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