Windsor Gardens Convalescent Hospital

F-F656

Findings:

A review of Resident 2 ' s Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing food or liquid) and type two diabetes mellitus (DM II-a chronic condition that affects the way the body processes blood sugar [glucose]).

A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 6/20/2024, indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact for daily decision-making and required maximal assistance from staff for activities of daily living (ADL- oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene).

A review of Resident 2 ' s Medication Self-Administration Evaluation, dated 3/28/2024 indicated, Resident (2) was approved to administer oral, nasal, and inhaler medication only, as resident range of motion (ROM) was too limited to administer other medication.

A review of Resident 2 ' s Care Plan (CP) for non-compliance manifested by keeping medication at bedside, initiated on 3/27/2024 indicated a goal of Resident 2 complying with facility ' s policy/protocols, Medical Doctor (MD) ' s orders daily with interventions including documenting resident ' s response to specific non-compliance as needed, notifying of any risk/consequences in result of non-compliance and providing redirection as needed. A further review of Resident 2 ' s CP indicated, there was no CP implemented regarding Resident 2 ' s self-administration of oral, nasal and inhaler medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 056194 Department of Health & Human Services Printed: 09/17/2025 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 056194 B. Wing 07/18/2024

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

Windsor Gardens Convalescent Hospital 915 S. Crenshaw Blvd. Los Angeles, CA 90019

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 0755 A review of Resident 2 ' s Order Summary Report, as of 7/18/2024 indicated, there was no physician order for Tums and lactulose oral solution, there was also no physician ' s order that Resident 2 was allowed to Level of Harm - Minimal harm or keep and store personal medications at bedside. potential for actual harm

During a concurrent observation and interview with Resident 2 on 7/17/2024 at 2:44 p.m., Resident 2 was Residents Affected - Few observed with a Tums bottle containing three tablets of Tums and a small green tablet on top of Resident 2 ' s bedside table, as well as a lactulose oral solution on another bedside tablet. Resident 2 stated, he took his Tums every two hours and nurses were aware that the resident kept his medications at bedside and self-administered medication.

During a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 7/17/2024 at 2:53 p.m. and

observation of Resident 2, LVN 2 observed Resident 2 ' s Tums bottle with 4 tablets on top Resident 2 ' s bedside table and a lactulose bottle on another bedside tablet. LVN 2 stated Resident 2 was not allowed to take or keep his own medications at bedside. LVN 2 stated there had to be a self-administration assessment completed, a care plan and a physician ' s order when residents wished to take his/her own. LVN 2 reviewed Resident 2 ' s physician ' s orders and verified there was no physician ' s orders indicating Resident 2 could keep his own medications or self-administer them.

During an interview with Director of Nursing (DON) on 7/18/2024 at 3:33 p.m., DON stated there had to be

an order in place if resident wished to take his own medication at bedside. DON stated a care plan also had to be in place as the resident was at risk of complications due to medications.

A review of the facility ' s P&P titled, Self-Administration of Medications, reviewed on 12/14/2023 indicated,

The Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: the medication is appropriate for self-administration; the resident is able to read and understand medication labels; the resident can follow directions and tell times to know when to take the medication; the resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report

these to the staff; the resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow the medications; and the resident is able to safely and securely store the medication . if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . for self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken.

A review of the facility ' s P&P titled, Bedside Medication Storage, reviewed on 12/14/2023 indicated, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility ' s interdisciplinary resident assessment team . bedside storage of medication is indicated on the resident medication administration record (MAR) and the medication label for the appropriate medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 056194

F-F755

Findings:

1. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 6/19/2024 with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), fusion of spine (refers to various spinal surgery techniques that connect two or more vertebrae in the lumbar spine [lower back]), lumbar region (lower back), and hypertension (HTN - elevated blood pressure).

A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 6/26/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required maximal assistance to dependence from staff for activities of daily living (ADLs- toileting hygiene, shower/bathe self, upper and lower body dressing, mobility/repositioning: sit to lying, sit to stand and rolling left to right). The MDS indicated, Resident 1 had an indwelling foley catheter.

