Landmark of Rayne

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices when staff failed to immediately sign out narcotic medications on the narcotic record form at the time they were administered for the for 5 residents (#23, #29, #71, #76 and #77).

Inspectors wroteBased on observations, record review, and interview, the facility failed to accurately assess 1 (#27) of 3 residents investigated for dental out of 55 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement a person-centered care plan for 1 (#6) of 55 sampled residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident who was assessed as an unsafe smoker received adequate supervision while smoking for 1 (#24) out of 3 (#2, #11, #24) residents investigated for accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 25 opportunities were observed with 2 medication errors which resulted in a medication error rate of 8.00%. The facility failed to: 1. Administer Resident #38's Budesonide per manufacturer's instructions. 2. Administer Resident #98's Cholecalciferol per physician's ordersFindings:A review of the facility's policy titled Administration of Medications which was last reviewed on 01/29/2026, read in part, Purpose: To administer medications in accordance with best practice; Oral Medication Administration Procedure: 3. Verify the physician order, comparing the medication label to the MAR (Medication Administration Record) to verify the following: a. Right Medication, b. Right dosage, c. Right route, d. Right time, e. Right resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse performed hand hygiene and changed gloves while administering wound care treatments for 1 resident (#17) out of 2 residents reviewed for pressure ulcer/injury out of a final sample of 55 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's comprehensive care plan was revised for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure that the comprehensive care plan was updated to include accurate advance directive code status for Resident #2.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure a Minimum Data Set (MDS) assessments were completed using the Resident Assessment Instrument (RAI) process within regulatory timeframes for 17 (#3, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #61, #66, #67, #82, #89, #307) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) total residents reviewed for assessments.

Inspectors wroteBased on interview and record review, the provider failed to transmit a completed Discharge MDS (Minimum Data Set) Assessments within 14 days after completion for 7 (#9, #52, #68, #74, #83, #90, #95) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) resident's investigated for resident assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received food in the amount required to meet nutritional needs of residents by failing to use the appropriate serving sizes as indicated by the diet spreadsheet. This deficient practice had the potential to affect the 21 residents residing on the secured unit.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to esnure: 1. S6TXN (Treatment Nurse) wore proper PPE (Personal Protective Equipment) while providing wound care to Resident #11, and S10CNA (Certified Nursing Assistant) wore proper PPE while providing care to Resident #83 who was on Enhanced Barrier Precautions; 2. S6TXN appropriately removed and discarded soiled PPE; after completing wound care. This deficient practice had the potential to affect a census of 96 residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (#7) resident in a final sample size of 33. The deficient practice has the potential to affect a census of 96.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for restraint use for 1 (#28) of 33 sampled residents whose records were reviewed.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive centered care plan for a Level II PASRR (Preadmission Screening and Resident Review) for 1 (Resident #47) out of 33 sampled residents. This deficient practice had the potential to affect a census of 96.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a resident was invited to the resident's care planning meetings for 1 (Resident #54) out of a sample of 33 residents. This deficient practice had the potential to affect a census of 96.

Inspectors wroteBased on record review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of improvement as evidenced by failing to have documented evidence of monitoring the effectiveness of the proposed plan of action. This deficient practice had the potential to affect a census of 98 residents.

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure that residents received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 2 residents (#2 and #3) out of a total of 6 (#1, #2, #3, #R4, #R5 and #R6) sampled residents. This deficient practice was evidenced by the facility staff failing to: 1. Conduct weekly body audits for Resident #3; 2. Identify a Stage 2 Pressure Ulcer for Resident #3; and 3. Provide ordered treatments for Resident #2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Discard expired foods from the kitchen refrigerator, freezer, and dry storage area; 2. Label opened foods with the date they were opened; 3. Remove compromised cans from the dry storage area; 4. Clean the inside of oven and outside of refrigerator and freezer; and 5. Ensure staff wore hair restraints in the kitchen. This deficient practice had the potential to affect the 92 residents who consumed food from the kitchen from a census of 93 Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards as evidenced by: 1. Failing to ensure oxygen equipment was stored appropriately when not in use for Resident #5 and Resident #68; 2. Failing to ensure oxygen equipment was changed for Resident #53, Resident #68, and Resident #80; 3. Failing to ensure oxygen equipment was properly dated for resident #80.

Inspectors wroteBased on observation and interview, the facility failed to ensure that menus met the nutritional needs of residents according to established guidelines, as evidenced by the kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to decreased intake, altered nutritional needs, and weight loss for the 9 residents who consumed pureed diets. 92 residents consumed foods from the kitchen.

Inspectors wroteBased on record review, interviews, and policy and procedure reviews the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in the facility.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents were free from unnecessary physical restraints for 1 (#76) resident out of 2 (#75, #76) residents investigated for physical restraints.

Inspectors wroteBased on interview, record review ,and policy review the facility failed to implement the resident's care plan by failing to administer medications per physician's orders for 1 ( #94) out of a total sample of 30 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for 1 (#18) out of 2 (#18, #69) residents investigated for ADLs out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were re-evaluated for the continued use of PRN (as needed) antipsychotic medications after 14 days for 1 (#75) resident out of a final sample of 30 residents.

Inspectors wroteBased on observations and interview the facility failed to maintain an infection prevention and control program as evidenced by staff failing to sanitize reusable resident care equipment after use and between residents. The deficient practice had the potential to effect a census of 93.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects and rodents. The deficient practice had the potential to affect 87 residents who resided in the facility.