Longwood Manor Conv.Hospital

In the surveyor’s words

From the most serious findings on record at Longwood Manor Conv.Hospital, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 8, 2023

  Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse and Mistreatment of Residents, which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, involuntary seclusion for two of three sampled residents (Resident 1 and Resident 2) by a License Vocational Nurse (LVN 1). LVN 1 cursed, yelled and pushed Resident 1 on to his bed. LVN 1 was rude and yelled at Resident 2. This deficient practice resulted in Resident 1 crying and feeling fearful. […]

• Actual harm, isolatedF689Apr 11, 2023

  Based on interview, and record review, the facility failed to inspect residents' bedrails routinely per the bed manufacturer's recommendations to prevent one of three sampled residents (Resident 1), from falling from the bed to the floor during care. As a result, Certified Nursing Assistant (CNA) 2, while providing care to Resident 1, turned the resident toward her (CNA 2), the side rail broke, and Resident 1 fell to the floor and sustained a fracture (broken bone) to her left femur (long bone in the upper leg). Findings: During a review of Resident 1's Face sheet (Admission Record), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Mar 11, 2022

  Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization or supervision) for one (1) of three (3) sampled residents (Resident 1), as indicated in the resident's Medication Administration Record (MAR). Resident 1 was found in a parking lot bloody, bruised, disheveled and wearing diapers, by the police. This deficient practice resulted in Resident 1 eloping from the facility, being found 8 hours later, by a Social Worker who then called Los Angeles Police Department (LAPD). Resident 1 was admitted to a general acute care hospital (GACH) and was noted to be bloody, bruised, and disheveled. […]

• Actual harm, isolatedF686May 5, 2021

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was discharged from the facility and readmitted to the facility with a pressure ulcer of the sacrum /coccyx (tail bone) and did not receive wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] This deficient practice resulted in Resident 1 developing a Stage 3 (the sore has gone through all layers of skin into the fat tissue, exposing the patient to infections) pressure ulcer to the sacrum and deep tissue injury ([DTI] persistent deep red, maroon or purple discoloration to intact or non-intact skin revealing a dark wound bed or blood filled blister) to both the left and right buttocks and thighs. […]

• Actual harm, isolatedF684May 4, 2021

  Based on interview and record review, the facility failed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1, who had a COC and was experiencing confusion, respiratory distress (shortness of breath [SOB]), had an elevated body temperature of 101 degrees Fahrenheit ([F]) (Normal Reference Rate [NRR] is ,d+[DATE] F), had no current V/S documented during the COC and physician was not notified. This deficient practice resulted in a four-hour delay in diagnosis, care and services for Resident 1, who required a transfer to the general acute care hospital (GACH) after the resident became unresponsive (not verbally responding) and unarousable (unable to waken), on [DATE] by emergency transport services via 911 call (an emergency service). […]