A review of Resident 1 ' s complete care plans indicated there no CP created or implemented upon admission which was on 6/19/2024.

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 9 056194 Department of Health & Human Services Printed: 09/17/2025 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 056194 B. Wing 07/18/2024

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

Windsor Gardens Convalescent Hospital 915 S. Crenshaw Blvd. Los Angeles, CA 90019

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 A review of Resident 1 ' s Care Plan for indwelling catheter for need of exact measurement of urine output, initiated on 7/18/2024, indicated a goal of the having minimized risk for complications from indwelling Level of Harm - Minimal harm or catheter, with interventions including to secure catheter to facilitate urine flow. potential for actual harm

During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 7/17/2024 at 2:35 p.m., and Residents Affected - Few record review of Resident 1 ' s CP, LVN 1 reviewed Resident 1 ' s CP and stated, there was no CP developed for Resident 1 ' s foley catheter. LVN 1 further stated, the CP should have been developed regarding foley catheter care and treatment upon admission, as Resident 1 was admitted with a foley catheter.

2. A review of Resident 2 ' s Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), dysphagia (difficulty swallowing food or liquid) and type two diabetes mellitus (DM II-a chronic condition that affects the way the body processes blood sugar [glucose]).

A review of Resident 2's MDS dated [DATE REDACTED], indicated Resident 2 ' s cognition was intact for daily decision-making and required maximal assistance from staff for activities of daily living.

A review of Resident 2 ' s Medication Self-Administration Evaluation, dated 3/28/2024 indicated, Resident (2) was approved to administer oral, nasal, and inhaler medication only, as resident ' s range of motion (ROM) was too limited to administer other medication.

A review of Resident 2 ' s CP for non-compliance manifested by keeping medication at bedside, initiated on 3/27/2024 indicated a goal that Resident (2) would comply with facility ' s policy/protocols, Medical Doctor (MD) ' s orders daily with interventions including document resident ' s response to specific non-compliance as needed, notify of any risk/consequences in result of non-compliance and provide redirection as needed. A further review of Resident 2 ' s CP indicated, there was no CP implemented regarding Resident 2 ' s self-administration of oral, nasal and inhaler medications.

During a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 7/17/2024 at 2:53 p.m., LVN 2 stated, there was no CP developed regarding Resident 2 ' s self-administration of medication and storing his own medications at bedside.

A review of facility ' s policy and procedures (P&P), titled, Care Plan Comprehensive reviewed on 12/14/2023 indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, physical, mental, and psychosocial needs shall be developed for each resident . The resident ' s comprehensive care plan is developed within seven days of the completion of the resident ' s comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and resident ' s condition change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 9 056194 Department of Health & Human Services Printed: 09/17/2025 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 056194 B. Wing 07/18/2024

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

Windsor Gardens Convalescent Hospital 915 S. Crenshaw Blvd. Los Angeles, CA 90019

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454 potential for actual harm Based on interview and record review, the facility failed to ensure that one of six sampled residents, Residents Affected - Few (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure a physician ' s order dated 6/21/2024 indicating Resident was to be seen by a Neurologist (a medical doctor who diagnoses, treats and manages disorders of the brain and nervous system) on 6/24/2024. Resident 1 was not seen by the Neurologist.

This deficient practice resulted to failure in the delivery of necessary care and services for Resident 1.

Findings:

A review of Resident 1 ' s Admission Record indicated resident was admitted to the facility on [DATE REDACTED] with diagnoses including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), fusion of spine (refers to various spinal surgery techniques that connect two or more vertebrae in the lumbar spine [lower back]), lumbar region (lower back), and hypertension (HTN - elevated blood pressure).

A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 6/26/2024, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required maximal assistance to dependence from staff for activities of daily living (ADLs- toileting hygiene, shower/bathe self, upper and lower body dressing, mobility/repositioning: sit to lying, sit to stand and rolling left to right).

A review of Resident 1 ' s Physical Therapy Evaluation and Plan of Treatment dated 6/20/2024 indicated, Patient (Resident 1) demonstrated 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 and reduced ADL participation.

