Windsor Gardens Convalescent Hospital
WINDSOR GARDENS CONVALESCENT HOSPITAL in LOS ANGELES, CA — inspection on July 18, 2024.
Found 7 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.
Inspection Findings
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.
056194 07/18/2024
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
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.
056194 07/18/2024
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
12/14/2023 indicated, Ensure the catheter is secured to the patient ' s upper thigh (female patient) or
flowing freely into it.
056194 07/18/2024
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
During an interview with Licensed Vocational Nurse 3 (LVN 3) on 7/17/2024 at 3:46 p.m., LVN 3 stated, she assisted with scheduling the licensed nurses staffing. LVN 3 stated, the facility only had one RN supervisor who was also the DON in the facility.
During an interview with DON on 7/17/2024 at 3:33 p.m., DON confirmed by stating she was the only RN staffed in the facility since she started as a DON about a month prior. DON stated the current role was her first job as a DON. DON further stated she did the RN supervisor job, including administering intravenous (IV) medications, admission, etc., as well as the DON ' s responsibility.
A review of facility ' s policy and procedure (P&P) titled, Director of Nursing Services (DNS) reviewed on 12/14/2023 indicated, the director is employed full-time (40 hours per week) and is responsible for, but is not necessarily limited to: . recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident .
The DNS (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
056194 07/18/2024
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
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.
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.
056194
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.
056194
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 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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.