Inspection Reports for Longview Hill Nursing Center and Rehabilitation

The complaint involved an allegation of abuse overheard by a CNA from Resident #1's sitter on August 25, 2025. The facility followed internal reporting protocols but did not take further protective actions or assessments because the resident was discharged at the family's request. The investigation concluded the allegations were unconfirmed due to lack of witnesses or identified perpetrators.

The facility failed to thoroughly investigate the abuse allegation as the Administrator did not interview the resident, her representative, or the caregiver who verbalized the allegation. The internal investigation found no witnesses or identified perpetrators, and the findings were unconfirmed. Staff re-education on abuse and neglect was conducted.

The complaint investigation substantiated an Immediate Jeopardy situation identified on 2025-05-15 due to a medication error where Resident #1 was given another resident's medications, including a medication to which he was allergic. The facility removed the Immediate Jeopardy on 2025-05-16 but remained out of compliance at a lower severity level pending completion of staff training and evaluation of corrective actions.

The facility failed to ensure residents were free from significant medication errors, resulting in Resident #1 receiving Resident #2's evening medications, including Trazodone, to which Resident #1 was allergic. This error led to immediate jeopardy, with Resident #1 experiencing altered mental status, neurological changes, and hospitalization. The facility implemented a Plan of Removal including staff re-education and monitoring.

The complaint investigation revealed failures in timely physician notification for significant changes in residents' conditions and medication administration errors, leading to an Immediate Jeopardy situation identified on 2025-02-13 and removed on 2025-02-14.

The facility failed to notify physicians timely about significant changes in residents' conditions, including dislodged PICC line and worsening surgical wound, resulting in life-threatening consequences for two residents. Additionally, the facility failed to provide pharmaceutical services ensuring accurate medication dispensing and administration, including use of expired insulin.

The complaint investigation was triggered by allegations that the facility failed to treat residents with dignity and respect, failed to provide scheduled smoke breaks, roughly handled a resident during care, and failed to provide timely discharge notification to a resident's representative.

The facility failed to treat residents with dignity and respect during care, failed to provide scheduled smoke breaks for a resident on the secured memory care unit, roughly handled a resident during mechanical lift transfer and incontinent care, and failed to provide timely written discharge notification to a resident's representative.

The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete consent forms for antipsychotic medications, unclean and unsafe resident environments, failure to provide scheduled smoke breaks, inaccurate assessments, incomplete care plans, improper medication administration and storage, failure to follow dietary recommendations, inadequate infection control practices, and failure to provide palatable food at appropriate temperatures.

The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days and re-evaluated by a physician as required. Two residents had PRN orders for Lorazepam and Ativan that were continued beyond 14 days without documented re-evaluation, posing a risk of unnecessary medication use and potential harm.

The facility failed to maintain a 7-day food supply to meet the nutritional needs of 123 residents, resulting in meal substitutions without proper dietician approval and inadequate emergency food supplies. Interviews and record reviews confirmed insufficient food inventory and deviations from planned menus, potentially risking resident nutrition.

The complaint investigation focused on Resident #1's worsening skin conditions that were not properly reported or treated, and Resident #2's fall due to malfunctioning call lights that were not promptly answered. Resident #1's family expressed concerns about lack of treatment and communication. Resident #2 fell while attempting to transfer due to unanswered call light.

The facility failed to notify Resident #1's nurse practitioner of worsening skin conditions, failed to apply ordered treatments, and failed to document skin assessments accurately. Resident #1 had worsening moisture associated skin damage and allergic dermatitis. The facility also failed to ensure Resident #2's call light was functioning properly and answered promptly, resulting in a fall. Documentation errors were noted in Resident #1's medical records.

The facility was found deficient in multiple areas including resident dignity and privacy, care planning, medication management, infection control, environmental safety, resident hygiene, respiratory care, dialysis care, food safety, and equipment maintenance. Specific failures included lack of privacy bags for catheterized residents, missed care plan interventions, medication diversion, improper wound care, unsafe mechanical lift use, expired food storage, and non-functioning wheelchair brakes.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete care planning and implementation, inadequate infection control practices, improper medication management including drug diversion and insulin administration errors, unsafe mechanical lift transfers, failure to provide adequate personal care and hygiene, unsafe respiratory care, improper food handling, and failure to maintain essential equipment. Several residents were affected by these deficiencies, placing them at risk for harm, infection, injury, and decreased quality of life.

The investigation was complaint-driven, focusing on allegations of neglect, abuse, injury of unknown origin, and quality of care issues involving multiple residents.

The facility failed to protect residents from neglect and abuse, failed to report an injury of unknown origin, failed to provide appropriate treatment and care to prevent fecal impaction and pressure ulcers, and failed to ensure proper documentation and timely interventions. Resident #1 was found neglected with a worsening stage 3 pressure ulcer and poor hygiene. Resident #4 had an unreported subacute fracture of unknown origin. Resident #2 developed fecal impaction due to inadequate monitoring and documentation of bowel movements and pain assessment.

The complaint investigation included grievances about call light response delays, failure to notify physicians of resident condition changes, inadequate care planning, insufficient ADL assistance, respiratory care deficiencies, medication storage issues, food service complaints, infection control lapses, and inappropriate psychotropic medication use.

The facility failed to promptly resolve grievances, notify physicians of significant resident changes, implement baseline and individualized care plans, provide adequate ADL assistance, maintain respiratory equipment properly, store medications securely, follow menus and provide palatable food, maintain infection control practices, and ensure appropriate psychotropic medication use. Several residents experienced risks related to these deficiencies.