Windsor Gardens: Failed Neurologist Visits, Poor Care - CA
The resident, admitted June 19 with spinal stenosis and recent lumbar spine fusion, was ordered to see a neurologist on June 24 for post-surgical follow-up. But when staff tried to transfer the patient to a wheelchair that day, the resident was "in too much pain" and the transfer was halted.
The appointment was canceled because it was "too late to get gurney transportation" and the resident "may not tolerate being in wheelchair for over three hours," according to nursing notes.
A second appointment scheduled for July 9 also failed when "transportation was no show with no explanation."
The facility's Director of Nursing told inspectors the resident "was placed at risk of infection, blood clots and the resident could decline since Resident 1 had not been seen by the surgeon regarding the resident's recent surgery."
Communication breakdowns plagued the process from the start. The Social Services Director, who arranged the initial transportation, said "it was not communicated with her" that the resident needed a gurney instead of a wheelchair. The MDS Nurse Coordinator who input the physician's order said she "did not communicate with the clinical nursing department" about the gurney requirement.
Nobody held an interdisciplinary team meeting when the resident was admitted, despite facility policy requiring such meetings to coordinate care.
The resident required maximum assistance for all daily activities and had intact cognitive function, meaning they understood what was happening but couldn't advocate effectively for proper transportation arrangements.
Federal inspectors also found Windsor Gardens failed to develop required care plans for two residents with specific medical needs.
The first resident, the same spine surgery patient, had an indwelling catheter but no care plan addressing catheter management until July 18 — nearly a month after admission. A Licensed Vocational Nurse confirmed "there was no care plan developed for Resident 1's foley catheter" and said one "should have been developed regarding foley catheter care and treatment upon admission."
The second resident was approved to self-administer oral, nasal, and inhaler medications due to limited range of motion, but the facility created no care plan for medication self-administration. The resident had a care plan for "non-compliance manifested by keeping medication at bedside" but nothing addressing the approved self-medication program.
A Licensed Vocational Nurse confirmed "there was no care plan developed regarding Resident 2's self-administration of medication and storing his own medications at bedside."
Facility policy requires comprehensive care plans within seven days of completing resident assessments, with ongoing reviews as conditions change. The policy states plans must include "measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs."
Inspectors observed additional catheter care violations during their July visit. They found the spine surgery patient's catheter bag positioned above bladder level, which can cause urine to flow backward and increase infection risk. Proper catheter care requires the drainage bag to remain below the bladder at all times.
The facility's Social Services policy specifically states that social services "will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate." But the coordination failures left a post-surgical patient without necessary specialist follow-up for over a month.
By July 18, when inspectors completed their review, the neurologist appointment had been rescheduled to July 29 — more than five weeks after the original June 24 date ordered by the physician.
The resident's physical therapy evaluation from June 20 noted "reduced ability to safely perform functional bed mobility and transfer tasks, reduced balance, and reduced functional activity tolerance, causing an increased need for assistance from others." These limitations made wheelchair transport impossible, yet staff failed to communicate this crucial information when arranging medical appointments.
Windsor Gardens' failures illustrate how communication breakdowns between departments can leave vulnerable residents without essential medical care, particularly when multiple staff members handle different aspects of care coordination without adequate oversight or team meetings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Gardens Convalescent Hospital from 2024-07-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WINDSOR GARDENS CONVALESCENT HOSPITAL in LOS ANGELES, CA was cited for violations during a health inspection on July 18, 2024.
The resident, admitted June 19 with spinal stenosis and recent lumbar spine fusion, was ordered to see a neurologist on June 24 for post-surgical follow-up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.