LOS ANGELES, CA - Windsor Gardens Convalescent Hospital repeatedly administered dangerous blood pressure medications to a resident with critically low blood pressure readings, directly violating physician safety parameters designed to prevent life-threatening complications.
Dangerous Medication Administration Despite Low Blood Pressure
Federal inspectors documented multiple instances where nursing staff administered blood pressure medications to a resident whose systolic blood pressure fell well below the physician's established safety threshold of 110 mmHg. The resident received Entresto and carvedilol despite blood pressure readings as low as 103/74 and 106/46.
Licensed Vocational Nurse 6 administered carvedilol to the resident on February 16, 2025, when blood pressure was 103/74, and again on February 24, 2025, when it measured 106/46. Both readings fell below the 110 mmHg threshold that required holding the medication.
"When blood pressure medication was given outside of parameters, the outcome could be the resident's blood pressure would decrease drastically," the Director of Nursing told inspectors during the March 2025 survey.
When blood pressure medications are administered below safe parameters, patients face serious risks including hypotension, syncope (fainting), and vertigo. These conditions significantly increase fall risk in elderly nursing home residents, who already face heightened vulnerability due to age-related balance and mobility issues.
Medical Protocol Violations Put Residents at Risk
The facility's own policies required medications to be administered "in a safe and timely manner, and as prescribed" with adherence to "prescribed orders, including any required time frame." Physician orders specifically directed staff to hold both medications if systolic blood pressure dropped below 110 mmHg or heart rate fell below 60 beats per minute.
Licensed Vocational Nurse 5 explained the proper protocol to inspectors: "If a blood pressure was below the parameters, the nurses were to hold the medication and chart the reason why the medication was held. The nurses were to then call the doctor and notify family."
The nurse acknowledged the safety risks, stating that administering medications outside parameters "could cause a resident to become hypotensive, syncope, or vertigo which could lead to a fall."
Entresto, prescribed for the resident's congestive heart failure, works by blocking certain enzymes that can worsen heart failure symptoms. However, when given to patients with already low blood pressure, it can cause dangerous drops that compromise blood flow to vital organs.
Carvedilol, a beta-blocker used to treat high blood pressure and heart failure, specifically carries warnings about administration to patients with low blood pressure. The medication's mechanism of action includes reducing heart rate and blood vessel constriction, effects that can become dangerous when baseline blood pressure is already compromised.
Improper Medication Preparation Creates Dosing Risks
Inspectors also documented a separate medication safety violation involving carbamazepine, an anti-seizure medication prescribed for nerve pain. A Licensed Vocational Nurse was observed preparing the liquid suspension without first shaking the bottle, despite clear labeling requiring this step.
"All liquid medications in suspension form need to be shaken prior to preparing the dose because the medication separates from the vehicle," the nurse explained when questioned by inspectors.
The failure to shake suspension medications can result in patients receiving either too much or too little of the active ingredient, potentially leading to medical complications or inadequate pain control. Carbamazepine suspensions specifically require thorough mixing because the medication particles settle over time, creating uneven concentrations throughout the bottle.
Food Safety and Dietary Violations Compound Care Issues
Beyond medication errors, the facility failed to follow established menus and provide appropriate dietary accommodations. Kitchen staff served residents incorrect food items that deviated from both planned menus and special dietary requirements.
A vegan resident received mashed potatoes prepared with chicken bouillon powder, directly violating their plant-based dietary restrictions. Kitchen staff acknowledged they had not prepared any vegan menu items for the resident despite documented dietary orders.
"Chicken is not on vegetarian diet," one cook admitted to inspectors when questioned about the preparation method.
Six residents on renal diets received peas instead of the planned oven French fries, while another resident received boiled diced chicken instead of the baked chicken specified on the menu for fish alternatives.
Infection Control Failures During Wound Care
Treatment nurses violated basic infection control protocols during wound care procedures for a resident with multiple ulcers. Inspectors observed a nurse failing to change gloves between removing soiled dressings and applying clean ones, creating cross-contamination risks.
"When I removed the soiled dressing, I should change the gloves before cleaning the wound," the treatment nurse acknowledged when questioned about proper protocol.
The resident being treated had arterial ulcers on both feet and a pressure ulcer on the buttocks, conditions requiring strict aseptic technique to prevent infection and promote healing.
Equipment Safety Hazards in Food Preparation
Kitchen equipment posed additional safety risks, with inspectors finding a can opener blade that was "worn and dented" with "brown residue and metal shavings." The Dietary Supervisor acknowledged the contamination risk and committed to immediate replacement.
Damaged can openers can introduce metal fragments into food and harbor harmful bacteria in areas that cannot be properly cleaned or sanitized.
Regulatory Standards and Expectations
Federal regulations require nursing homes to ensure medications are administered safely according to physician orders and that residents receive proper nutrition tailored to their individual needs. The violations documented at Windsor Gardens represent fundamental failures in basic care protocols that protect resident safety and health.
Proper medication administration requires verification of the "five rights": right resident, right medication, right dosage, right time, and right route. Safety parameters established by physicians serve as additional safeguards to prevent adverse drug events in vulnerable populations.
The facility's violations received citations for minimal harm with potential for actual harm, indicating that while no residents suffered documented injuries, the practices created significant risk for serious complications.
Windsor Gardens must develop and implement corrective action plans addressing each violation area, including staff retraining on medication administration protocols, dietary accommodation procedures, infection control practices, and equipment maintenance standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Gardens Convalescent Hospital from 2025-03-02 including all violations, facility responses, and corrective action plans.
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