Landmark Medical Center: Supervision Failures - CA
The September 2025 complaint inspection, conducted by federal surveyors, identified failures in the facility's resident supervision system under citation F0689, covering hazards and supervision. The level of harm was cited as minimal harm or potential for actual harm, and the violations affected some residents.
The problem was not that the facility lacked a policy. It had two of them.
One, titled "Zoning and Supervision," described a monitoring system built around accountability. Staff were to check rooms on a schedule, confirm that sleeping residents were free from distress, and for the overnight shift, maintain active awareness of resident activity for the entirety of the shift. Not a glance at a doorway. Not an assumption that quiet meant safe. The policy said staff were to be alert and pay attention to resident activity the entire time they were on duty.
The second policy, which the facility left undated, addressed how those checks were supposed to be recorded. It was called "Timely and Accurate 1:1 Monitoring and Q:15 Monitoring Documentation in Point Click Care." Q:15 means checks every fifteen minutes, the kind of close watch ordered for residents whose condition warrants it. The policy stated plainly that when a staff member entered documentation into the Point Click Care electronic system showing a resident had been located, that entry was an honest and accurate statement that the staff member had visually seen and identified that resident.
An honest and accurate entry. That phrase is in the facility's own policy.
Inspectors found that the entries were being made. The documentation existed. What the investigation put in question was whether the visual confirmation behind those entries existed too.
That gap, between what the electronic record showed and what staff had actually done, is the center of this citation. Point Click Care is the system nursing facilities across the country use to track care, document observations, and demonstrate to regulators and families that residents are being monitored. When a staff member logs a check, it timestamps. It creates a record that looks, from the outside, like supervision happened.
But a log entry is not a set of eyes on a person. It is not a hand checking for a pulse, or a moment standing in a doorway watching a chest rise and fall. For residents on close monitoring, the fifteen-minute check exists because something about their condition, their history, or their behavior has made the facility and their care team decide that regular visual confirmation is necessary for their safety.
The overnight shift carries particular weight in this kind of citation. The "Zoning and Supervision" policy specifically called out the NOC shift by name, requiring staff to supervise surroundings and remain alert to resident activity for the entirety of the shift. Nights are when residents are least able to call for help, least likely to be noticed by visitors, and most vulnerable to the kinds of quiet emergencies that go undetected until morning.
The facility's own written standard acknowledged all of this. It described monitoring as the mechanism by which staff could account for each person and ensure each resident was free from distress. That language, account for each person, carries real weight when inspectors are looking at records that show checks logged and then asking whether anyone was actually there.
Landmark Medical Center had built a paper system, and then an electronic one, designed to answer a single question at any given moment: where is this resident, and are they safe? The inspection found that the answer being recorded in that system could not be trusted to reflect what staff had actually seen.
For the residents affected, the question of what actually happened during those unconfirmed checks remains open. The citation does not describe a resident who was harmed because a check was missed. It describes a system in which harm became more possible because the checks that were supposed to prevent it were not reliably happening, even as the records suggested they were.
A family reading a loved one's monitoring log in Point Click Care would have no way to know the difference.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark Medical Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LANDMARK MEDICAL CENTER in POMONA, CA was cited for violations during a health inspection on September 15, 2025.
The level of harm was cited as minimal harm or potential for actual harm, and the violations affected some residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.