Kendal At Longwood

In the surveyor’s words

From the most serious findings on record at Kendal At Longwood, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF684Feb 2, 2024

  Based on clinical record review and staff interview it was determined the facility failed to notify the physician of missed medication doses for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R1's clinical record revealed the physician was not notified of the missed does of medication. […]

• No harm, potential for more than minimal, patternF755Feb 2, 2024

  Based on clinical record review and staff interview it was determined the facility failed to provided pharmacy services by not obtaining needed medications for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023. […]

• No harm, potential for more than minimal, isolatedF760Oct 5, 2023

  Based on a review of the facility's policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure the correct dose of medication was administered for one of the 14 residents reviewed (Resident 17). Findings include: Review of the facility's policy titled, General Policies for Administration and Documentation of Medications and Treatments last review date January 2017, revealed medications and treatments will be administered by a licensed nurse, in accordance with the Pennsylvania Nursing Code, physician orders and principles of safe medications administration. […]

• No harm, potential for more than minimal, isolatedF661Nov 17, 2022

  Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of two residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on October 10, 2022. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the licensed staff E4 on November 16, 2022, confirmed that the discharge summary was incomplete. 28 Pa Code 211.5 (f) Clinical records

• No harm, potential for more than minimal, isolatedF689Nov 17, 2022

  Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure residents were free from accidents and hazards for one of eighteen sampled residents (Resident 2). Findings include: Review of facility policy and procedure titled Administration of Oral Medications, revised March 2022, revealed Oral medications will be administered safely and effectively, following Physicians Orders and all regulations. Further review of this policy and procedure revealed Administration - stay with the resident until all medications have been swallowed. […]