LANDMARK VILLA

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended...... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in unlocked and unattended laundry and housekeeping rooms which pose an immediate risks to persons in care.

Official plan of correction

Staff locked the rooms immediately. Executive Director stated she'll in-service the staff. Copy of training topics with attendees signatures to be submitted by 8/05/26.

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

§1569.695 Emergency Plans (f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above in 1 out of 5 stairwells not having evacuation chair which pose a potential risk to persons in care.

Official plan of correction

Executive Director stated she'll have an evacuation chair purchased. Proof of purchase and picture showing it is installed to be submitted by 8/18/26.

Deadline recorded: Aug 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.50(a)(3)

Regulation authority

HSC

What the official deficiency says

§1569.50 Denial, suspension or revocation of license; grounds; application of remedies; temporary suspension pending hearing; exclusion from licensure without right to petition for reinstatement (a) The department may deny an application for a license or may ....suspend or revoke a license issued under this chapter upon any of the following...(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual ...... -This requirement is not met as evidenced by:

Official plan of correction

The licensee rescinded the notification after the Department conducted an Office Meeting.

Deadline recorded: Jul 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

000000

Regulation authority

CCR

What the official deficiency says

BELOW IS A CONTINUATION OF THE DEFICIENCY ABOVE: -Based on document review, the licensee did not comply with the section above for conduct inimical to the health, safety and/or morals of persons in care.

Deadline recorded: Jul 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(20)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (20) To select their own physicians, pharmacies, privately paid personal assistants, hospice agency, and health care providers....... -This requirement is not met as evidenced by: - Based on records review and interviews, the licensee did not comply with the section above in having the residents seen by different doctor without consent from the residents and resident's responsible person which pose a potential personal rights risks to persons in care.

Official plan of correction

Licensee and IADM to read the Regulation and self certify compliance. Proof to be submitted by 4/02/26.

Deadline recorded: Apr 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(9)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (9) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding the care and services -This requirement is not met as evidenced by: - Based on records review and interviews, the licensee did not comply with the section above in not having the residents and resident's responsible person participate regarding residents' care which pose a potential rights risk to persons in care.

Official plan of correction

Licensee and IADM to read the Regulation and ensure compliance. Self-certification to be submitted by 4/02/26.

Deadline recorded: Apr 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations ...function. The facility shall be large enough to provide comfortable living ... ...e residents, staff, and others who may reside in the facility. The following provisions shall apply: (3)... supplies necessary for personal care and maintenance of adequate hygiene ...resident. The resident may provide the following items; ... shall ... (D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having adiquate hygiene supplies avaliable for residents in care which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator will read and understand the regulation self certifity. Facility will purchase hygiene supplies and submit a photo to the Department by the POC date.

Deadline recorded: Feb 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(f)(h)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following ...(f) All personnel records shall be available to the ..., audit, and copy upon demand during normal .... Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: (h) All personnel records shall be retained for at least three (3) years following termination ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having former staff file avaliable which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator to read and understand regulation self certify and conduct in-service with all staff responsible for staff records and provide the Department with a copy of the sign in sheet by the POC date.

Deadline recorded: Feb 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above fpr unlocked chest rub in resident's room which poses an immediate health and safety risks to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Staff locked the iitems. In addition, ED to conduct in-service training and submit copy of training topic with attendees signature by 9/29//23.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. -This requirement is not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section above by not updating R1's Appraisal/Needs and Services Plan which posed potential health risks to person in care.

Official plan of correction

R1 is no longer at the facility. Executive Diretor to review all residents records, ensure reappraisals are updated and submit a self certification of completion by POC due date.

Deadline recorded: Jun 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. -This requirement is not met as evidenced by: -Based on interview, the licensee did not comply with the section above for not keeping R1's records for at least 3 years which posed potential health and personal rights risks to person in care.

Official plan of correction

R1 is no longer at the facility. Executive Diretor to read the Regulations and by POC due date send a self-certification that residents' records will be kept for a minimum of 3 years.

Deadline recorded: Jun 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ....and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s...... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above. R1 who has dementia didn't have medical assessments for 2018 and 2019 which posed potential health and safety risks to person in care.

Official plan of correction

R1 is no longer in the facility. Executive Director to have all the residents' records reviewed and ensure all residents with dementia have annual medical assessments. A certification indicating these have been completed to be submitted by 10/27/2021.

Deadline recorded: Oct 27, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). --This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above by retaining R1 who has dementia when facility does not have Dementia Care Plan nor submit an addendum tothe Plan of Operation which poses potential health and safety risks to person in care,

Official plan of correction

Executive Director to submit the following: 1. Addendum to facility's Plan of Operation 2. Demential Care Plan

Deadline recorded: Oct 27, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above for retaining R1 with dementia. R1 was able to AWOL which posed immediate safety risk to person in care.

Official plan of correction

R1 is no longer in the facility. Executive Director to do the following and submit proof by 10/14/2021: 1. Have auditory signals installed on entrance and exit doors, and ensure they are functional at all times and submit pictures. 2. In-service all staff and submit copy of in-service training with attendees signatures.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a).... elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. -This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above. R1was able to AWOL unnoticed. R1 fell resulting to sustaining injuries. These posed immediate safety and personal rights and safety risks to person in care. Civil penalty is assessed.

Official plan of correction

Executive Director to conduct in-service training and submit proof by POC date. A $500.00 civil penalty is assessed.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.