A review of Resident 1 ' s Order Summary Report dated 6/21/2024 indicated, physician ordered, appointment with Neurologist on 6/24/2024.

A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Meeting Notes, as of 7/18/2024, indicated there was no IDT meeting notes conducted upon Resident 1 ' s admission.

A review of Resident 1 ' s Progress Notes indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 056194 Department of Health & Human Services Printed: 09/17/2025 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 056194 B. Wing 07/18/2024

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

Windsor Gardens Convalescent Hospital 915 S. Crenshaw Blvd. Los Angeles, CA 90019

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 0684 i. dated 6/24/2024 at 5:49 p.m., indicated, Resident (1) had appointment today with the Neurologist 1 (a medical doctor who diagnoses, treats, and manages disorders of the brain and nervous system [brain, spinal Level of Harm - Minimal harm or cord, and nerves]) for surgery follow-up . Resident (1) was attempted to transfer to wheelchair (w/c), but potential for actual harm resident was in too much pain. Transfer was halted and requested for appointment to be rescheduled until gurney (a hospital bed with wheels that makes it easy to move patients around) transportation could be Residents Affected - Few arranged.

ii. dated 6/24/2024 at 5:42 p.m., indicated, Resident (1) was reported by nursing staff that resident is complaining about pain . recommended for Resident (1) to go with gurney, it was too late to get her gurney transportation and she may not tolerate being in w/c for over three hours.

iii. dated 7/9/2024 at 1:7 p.m., Resident 1 had appointment with the Neurologist 1 . transport via gurney . transportation was no show with no explanation.

iv. Dated 7/11/2024 at 8:16 p.m., Resident (1) was supposed to go for neurologist appointment on 7/9/2024,

the transportation did not show up . rescheduled the neurologist appointment for 7/29/2024.

During an interview with Licensed Vocational Nurse 1 (LVN 1) on 7/17/2024 at 2:40 p.m., LVN 1 stated, Resident 1 ' s neurologist appointment was rescheduled due to Resident 1 ' s inability to tolerate sitting in a w/c for a long period of time due to pain. LVN 1 stated she did not remember having to talk to the Social Services Department and Minimum Data Set Nurse Coordinator (MDSN) regarding setting-up the neurologist appointment.

During an interview with Social Services Director (SSD) on 7/18/2024 at 2:00 p.m., SSD stated, when the initial transportation appointment was ordered, it did not indicate Resident 1 needed a gurney instead of a w/c. SSD stated, it was not communicated with her when she arranged the transportation on 6/24/2024. SSD further stated, there was no IDT meeting notes conducted upon admission and they were not aware that Resident 1 was unable to tolerate siting for a long period of time on a w/c due to recent surgery.

During an interview with MDSN on 7/18/2024 at 1:44 p.m., MDSN stated, she coordinated Resident 1 ' s neurologist appointment and inputted the physician ' s order in the system. MDSN stated, she did not communicate with the clinical nursing department Resident 1 required a gurney transportation.

During an interview with Director of Nursing (DON) on 7/18/2024 at 3:33 p.m., DON stated, the IDT meeting should have discussed Resident 1 ' s treatment so that everyone in the team was aware of Resident 1 ' s needs. DON stated, the facility should have provided the transportation for Resident 1 especially if they knew that there was an issue with transportation the second time it was arranged and especially if it pertained to a follow-up appointment with a surgeon after a surgery. DON stated, Resident 1 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.

A review of the facility ' s policy and procedure (P&P) titled, Referrals, Social Services, reviewed on 12/14/2023 indicated, Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 056194 Department of Health & Human Services Printed: 09/17/2025 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 056194 B. Wing 07/18/2024

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

Windsor Gardens Convalescent Hospital 915 S. Crenshaw Blvd. Los Angeles, CA 90019

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 1) by failing to ensure Resident 1 ' s indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times.

This deficient practice had the potential to result or resulted in urinary tract infections for Resident 1.

Cross Reference