Skip to main content
Complaint Investigation

Cheviot Hills Post Acute

May 28, 2025 · Los Angeles, CA · 3533 Motor Avenue
Citations 2
CMS Rating 2/5
Beds 99
Provider ID 056451
Healthcare Facility
Cheviot Hills Post Acute
Los Angeles, CA  ·  View full profile →
Inspection Summary

Cheviot Hills Post Acute in Los Angeles, CA — inspection on May 28, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF641
centered care plan Few comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk and affected

During a review of Resident 1's History and Physical (H&P) dated 5/2/25, the H&P indicated the resident during her hospital course patient was found to have hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome ([NAME]- a condition where individuals who are obese experience hypoventilation [reduced breathing]) /OSA treated with BiPAP (a breathing therapy that uses a small machine to deliver pressurized air through a mask worn over the nose or nose and mouth) with improvement and resolution of her metabolic (complex set of chemical reactions that occur within living organisms to maintain life)/hypercapnic (a condition where there is an abnormally high level of carbon dioxide [CO2- exhaled gas] in the blood) encephalopathy (condition affecting the brain).

During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/7/25, the MDS indicated Resident 1's had intact cognition (the mental processes involved with knowing, learning, reasoning, understanding).

The MDS further indicated Resident 1 was dependent on staff for bed mobility, bathing, dressing and personal hygiene and required supervision to partial moderate assistance for eating and oral hygiene respectively.

During a concurrent interview and record review with ADON on 5/28/25 at 4:23 pm, Resident 1's care plans were reviewed.

The ADON verified there was no care plan developed for OSA or BiPAP and stated it could affect the resident's overall health.

056451

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056451 B.

Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center of Cheviot Hills 3533 Motor Avenue Los Angeles, CA 90034

During a review of Resident 1's History and Physical (H&P) dated 5/2/25, the H&P indicated the resident during her hospital course patient was found to have hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome ([NAME]- a condition where individuals who are obese experience hypoventilation [reduced breathing]) /OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) treated with BiPAP (a breathing therapy that uses a small machine to deliver pressurized air through a mask worn over the nose or nose and mouth) with improvement and resolution of her metabolic (complex set of chemical reactions that occur within living organisms to maintain life)/hypercapnic (a condition where there is an abnormally high level of carbon dioxide [CO2- exhaled gas] in the blood) encephalopathy (condition affecting the brain).

During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's had intact cognition (the mental processes involved with knowing, learning, reasoning, understanding).

The MDS further indicated Resident 1 was dependent on staff for bed mobility, bathing, dressing and personal hygiene and required supervision to partial moderate assistance for eating and oral hygiene respectively.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056451

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056451 B.

Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Care Center of Cheviot Hills 3533 Motor Avenue Los Angeles, CA 90034

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Los Angeles, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cheviot Hills Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement