Windsor Gardens Convalescent Hospital
WINDSOR GARDENS CONVALESCENT HOSPITAL in LOS ANGELES, CA — inspection on March 2, 2025.
Found 3 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 an interview on 3/2/25 at 11:52 AM, the DON stated the facility failed to obtain informed consent prior to initiating therapy with divalproex for Resident 26.
The DON stated
the facility was required to obtain informed consent prior to use for any medication used to treat behavioral issues, whether it is a psychotropic medication or not.
The DON stated informed consent may have been missed for Resident 26's divalproex because it was not a traditional psychotropic medication.
The DON stated this increased the risk that Resident 26 might not have been able to exercise his right to opt out of treatment with divalproex and its risk of adverse effects such as drowsiness and dizziness which could lead to a decline in his quality of life.
A review of the facility's policy titled, Psychotropic medication Use, revised July 2022, indicated When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident.
The evaluation will attempt to clarify whether . the actual or intended benefit of the medication is understood by the resident/representative.
Residents (and/or representatives) have the right to decline treatment with psychotropic medications.
The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.
46144
b.
During a review of Resident 10's Admission Record, the Admission Record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included encephalopathy (brain disorder disease or damage that affects your brain's function or structure), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and post-traumatic stress disorder ([PTSD]- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).
During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 1/7/2025, the MDS indicated Resident 10's cognition (ability to learn, reason, remember, understand, and make decisions) was intact.
The MDS indicated Resident 10 required substantial assistance for showering, dressing, and toileting hygiene.
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 03/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
During an observation on 3/1/25 at 8:08 AM with the Licensed Vocational Nurse (LVN) 2, LVN 2 was observed pouring out 2.5 ml of carbamazepine 100 mg/5 ml suspension from a pharmacy bottle for Resident 48 labeled shake well into a small plastic dosage cup without first shaking the bottle.
During an observation on 3/1/25 at 8:25 AM, LVN 2 was observed attempting to administer the carbamazepine suspension to Resident 48 and was stopped by the surveyor and advised to discuss the medication preparation with the surveyor in the hallway.
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 03/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens Convalescent Hospital 915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
During an observation on 3/1/25 at 8:08 AM with the Licensed Vocational Nurse (LVN) 2, LVN 2 was observed pouring out 2.5 ml of carbamazepine 100 mg/5 ml suspension from a pharmacy bottle for Resident 48 labeled shake well into a small plastic dosage cup without first shaking the bottle.
During an observation on 3/1/25 at 8:25 AM, LVN 2 was observed attempting to administer the carbamazepine suspension to Resident 48 and was stopped by the surveyor and advised to discuss the medication preparation with the surveyor in the hallway.
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 03/02/2025
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.