Longleaf Neuro-Medical Treatment Center

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to ensure safe wheelchair transport for one resident reviewed for accident prevention. Staff transported the resident in a wheelchair without leg rests attached, resulting in the resident's left leg dragging on the floor and becoming caught underneath the wheelchair, causing minor injury to the resident's knee. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2).

Inspectors wroteBased on record review and staff interview, the facility failed to provide care in a safe manner. During incontinence care a resident fell while standing and sustained a fracture of the left distal femoral shaft (break in the lower portion of the thighbone just above the knee) with malalignment. This practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was admitted to the facility on [DATE] with diagnoses that included major neurocognitive disorder due to vascular disease with behavioral disturbance and disorganized schizophrenia. Resident #1 was not available for interview because she was hospitalized at the time of the investigation. The care plan dated 7/9/2025 and revised 3/26/2026 documented Resident #1 was at risk for falls/injury related to dementia, poor safety awareness, aggression, and medication use. [...]

Inspectors wroteBased on record review, staff interviews, and Medical Director interview, the facility failed to provide care and services in accordance professional standards of practice when staff moved and repositioned the resident after a fall prior to nursing assessment for 1 of 3 resident reviewed for accidents (Resident #1).

Inspectors wroteBased on observations, record review, and resident, staff and physician interviews, the facility did not provide care in a safe manner when 1.) Resident #3 fell to the floor from a mechanical lift (a device that uses electric or hydraulic power to safely transfer patients who have limited mobility) during a transfer from the bed to a chair sustaining a 4-centimeter posterior (at the back or rear of something) scalp laceration (cut or tear in the skin of the scalp) requiring evaluation in the emergency room and wound closure with 7 staples and 2.) Resident #4 fell out of a shower bed requiring evaluation in the emergency room sustaining an occipital hematoma (a collection of blood in or around the back part of the brain), a 2 x 2 centimeter (cm) reddened area to the left elbow, and an abrasion (superficial skin injury) to the left buttocks. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to protect residents from the accused staff during an investigation of staff to resident abuse. On 2/15/24 staff observed Nurse Aide (NA) #1 strike Resident #21 with a closed fist twice in the face and push him down on the floor. An abuse investigation was initiated on 2/15/24. On 2/16/24, during the abuse investigation, NA #1 arrived at the facility, clocked in at 6:56 AM and was given a resident care assignment. NA #1 clocked out at 10:56 AM. This deficient practice was for 1 of 3 residents (Resident #21) reviewed for abuse and had the high likelihood of serious injury/harm for other residents. Immediate Jeopardy began on 2/16/24 when Nurse Aide #1 provided direct care to residents following witnessed physical abuse of Resident #21 on 2/15/24. [...]

Inspectors wroteBased on record review, observation, and interviews with police, psychologist, physician, resident, and staff, the facility failed to protect Resident #21 from physical abuse perpetrated by Nurse Aide (NA) #1. On [DATE] Resident #21 was attempting to leave a common area of the facility by lifting his walker up over his head to get past two residents who were seated. NA #1 prevented his exit by placing her hands on the walker to position it back on the floor. Resident #21 hit NA #1 and told her to shut up followed by the use of profanity. NA #1 then struck Resident #21 with a closed fist twice in the face and pushed him down to the floor. The resident sustained a small scratch on his face. He indicated the incident made him mad. A reasonable person would have been traumatized by being physically abused by their caregiver in their home environment. [...]

Inspectors wroteBased on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the complaint investigation survey of 6/29/23. This was for one deficiency in the area of investigate/prevent/correct alleged violation (F610) that was recited on the current recertification and complaint investigation survey of 3/14/24. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, observation, staff interviews, and resident interviews the facility failed to implement their abuse policy in the area of reporting related to notifying Adult Protective Services (APS) and law enforcement of an allegation of staff physical abuse towards a resident for 1 of 3 residents investigated for abuse (Resident #21).

Inspectors wroteBased on record review and staff interviews, the facility failed to have a transfer agreement in place for transferring residents to the local hospital for evaluation and treatment, which had the potential to effect 89 of 89 residents who resided in the facility.

Inspectors wroteBased on observation, record review, resident, staff and Physician interviews the facility failed to safeguard a resident from entrapment when Resident #21's half side rail was in the up position, he fell out of bed, his right arm became caught between the side rail and the mattress, and he was unable to free himself. Resident #21 sustained 2 abrasions to his knee and was at high likelihood of suffering serious injury or death as a result of the entrapment. The facility also failed to follow the manufacturer's instructions for a mechanical lift when transferring Resident #8 out of bed resulting in the resident falling out of the lift face first to the floor. Resident #8 experienced pain and sustained soft tissue swelling, a scalp hematoma, and a laceration to the forehead. This deficient practice affected 2 of 6 residents reviewed for accidents. [...]

Inspectors wroteBased on observations, record review resident staff, and Physicain interviews the facility failed to provide oversight to ensure effective systems were in place for ongoing monitoring after concerns were identified with side rails and mechanical lift transfers placing other residents at risk for entrapment with side rails and accidents involving mechanical lifts. In addition, Administration failed to act or revise measures implemented for the use of side rails when auditing revealed the system implemented was ineffective. Immediate Jeopardy for example #1 began on 8-16-22 when the facility failed to act and revise the ongoing monitoring of side rails and a resident was found entrapped in his half side rail. Example #2 began on 1-20-22 when the facility failed to have ongoing monitoring of staff after a resident's fall from a mechanical lift. [...]

Inspectors wroteBased on record reviews, staff, facility Pharmacist, and Physicians' interviews, the Pharmacist failed to identify drug irregularities and provide recommendations for the use of as needed (PRN) psychotropic (drug that affect the mental state) for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69 and #5).

Inspectors wroteBased on record reviews, staff, facility Pharmacist, and Physician interviews, the facility failed to ensure Physician's orders for as needed (PRN) psychotropic (drug that affect the mental state) were time limited in duration for 4 of 5 residents reviewed for unnecessary medications (Residents #7, #32, #69, and #5).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately complete the Minimum Data Set (MDS) assessment in the areas of anticoagulant medication (Resident #49) and ventilator or respirator (Resident #67) for 2 of 23 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to develop and implement an individualized person-centered care plan for 1 of 1 resident (Resident #41) reviewed for care plans.

Inspectors wroteBased on observations, record review and facility staff interviews, the facility failed to ensure a physician's order was obtained for the use of a personal alarm for 1 of 5 residents reviewed for falls (Resident #72).

Inspectors wroteBased on observations and staff interviews the facility failed to discard a refrigerated food item prior to the use by date on the label for 1 (walk-in #2) of 2 walk-in refrigerators observed during the initial tour of the kitchen.

Inspectors wroteBased on observations, record review, and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the focused infection control survey of 6/3/20 and the recertification and complaint survey on 8/12/21. This was for 1 recited deficiency in the area of infection control (F880). The continued failure during 3 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to wear Personal Protective Equipment (PPE) while providing care to a resident (Resident #57) who was unvaccinated for COVID-19 while in outbreak status for 1 of 1 Health Care Technician (HCT #4) who was observed in a room where PPE was required.

Inspectors wroteBased on record review and staff, Guardian of Person (GOP), Physician (MD) and Doctor of Pharmacy (PharmD) interviews the facility failed to either administer a pneumococcal vaccine or document the provision of education which included the risks versus benefits of the vaccine and a refusal in the medical record for 1 of 5 residents (Resident #49) reviewed for immunizations.

Inspectors wroteBased on record review and staff interviews the facility failed to provide required dementia management training for 1 of 3 current nursing staff (Health Care Tech (HCT) #7) reviewed for annual education.