changes in the resident's condition for one (1) of eighteen (18) residents reviewed. (Resident #18)

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve range of motion by not ensuring a physician ordered splint was applied daily for 1 (one) of 2 (two) residents reviewed. Resident #17. Findings Included:Record review of the facility policy Range of Motion with revision date of 01/24, revealed that the purpose was To improve or maintain joint mobility and muscle strength and To prevent contractures Observations on 03/17/25 at 10:55 AM and on 03/18/26 at 8:15 AM revealed Resident #17 lying in bed, he was non-verbal with his eyes open. His right hand was contracted and there was no wrist splint device in place. It was observed that there was a hand splint on the seat of the wheelchair that was against the wall. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper positioning and management of an indwelling urinary catheter drainage system for one (1) of one (1) resident reviewed for urinary catheter. Resident #11 Findings Include: Review of the facility policy titled Perineal Care, revised 1/24, revealed under Resident with Catheter: . 7. Ensure tubing is not positioned above the level of the bladder. An observation conducted on 3/17/26 at 11:29 AM revealed Resident #11 lying in bed with a urinary catheter drainage bag attached to the lower portion of the bed frame. Record review of Resident #11's Order Summary Report revealed an order dated 7/3/25, Foley catheter care Q (every) shift and PRN (as needed). [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure insulins were properly stored in accordance with manufacturer's guidelines to maintain safety and effectiveness for one (1) of two (2) medication carts observed. 300 hall Findings Include:Review of the facility policy titled Medication Storage, revised 11/17, revealed, Storage, supplies and equipment necessary for appropriate temperatures and conditions per the manufacturer's specifications. An observation of the 300 hall medication cart on 3/18/26 at 9:45 AM, with Licensed Practical Nurse (LPN) #1, revealed the following insulins were in use and either exceeded the manufacturer's 28-day room temperature storage limit or were not dated when opened:Resident #2 - Open vial of Novolog that was undated. Resident #3 - Open vial of Humalog dated 12/23/25. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to properly disinfect a glucometer after use, in accordance with infection control standards during one (1) of 6 (six) medication administration passes observed and failed to ensure contact precautions were in place for one (1) of five (5) residents reviewed for infection control. Resident #30. Findings Included: Review of the facility policy Infection Control Policy for General Cleaning and Maintenance of Equipment with revision date of 02/26 revealed that .Critical and invasive resident care devices (e.g. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with pressure ulcers for two (2) of 20 sampled residents. Resident # 28 and Resident # 209 Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 8/17 revealed, .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #28 A review of the Skin & Wound Evaluation dated 9/19/24 revealed that Resident #28 acquired an unstageable pressure ulcer on the right fourth (4th) ring finger on 9/19/24. [...]

Inspectors wroteBased on observation, record review, resident and staff interview the facility failed to provide treatment and services to prevent pressure ulcers for two (2) of five (5) residents observed with pressure ulcers. Resident #28 and Resident # 209 Findings Included: Record review of facility policy Pressure Ulcer Prevention and Treatment Intervention Guidelines, revised 10/22, revealed C. Protection from Fiction or Shear .4. Provide padding for casts, braces, splints, oxygen tubing, shoes etc. as needed to prevent friction. 5. Remove orthotics on a regular basis for skin inspection .Therapy Department Interventions .3. Explore possible therapy interventions for .c. Splinting/orthotic modifications . 1. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required for the third quarter (Q3) of fiscal year (FY) 2024 (April 1-June 30).

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to provide privacy for one (1) of 20 residents reviewed as evidenced by a resident who was left uncovered and visible from the hallway. Resident # 17 Findings Include: A review of the facility's Dignity and Respect policy, revised on 7/22, stated: A facility must treat each resident with dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility shall protect and promote the rights of the resident . Residents will be examined and treated in a manner that maintains bodily privacy . [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to honor a resident's right to make health care decisions related to cardiopulmonary resuscitation (CPR) for one (1) of 20 sampled residents. Resident #58 Findings Include: Review of the facility policy titled Advance Directives with a revision date of 7/15 revealed under, Policy: The facility recognizes that all adults have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. Also revealed under, Procedure: . The resident will be encouraged to participate in all aspects of decision-making regarding care and treatment. Statements by a competent resident regarding his/her desire to accept or refuse treatment will be documented in the resident's clinical record. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide appropriate care services for (1) one of (5) resident care observations. (Resident # 57)

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to maintain a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for (1) one of (3) three narcotic storage areas reviewed.

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards, as evidenced by, medications left at bedside for one (1) of twenty sampled residents. Resident #58 Findings Include: Review of the facility policy titled Medication Storage with a revision date of 11/17 revealed under, There shall be storage areas provided that assure adequate space, equipment and security for medications within the facility . An observation and interview on 10/28/24 at 9:50 AM, revealed Resident #58 lying in bed and on the bedside table was a six (6) ounce bottle of red spray liquid with a label that read, Sore Throat Spray and a one (1) fluid ounce white bottle that read, Lubricating Eye Drops. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to a implement a comprehensive care plan for a resident requiring oral care and a resident requiring nail care and for two (2) of 18 residents care plans reviewed.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene to residents as evidenced by chapped peeling lips, long nails with a brown substance underneath, and yellow substance on teeth for two (2) of 18 residents sampled for activities of daily living (ADL'S). Resident #23, and #39.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by staff not cleaning vital sign equipment between residents for one (1) of four (4) survey days.