Inspection Reports for
Windsor Gardens Convalescent Hospital of Los Angeles

The investigation was complaint-driven, focusing on allegations that staff did not respond timely to residents' requests for assistance and that proper medical orders were not obtained for blood sugar testing. The complaints were substantiated based on interviews and record reviews.

The facility failed to respond timely to call lights and requests for assistance for three sampled residents, resulting in resident dissatisfaction. Additionally, the facility failed to obtain a physician order for fingerstick blood sugar testing for one resident, potentially risking improper treatment of hyperglycemia.

The investigation was triggered by a complaint regarding a fall incident involving Resident 1 on 2025-06-19. The fall was substantiated as the resident was found on the floor and transferred to a hospital for evaluation.

The facility failed to ensure the safety of Resident 1, who had severe cognitive impairment and mobility limitations, resulting in a fall on 2025-06-19. The fall led to the resident being transferred to a hospital for evaluation, indicating inadequate supervision and accident hazard prevention.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, improper call light accessibility, incomplete documentation of nicotine patch removal, inaccurate resident assessments, incomplete care plan revisions, inadequate fingernail care, failure to assist with hearing aids, incorrect pressure ulcer mattress settings, failure to report urinary catheter sediment to physician, gastrostomy tube leakage, failure to monitor for bleeding with anticoagulants, improper use and dosing of psychotropic medications, medication administration errors, failure to follow dietary menus and provide correct food textures, unsanitary kitchen equipment, and improper wound care infection control practices.

The facility failed to provide Resident 1's legal representative with requested medical records due to misdirected fax transmission and staff absence. The facility's policy requires access to records within 24 hours of request, but this was not met.

The complaint investigation found that the facility failed to administer and document medication and treatment for Resident 1 as required. The deficiency was substantiated with evidence from record reviews and interviews.

The facility failed to ensure that Resident 1 received and had documented both skin treatment and eye drops on specified dates. The Treatment Administration Record and Medication Administration Record were not signed for treatments on 12/20/24, 12/21/24, 12/22/24, and 12/23/24, indicating the treatments were not administered or documented properly.

The complaint investigation focused on whether the facility honored Resident 1's DNR status. It was substantiated that the facility did not verify or document the DNR code status with the resident or next of kin, despite hospital records indicating a DNR order.

The facility failed to verify and document Resident 1's DNR code status with the resident or next of kin upon admission, resulting in a discrepancy between hospital records and facility status. Interviews with staff confirmed the lack of documentation verifying the resident's code status.

The facility failed to permit one resident to return after hospitalization despite having available beds, violating their bed-hold policy. Interviews confirmed the resident was ready for discharge and should have been readmitted, but was not due to contact isolation status.

The facility failed to ensure that oxygen tubing for a resident on nasal cannula was changed weekly and kept off the floor as per facility policy. This deficiency posed a risk of infection, including pneumonia, to the resident.

The complaint investigation found substantiated lapses in infection control practices related to COVID-19 isolation precautions, including failure to wear gloves and improper doffing of PPE by staff.

The facility failed to ensure that a Certified Nurse Assistant wore gloves when entering a COVID-19 isolation room and properly doffed personal protective equipment after leaving the room. These lapses had the potential to increase the spread of infection among residents and staff.

The facility failed to develop and implement comprehensive care plans for residents, ensure appropriate treatment and follow-up care, maintain proper catheter care to prevent infections, provide adequate registered nurse staffing, and ensure pharmaceutical services including medication self-administration assessments and physician orders for bedside medication storage.

The complaint investigation found that Resident 1 sustained an acute subcapital fracture of unknown origin. The injury was not reported to the Department of Public Health within the required two-hour timeframe, delaying investigation. Resident 1 had dementia and a history of wandering but lacked a comprehensive care plan and adequate supervision. The investigation was substantiated with findings of delayed reporting and inadequate care planning.

The facility failed to report Resident 1's injury of unknown origin to the State Survey Agency within two hours, causing a delay in onsite inspection. Additionally, the facility failed to develop a comprehensive care plan for Resident 1's dementia diagnosis, did not complete quarterly wandering and fall risk assessments, and did not provide adequate supervision to prevent injury, resulting in Resident 1 sustaining an acute subcapital fracture of the right femur.

The facility failed to ensure that three of four nursing staff used the facility's vital signs equipment, instead using their own equipment. This practice had the potential to negatively impact the delivery of care to all residents.

The investigation was complaint-driven, focusing on failure to notify physicians of changes in condition, unresolved grievances, incomplete care plans, and medication administration delays. Substantiation status is not explicitly stated.

The facility failed to notify physicians about changes in condition for two residents, did not promptly resolve a resident grievance regarding reimbursement, failed to develop comprehensive care plans for medication refusals for one resident, and delayed medication administration for another resident.

The facility failed to provide adequate communication means for a non-verbal resident, resulting in potential delays in care. Additionally, the facility lacked consistent policies and documentation for informed consent and evaluation of psychotropic medication use, including behavior monitoring and gradual dose reductions, for several sampled residents.

The complaint investigation was triggered by a fall incident on 2/25/2024 where Resident 1 was transferred from wheelchair to bed without assistance, resulting in a fall and serious eye injury. The fall was substantiated with findings of inadequate staff assistance and failure to follow fall protocols.

