Federal inspectors declared Longview Hill Nursing and Rehabilitation Center posed immediate jeopardy to residents on February 13 after finding the facility failed to provide timely medical care to two patients. The violations were removed the next day after emergency staff training and policy changes.
The first patient, a male with traumatic brain injury and quadriplegia, was receiving meropenem intravenously every eight hours for pneumonia caused by COVID-19. His PICC line came out on February 5, but the nursing home couldn't replace it due to severe arm contractures that prevented the insertion company from accessing his veins.
Nobody told the patient's nurse practitioner that the antibiotic treatment had stopped.
The patient's medication records show he received his last dose at 11 p.m. on February 5. Nursing notes from February 6 through February 7 repeatedly documented "no PICC line access" at medication times, but staff never contacted the physician about the missed treatments.
LVN C called the PICC replacement company on February 6 after the nurse practitioner told her to arrange the service. The patient refused to let staff unbend his contracted arm for the procedure that evening.
The next day, LVN E called the company again. By 2:58 p.m. on February 7, she documented "no PICC line in place for administration of medication." At 10:12 p.m., LVN F wrote "no PICC line access."
The replacement company told staff they wouldn't return because the patient's contractures made insertion impossible.
LVN E said she informed the director of nursing about the company's refusal when leaving her shift on February 7. The DON told her to notify the physician. But LVN E told the oncoming nurse, LVN F, about the situation during shift change instead.
LVN F assumed LVN E had already called the physician and didn't make the call herself.
The patient's chest X-ray, ordered and completed on February 7, showed "bilateral pneumonia" that was "worse compared with prior." The report was electronically signed at 11:07 a.m. that morning.
No nurse reviewed the X-ray results over the weekend.
On Monday, February 10, LVN E found the patient had developed a deeper cough and discovered the pneumonia results. She called the nurse practitioner, who ordered immediate transfer to the hospital.
The patient was admitted with right lower lobe pneumonia and the same antibiotic-resistant bacterial infection he'd been treated for since his previous hospitalization. Hospital records noted the nursing home's PICC line had been out since February 5.
The nurse practitioner told inspectors he would have ordered hospitalization immediately if staff had informed him the patient couldn't complete antibiotic therapy. "If they had informed me [the patient] was not able to finish his antibiotic, I would have told them to send him to the hospital," he said during a telephone interview.
The administrator said staff thought the antibiotic order was complete because it fell off the computer system on February 7. "They did not see any issues and they did not review the records to see if there was a problem because they thought the antibiotic was completed."
A second patient, a double amputee, was hospitalized with sepsis two days after staff documented his surgical wound was "deteriorating" but failed to notify his physician.
The patient had both legs amputated below the knee and was taking oral antibiotics for cellulitis. His wound care records show he refused treatment on February 6, two days before his last antibiotic dose.
The treatment nurse completed a wound evaluation on February 7 that documented "evidence of infection such as increased drainage, increased pain, redness/inflammation, warmth, and bleeding." The wound measured over 44 square centimeters with "50 percent granulation and 50 percent slough."
The evaluation noted the wound was "deteriorating" and the physician had "diagnosed the infection."
But the treatment nurse didn't call the patient's medical provider about the worsening condition. She told inspectors she thought the patient was scheduled for surgery that day and wanted to document the wound's condition before he left.
The patient had actually missed his February 7 surgical appointment due to a scheduling error. Staff rescheduled the procedure for February 12 but didn't inform anyone about the missed appointment or the deteriorating wound.
LVN B assisted with wound care on February 7 and observed drainage and expanding darkness above the surgical site. She didn't notify the physician either.
On February 9, the patient developed lethargy, confusion, loss of appetite, and an elevated heart rate of 115 beats per minute. Staff sent him to the hospital that afternoon.
Hospital records show he arrived with left lower extremity wound pain and fever. His temperature was 100.4 degrees and blood pressure was 173/95. X-rays revealed "gas within the wound that could be either an abscess or gaseous gangrene."
He was diagnosed with sepsis from the infected amputation site.
The nurse practitioner told inspectors he wasn't informed the patient's wound had deteriorated, only that there was a change in condition requiring hospitalization.
The Regional Nurse Consultant told inspectors that administrators couldn't find any nurse who admitted to seeing the first patient's X-ray results over the weekend. "It appeared the first time the X-rays were noted was on 2/10/25," he said.
The facility lacked a policy on reporting changes in condition to physicians.
Inspectors found the nursing home's laboratory policy required staff to "promptly notify the ordering physician, or nurse practitioner of the laboratory results that fall outside the clinical reference range." The policy made no mention of radiology results or wound assessments.
The immediate jeopardy determination was removed after the facility conducted emergency training on February 13 and 14 covering provider notification, medication administration, wound care, and documentation requirements.
All 25 facility staff members interviewed after the training could explain procedures for notifying physicians of changes in condition and reviewing laboratory and radiology results during shift changes.
Both patients' cases illustrated what inspectors called "life threatening consequences" that "put other residents at risk for not receiving timely medical interventions."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Longview Hill Nursing and Rehabilitation Center from 2025-02-14 including all violations, facility responses, and corrective action plans.
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