The March 2025 inspection revealed the Los Angeles facility failed to obtain proper consent before administering powerful psychiatric medications to residents with schizophrenia and bipolar disorder. Federal inspectors documented multiple cases where staff gave antipsychotic drugs without completing required disclosure forms or explaining risks to patients or their representatives.
Resident 26, diagnosed with schizophrenia and bipolar disorder, received divalproex for mood swings starting December 27, 2024, without any documentation that he or a responsible party understood the medication's risks and benefits. The drug treats rapid emotional fluctuations from calmness to anger.
The Director of Nursing told inspectors the facility failed to obtain informed consent because divalproex "was not a traditional psychotropic medication." She acknowledged this prevented Resident 26 from exercising his right to refuse treatment and increased his risk of adverse effects including drowsiness and dizziness.
Resident 10 received monthly injections of Aripiprazole Lauroxil without a completed consent form. The February 15, 2025 disclosure document contained no resident signature. Staff confirmed the resident had intact cognitive abilities but administered the antipsychotic medication anyway.
"The purpose of the consent was to ensure Resident 10 was aware of the medication's risks," the Director of Nursing stated. "If Resident 10 knew the risks and benefits, the resident would be able to tell facility staff about side effects if the resident were to have them."
A third psychiatric medication case involved Resident 43, whose aripiprazole dose doubled from 10 mg to 20 mg when she returned from the hospital in February. The Director of Nursing called the increase "likely unintentional," explaining staff continued the hospital's 20 mg dose instead of the 10 mg she had been receiving before hospitalization. No clinical justification existed for the higher dose.
The unintended increase exposed Resident 43 to greater risks of movement disorders, drowsiness, dizziness, and blurry vision. She had been receiving the excessive dose since February 20, 2025.
Beyond medication consent failures, inspectors found the facility's overall medication error rate of 7.69 percent exceeded federal standards. During observations of 26 medication administration opportunities, staff made two significant errors.
A nurse attempted to give Resident 48 carbamazepine suspension without first shaking the bottle. Liquid suspensions require agitation to ensure the medication is properly distributed throughout the liquid.
Staff gave Resident 19 the wrong formulation of multivitamins during the medication pass.
Basic care standards also faltered throughout the facility. Resident 27, who has dementia and cannot make medical decisions, was found with her call light hanging toward the floor, out of reach. Staff acknowledged this placed her at risk for falls if she attempted to get up without assistance.
Two residents had excessively long and dirty fingernails during inspection. Resident 22's certified nursing assistant admitted the nails were "long with some dirt" and acknowledged this created risks for scratching and skin breakdown. The assistant explained dirty fingernails could harbor microbes leading to skin infections.
Resident 47's fingernails were similarly unkempt. The same nursing assistant promised to trim them "after lunch."
The facility's infection control policies require daily nail cleaning and regular trimming to prevent skin problems and accidental injuries from scratching.
Equipment failures compounded care problems. Resident 341's low air loss mattress was set for a 325-pound person despite physician orders specifying 113 pounds. The incorrect setting increased pressure ulcer risks for the resident, who already had an unstageable pressure wound covered by dead tissue.
Staff failed to properly monitor a resident's feeding tube, allowing formula to leak onto his skin and bedding for hours. The certified nursing assistant responsible said she only checked if residents were "alive" during assessments, not whether their medical equipment functioned properly.
"I do not assess the resident's body. I assess the face to see if they are alive," the assistant told inspectors.
The leaking feeding tube soaked towels and wet the resident's skin, creating risks for malnutrition and skin breakdown since the nutrition wasn't reaching his stomach.
Documentation failures extended to basic medication tracking. Staff couldn't show when nicotine patches were removed from Resident 10 after the required 24-hour application period. Without removal documentation, subsequent shifts had no way of knowing whether patches were effective or still in place.
A resident with an indwelling catheter showed cloudy sediment in his urine tubing, but staff never notified his physician despite care plans requiring such reporting. The Licensed Vocational Nurse acknowledged the sediment indicated possible infection requiring medical attention.
"A resident can get a UTI if it's not addressed to the MD," the nurse stated.
Assessment accuracy problems affected care planning when staff failed to include schizophrenia, depression, and bipolar disorder diagnoses in Resident 26's November 2024 assessment. His medical record clearly documented all three conditions and corresponding medications, but the assessment marked him as having none of these psychiatric disorders.
The Director of Nursing confirmed the assessment was "inaccurate compared to his medical records" and could interfere with proper care planning, potentially causing "a decline in his quality of life due to potential unmet needs."
One resident requiring hearing aids was repeatedly observed without them, unable to communicate effectively with staff. Her care plan specified daily hearing aid placement, but the devices remained in the medication cart. Staff said she "did not like wearing her hearing aids" but acknowledged they should be offered daily.
A dialysis patient taking both aspirin and Eliquis for blood clot prevention received no monitoring for bleeding or bruising risks despite his care plan identifying him as "high risk" for these complications. The Director of Nursing emphasized this was "very important because his frequent dialysis port access further increases his risk for bleeding."
The facility's own policies required monitoring for bleeding complications in patients on blood thinning medications, but staff documented no such assessments between February 3 and February 28, 2025.
Care plan revisions lagged behind changing resident needs. When the hearing aid patient began refusing the devices, staff never updated her care plan to address the refusal or establish alternative communication strategies.
Similarly, when Resident 10 began receiving nicotine patches, his smoking-related care plan was never revised to include monitoring and removal protocols for the patches.
The inspection covered multiple areas of resident care and safety, revealing systemic problems with medication management, basic hygiene assistance, equipment monitoring, and care plan accuracy. The facility's policies existed but weren't consistently followed, leaving vulnerable residents at risk for medical complications and declining quality of life.
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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