The facility failed to provide adequate supervision and assistance during transfers for Resident 1, leading to a fall that caused serious eye injury requiring hospitalization and surgery. Additionally, the facility failed to administer Parkinson's medication as ordered, potentially increasing fall risk.

The complaint involved an alleged abuse incident between Resident 1 and Resident 2 on 2/16/2024. The facility reported the incident to the Department on 2/20/2024, four days later. Interviews with staff and residents confirmed the incident and the delay in reporting. The complaint was substantiated based on the findings.

The facility failed to report the alleged abuse incident to the California Department of Public Health within the required 2-hour timeframe. The investigation found that the report was sent four days after the incident, potentially delaying the investigation.

The facility was found deficient in multiple areas including failure to provide care according to resident preferences, incomplete informed consent for psychotropic medications, missing advance directive forms, incomplete PASARR reassessments, inadequate care plans for multiple residents, lack of communication aids, incorrect pressure ulcer prevention mattress settings, unlabeled opened medications, failure to date oxygen tubing changes, and failure to post actual direct care staffing hours.

The facility was found deficient in multiple areas including failure to provide care according to resident preferences, incomplete informed consent for psychotropic medications, missing advance directive forms, incomplete PASARR reassessment, inadequate care plans for multiple residents, lack of communication devices for a resident with aphasia, incorrect pressure ulcer prevention mattress settings, and failure to post actual nurse staffing hours.

The facility was found deficient in documenting wound care treatment, assisting residents with attending appointments, meeting food preferences, and ensuring call lights were accessible to residents. These deficiencies had the potential to cause miscommunication, missed medical care, inadequate nutrition, and delayed staff response to resident needs.

The investigation was complaint-driven, focusing on medication management and storage issues for Resident 1. The deficiencies were substantiated with observations, interviews, and record reviews.

The facility failed to ensure that Resident 1's baclofen medication was properly ordered by a physician and accurately dispensed and administered. Additionally, Resident 1's self-administered medications were found unsecured at bedside, posing potential safety risks.

The complaint involved an allegation of financial abuse reported by the facility to CDPH on 9/28/2023. The facility did not investigate the allegation, citing uncertainty about how to proceed since the alleged perpetrator was a family member. The facility did not submit the required investigation summary within 5 days.

The facility failed to investigate the allegation of financial abuse and did not submit the required 5-day investigation summary to the California Department of Public Health for Resident 1. The facility staff were unsure how to handle the allegation and did not conduct a formal investigation.

The complaint investigation was substantiated. Resident 1 and family members reported persistent itching and discomfort since July 2023, which was not adequately addressed by the facility, leading to physical and emotional harm.

The facility failed to protect Resident 1 from neglect by not adequately addressing ongoing itching and skin discomfort, failing to notify a physician or follow up on a dermatology consult, resulting in physical harm including flaky and bleeding scalp, hair loss, pain, and emotional distress.

The facility failed to ensure accurate documentation of scattered hyperpigmentation in the sacral area for one of three residents reviewed. This resulted in an inaccurate representation of the resident's skin condition, potentially delaying identification of worsening conditions and necessary care.

The facility was found deficient in ensuring adequate supplies of incontinent briefs, preparing palatable and safe food, and maintaining proper infection prevention and control in the clean linen laundry room. These deficiencies posed risks of compromised skin integrity, malnutrition, choking hazards, and potential infection spread among residents.

The complaint investigation substantiated that Residents 1 and 2 were improperly restrained and that Resident 2 verbally abused Resident 1 and family with racial slurs. Resident 2 admitted to the verbal abuse and showed no regret.

The facility's nursing staff failed to prevent abuse of two residents, including improper physical restraint by tucking sheets and verbal racial abuse by one resident towards another and their family. The facility's policy commits to protecting residents from abuse by all individuals.

The facility failed to ensure that Resident 1 received appropriate treatment and education for self-irrigation of an indwelling catheter, posing a risk for urinary tract infections due to lack of documented assessment and education on safe self-flushing techniques.

The complaint investigation was substantiated, confirming the facility's failure to notify responsible parties in a timely manner about the outbreak.

The facility failed to timely notify residents' responsible parties about a Clostridium Difficile outbreak affecting four residents in isolation. The notification was delayed until 4/19/2022, despite the outbreak being identified on 4/15/2022, which posed potential harm to residents' health and psychosocial wellbeing.

The complaint investigation focused on Resident 1, who had multiple deficiencies including lack of a care plan for Levothyroxine, failure to monitor and treat an acute change of condition on 5/22/2021, and failure to collect ordered lab tests. Resident 1 was found unresponsive and later expired after hospital transfer. The investigation included interviews with nursing staff and review of medical records, confirming substantiated deficiencies.

The facility failed to develop a care plan for Levothyroxine for Resident 1, failed to monitor and provide timely medical intervention for Resident 1's acute change of condition on 5/22/2021, resulting in Resident 1 being found unresponsive and transferred to a hospital where Resident 1 later expired. Additionally, the facility failed to collect and report a thyroid stimulating hormone (TSH) lab test ordered for Resident 1, potentially delaying necessary care.

The facility was found deficient in multiple areas including resident care, infection control, dietary services, documentation, and safety practices. Deficiencies involved failure to maintain accurate medical records, improper infection control practices, inadequate dietary staffing and food handling, failure to provide appropriate care plans and equipment, and unsafe environmental conditions.