Longwood Health and Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility failed to provide the resident representative with access to personal and medical records within 24 hours (excluding weekends and holidays) of a written request for 1 of 2 residents reviewed for resident rights, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that physician ordered medications were not left unattended at residents' bedside for 1 of 2 residents, reviewed for quality of care, of a total of 4 sampled residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to transmission-based precautions for 2 of 7 residents reviewed for infection control, out of a total sample of 48 residents, (#81, and #29) and maintain a complete antibiotic stewardship program. The facility also failed to adhere to proper infection control practices related to hand hygiene and personal protection equipment (PPE) use.

Inspectors wroteBased on interview, and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 48 residents, (#68).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary maintenance services to ensure a homelike environment in 3 of 32 rooms in the B- wing, (rooms #13, #14, and #17).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services according to professional standards for monitoring and management of an intravenous (IV) therapy site for 1 of 2 residents reviewed for IV access, (#81), and failed to provide appropriate care and services according to professional standards for medication administration for 1 out of 2 residents, (#87), out of a total sample of 48 residents.

Inspectors wroteBased on interview, and record review, the facility failed to develop a trauma-informed care plan based on a resident's past experiences and preferences to mitigate triggers that could cause re-traumatization, for 1 of 1 resident reviewed for abuse, of a total sample of 48 residents, (#29).

Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmacy recommendations were implemented in a timely manner for 1 of 5 residents reviewed for Unnecessary Medication Regimen Review, out of a total sample of 48 residents, (#19).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical record reflected documentation of an incident between residents and follow-up assessments for 1 of 1 residents reviewed for abuse, out of a total sample of 48 residents, (#29).

Inspectors wroteBased on interview, and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed and failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary resuscitation (CPR) for 1 of 8 residents reviewed for Advanced Directives of a total sample of 8 residents, (#1). These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. [...]

Inspectors wroteBased on record review, and interview, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of resuscitation or code status in an emergency for 1 of 8 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#1). On [DATE] at approximately 11:48 PM, resident #1 was observed unresponsive in his wheelchair at the nurse's station. He was taken to his room where a licensed nurse initiated CPR without first verifying the resident's code status in the medical record. Emergency Medical Services (EMS) arrived at the facility at midnight and continued to provide CPR for another 20 minutes before resident #1 was transported to the hospital where he was intubated and stabilized. The facility failed to honor the resident's wishes not to be resuscitated and physician's order for Do Not Resuscitate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses had the skills and competencies to provide care and services, according to plans of care, to meet the needs of all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were attended by residents and/or their representatives, and the required members of the interdisciplinary team (IDT) for 2 of 4 residents reviewed for care planning, of a total sample of 43 residents, (#8 and #24).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and appropriate treatment and services to maintain and/or improve the ability to perform activities of daily livings (ADLs) related to eating for 1 of 1 resident reviewed for decline in ADLs, of a total sample of 43 residents, (#8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living care (ADLs) for dependent residents related to shaving and nail care for 3 of 5 residents reviewed for ADLs, of a total sample of 43 residents, (#73, #77, and #83).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services for intravenous (IV) catheters according to standards of practice for 2 of 2 residents reviewed for IV catheter care, of a total sample of 43 residents, (#90, & #108).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services related to timely acquisition and proper administration of physician-ordered medication to meet the needs of 3 of 6 residents reviewed for Medication Administration, of a total sample of 43 residents, (#73, #77, and #98).

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record accurately reflected administration of a prescribed eye ointment over a 34-day period for 1 of 6 residents reviewed for medication administration, of a total sample of 43 residents, (#73).

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves during wound care to prevent cross-contamination for 1 of 1 resident reviewed for pressure ulcers, (#90), of a total sample of 43 residents; failed to disinfect a glucometer according to manufacturer's instructions and facility policy and procedures, failed to appropriately dispose of a used sharp, and failed to ensure appropriate infection control practices prior to medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace a broken bed in a timely manner to promote the right to a comfortable environment for 1 of 5 residents reviewed for environmental concerns, out of a total sample of 43 residents, (#24); and failed to clean and store resident care items appropriately in a shared bathroom in 1 of 32 rooms on the B Wing, (room [ROOM NUMBER]).

Inspectors wroteBased on interview, and record review, the facility failed to report an alleged violation of neglect for 1 of 2 residents reviewed for abuse, of a total sample of 43 residents, (#38).

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate supervision to prevent a fall with minor injury for 1 of 5 residents reviewed for accidents, of a total sample of 43 residents, (#38).

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for 1 of 3 residents observed during the medication administration task, of a total sample of 43 residents, (#65). There were 2 errors in 29 opportunities for a medication error rate of 6%.

Inspectors wroteBased on observation and interview, the facility failed to keep medication under direct observation when not secured in a locked compartment, to prevent unauthorized access by residents, staff, and/or visitors, on 1 of 2 medication carts on the B Wing. Findings; On 4/08/24 at 1:59 PM, Registered Nurse (RN) J walked away from her medication cart at the B Wing nurses' station and entered a resident's room at the far end of the hallway. She performed a blood glucose check and returned to the medication cart. On 4/08/24 at 2:04 PM, a small medication cup with one large white pill was observed on the left side of RN J's medication cart. The medication cup was partially covered with the towel placed on top of the cart to catch moisture from a pitcher of water. RN J stated the cup contained one Gabapentin pill. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals that met dietary requirements and preferences according to the plan of care for 1 of 11 residents reviewed during the dining observation task, of a total sample of 43 residents, (#8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services furnished to a resident by an outside agency were arranged for 1 of 1 resident reviewed for Dialysis care, of a total sample of 43 residents, (#10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information daily, and failed to retain the postings for a minimum of 18 months, to ensure accurate and comprehensive data was accessible to residents and/or visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate personal hygiene related to nail care and shaving for 3 of 4 residents reviewed for activities of daily living, (ADLs) of a total sample of 51 residents, (#103, #111, and #665).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall interventions were in place for 4 of 6 residents reviewed for falls out of a total sample of 51 residents, (#32, #45, #26, and #67).