F-F641

Findings:

During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including; heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 056451 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of the facility's Policy and Procedures (P&P) titled Care Plan Comprehensive reviewed 10/21/24, the P&P indicated The facility's Interdisciplinary Team, in coordination with the resident and/or Level of Harm - Minimal harm or his/her family or representative, must developed and implement a comprehensive person-centered care plan potential for actual harm for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment . Each resident's Residents Affected - Few comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk and contributing factors associated with identified problems . g. Identify professional services that are responsible for each element of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 056451 

F-F656

Findings:

During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway).

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 REDACTED], 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 056451 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a concurrent interview and record review on 5/28/25 at 4:23 pm with Assistant Director of Nursing (ADON), the Resident 1's MDS Section I - Active Diagnoses dated 5/7/25 was reviewed. The ADON verified Level of Harm - Minimal harm or there was no diagnosis of OSA indicated on the assessment and stated it was missed. During the same potential for actual harm interview and record review of the MDS, Section O - Special Treatments, Procedures, and Programs was reviewed. The ADON verified BiPAP was not indicated as a special treatment on the assessment and stated Residents Affected - Few it should have been entered and it was missed.

During a review of the facility's Policy and Procedures (P&P) titled Resident Assessment reviewed 10/21/24,

the P&P indicated A comprehensive assessment of each resident is completed . Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident

observations/interviews.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 056451 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252

Residents Affected - Few Based on interview and record review the facility failed to develop a care plan for OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) for one of three sampled residents (Resident 1).

This failure resulted in no plan of care for Resident 1's OSA and had the potential to affect continuity and delivery of care.

Cross reference with