Longwood Community Living Center

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure adequate supervision for (1) one of (3) three residents reviewed for behaviors. Resident #1.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 3rd Quarter 2025. Findings Include: Record review of the facility policy titled, Staffing Hours-Monitoring of Policy and Procedure undated, revealed, Purpose: To assure the facility staffing meet federal and state guidelines. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 3 2025 (April 1-June 30), revealed the facility triggered on this report for excessively low weekend staffing. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the resident's right to participate in healthcare decision-making regarding advance directives and code status for (1) one of 18 sampled residents. (Resident #6)Findings Include: Review of the facility policy titled Advance Directives Policy and Procedure with no revision date revealed, .3. The resident's advance directives will be recorded in the resident clinical record . Record review on [DATE] at 2:00 PM revealed Resident #6's medical record indicated a code status of Do Not Resuscitate (DNR). The signed document located in the chart was a Cardiopulmonary Resuscitation (CPR) form, not a signed DNR order. Record review on [DATE] revealed the resident's DNR status was displayed on the patient profile in the electronic medical record (EMR). [...]

Inspectors wroteBased on observation, resident interview, and staff interviews, the facility failed to ensure a homelike environment by maintaining resident equipment in a clean condition, as evidenced by a visibly soiled wheelchair for one (1) of 38 wheelchairs observed at the facility. (Resident #48) Findings Include: On 12/09/25 at 11:30 AM, observation and interview revealed Resident #48's wheelchair was visibly dirty. The bottom frame of the wheelchair had a caked, dried brown substance present. The resident stated he did not realize his wheelchair was so dirty until it was brought to his attention and stated, Oh, I didn't notice it was that dirty. It does need to be cleaned. On 12/09/25 at 11:45 AM, Licensed Practical Nurse (LPN) #3 observed the wheelchair and stated it should have been cleaned on the night shift. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and facility policy reviews, the facility failed to implement care plans related to Activity of Daily Living (ADL) needs, such as personal hygiene, to include shaving, for four (4) of the eighteen sampled residents. Resident #7, #8, #27, and #40. Findings Include: Review of the facility policy titled, Care Plan Policy and Procedure, undated, revealed under Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Under Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for four (4) of 51 residents reviewed for Activities of Daily Living (ADL) care. Resident #7, #8, #27 and #40. Findings Include: Review of the facility policy titled, ADL Care of a Resident Policy and Procedure, undated, revealed Policy: Resident ADL care will be provided to the resident according to the individualized resident needs . Resident #7 An observation and interview on 12/08/2025 at 11:03 AM revealed Resident #7, a female resident, with sporadic facial hair on the chin measuring approximately one-half (1/2) inch in length. Resident #7 revealed she did not like the hair on her chin. An observation on 12/09/2025 at 9:00 AM revealed that Resident #7's facial hair in the chin area was unchanged from the previous day. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure oxygen tubing was properly stored when not in use, resulting in the potential for contamination and compromised resident safety for two (2) of 10 residents reviewed for respiratory. (Resident #19 and #27)

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure medications were stored in a properly secured refrigerator for one (1) of two (2) medication storage rooms. Findings Include: Review of the facility's policy titled Medications Storage Policy and Procedure with no revision date revealed, Purpose: To properly secure medications and biologicals according to CMS guidelines . An observation on 12/10/25 at 8:28 AM revealed the medication storage room on C Hall contained a narcotic lock box located inside the refrigerator, locked, but not secured/affixed to the refrigerator. The lock box was easily removable and contained a bottle of Lorazepam. An interview conducted on 12/10/25 at 8:30 AM with Licensed Practicing Nurse (LPN) #2, she stated she thought the lock box was secured properly. [...]

Inspectors wroteBased on observation, interviews, facility policy review, and record review, the facility failed to ensure a resident had a call system in her room for one (1) of 18 resident rooms reviewed. Resident #6 Findings Include: Review of the facility policy titled CALL LIGHTS USE OF POLICY AND PROCEDURE with no revision date revealed, Purpose: To provide the resident with a call light to notify staff to meet the need of the resident . On 12/08/25 at 10:50 AM, observation revealed Resident #6 was in her room without a call light within reach and no alternative method available to request assistance. A second observation on 12/09/25 at 2:18 PM, at the resident's bedside revealed no call light present within reach and no alternative method available for the resident to request assistance. [...]

Inspectors wroteBased on observation of a social media post, staff and resident interviews, record review, and facility policy review, the facility failed to provide care for a resident in a manner that maintained the resident's dignity. A picture of Resident #1 was posted to the facility's social media account which portrayed the resident in an undignified manner for one (1) of four (4) residents sampled.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure accuracy of a code status based on the Power of Attorney for one (1) of 14 residents sampled.

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to provide a safe environment as evidenced by an overbed table with exposed jagged edges for one (1) of 44 resident's observed. Resident #37 Findings Included: Record review of the facility policy titled, Maintenance Service with revision date of December 2009, revealed, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . On 08/21/24 at 9:10 AM, an observation and interview revealed Resident #37 lying in bed with her over bed table positioned beside her on the right side of the bed. The plastic protective border was missing from all four sides of the over bed table and there were rough, jagged areas exposed. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to develop a person-centered care plan for residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for two (2) of the 14 resident care plans reviewed. Resident #11 and Resident #37.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review the facility failed to complete a Trauma Informed Care Assessment for a resident with Post Traumatic Stress Disorder (PTSD) diagnosis for one (1) of two (2) residents reviewed for PTSD. Resident #37. Findings Included: Record review of the undated facility policy titled Trauma Informed Care undated, revealed It is the policy of this facility to provide culturally competent, trauma-informed care to residents who are trauma survivors in accordance with professional standard of practice. On [DATE] at 11:05 AM, an observation and interview with Resident #37 revealed her sitting up in her wheelchair in her room. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, dry storage room and on metal shelves were dated, labeled and discarded by the expiration date for one (1) of two (2) kitchen tours.

Inspectors wroteBased on observations, staff and resident interviews and facility policy review the facility failed to provide furniture in the resident's room that was not broken and failed to provide warm water in resident's rooms for four (4) of 47 residents reviewed during initial tour. Resident #1 for furniture and Residents #18, Resident #25 and Resident #42 for water.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review the facility failed to ensure that a resident who was unclothed had privacy and was free from view to maintain personal privacy for one (1) of 47 residents reviewed during initial tour.

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to implement a comprehensive care plan for a resident who required assistance with Activities Daily Living (ADL) nail care for one (1) of 12 residents sampled.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide personal hygiene as evidenced by long, jagged fingernails with a brown substance underneath the nails for one (1) of 12 sampled residents.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure that an as-needed (prn) psychotropic drug was limited to 14 days for one (1) of four (4) residents reviewed for psychotropic medication use.