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Inspection visit

Inspection

LONGWOOD HEALTH AND REHABILITATION CENTERCMS #1053771 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based 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).Findings:On 2/19/26 at 12:27 PM, a medication cup with four pills (one yellow tablet, one pink tablet, one white tablet, one pink and gray capsule), and one six-ounce clear plastic cup with clear liquid and a spoon inside of it was sitting on resident #1's bedside table with his lunch tray. Resident #1, alert to person, place and time, explained the medications in the cup were his 9:00 AM medications previously left by the nurse. He said the clear plastic cup with clear liquid was his MiraLAX that was also left at bedside by the nurse. On 2/19/26 at 12:51 PM, assigned Licensed Practical Nurse (LPN) A, stated she did not know where the medications left on the bedside came from. She mentioned the medications were not there when she administered the resident's 9:00 AM medications. The nurse stated she didn't usually leave medications at residents' bedsides but explained she left resident #1's 9:00 AM liquid stool softener (MiraLAX) on his bedside table in a clear six-ounce plastic cup. On 2/19/26 at 12:54 PM, the Director of Nursing (DON) acknowledged the cup with the medications on resident #1's bedside table, then took the cup from resident #1's bedside table and stated that he would investigate what the medications were. Review of resident #1's current physician orders revealed he had orders for Aspirin oral capsule 81 milligrams (mg) - give 1 tablet by mouth in the morning for PAD (peripheral artery disease) start date 10/25/25 9:00 AM, Flomax capsule 0.4 mg - give 1 capsule by mouth in the morning for benign prostatic hyperplasia - start date 12/24/25 at 9:00 AM, Losartan potassium tablet 25 mg - give 1 tablet by mouth one time a day for hypertension (high blood pressure) - start date 10/25/25, 9:00 AM, MiraLAX oral packet 17 grams - give 17 grams by mouth one time a day for constipation - start date 10/25/25 at 9:00 AM, and Oxybutynin chloride extended release 24 hour, 10 milligram tablet - give 1 tablet by mouth one time a day for overactive bladder - start date 11/27/25 at 9:00 AM. Review of the facility's Medication Administration Record (MAR) revealed that resident #1's 9:00 AM, medications were documented as given by LPN A, on 02/19/26 at 9:00 AM, in conflict with the medications observed still in a cup on resident #1's bedside table. On 2/19/26 at 2:25 PM, the DON stated he spoke to the physician by phone to verify resident #1 medications. He stated the 4 medications in the medication cup were Aspirin 81 mg, Flomax 0.4 mg, Losartan 25 mg, Oxybutynin 10 mg, and the clear liquid in the cup was MiraLAX. The DON confirmed these medications were resident #1's medications scheduled for 9:00 AM, still sitting on the bedside table three and a half hours later at 12:27 PM. Review of the facility's policy revised October 2023, entitled Medication Administration, indicated that medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines #15, indicated for staff to observe resident consumption of medication, and #19 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105377 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Longwood Health and Rehabilitation Center 1520 S Grant St Longwood, FL 32750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 indicated, Report and document any adverse side effects or refusals. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105377 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

FAQ · About this visit

Common questions about this visit

What happened during the February 19, 2026 survey of LONGWOOD HEALTH AND REHABILITATION CENTER?

This was a inspection survey of LONGWOOD HEALTH AND REHABILITATION CENTER on February 19, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LONGWOOD HEALTH AND REHABILITATION CENTER on February 19, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.