Windsor Gardens Convalescent Hospital
WINDSOR GARDENS CONVALESCENT HOSPITAL in LOS ANGELES, CA — inspection on August 14, 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.
Inspection Findings
During an interview on 8/14/25 at 8:42 a.m., the director of nursing (DON) stated the nurses can do anything on their 30 minutes break.
However, the DON stated the staff are not allowed to sleep in the nurses' station because this is a place of work.
During an interview on 8/14/25 at 11:57 a.m., the director of staff development (DSD) stated staff can do what they want during their 30 minutes break. DSD further added for the staff who want to sleep during their 30-minute break should sleep in the break room and not in the nurses station.
During a review of the facility Policy titled Accommodation of Needs revised on 3/13/25 the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe, independent functioning, dignity and well-being.
The same Policy indicated the resident's individual needs and preferences will be accommodated to the extent possible except when the health and safety of the individual or other residents would be endangered.
During a review of the facility's policy and procedures (P&P) titled Answering the Call Light revised on 3/13/25, indicated answer the resident call system immediately.
When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name. If the resident needs assistance, indicate the approximate time it will take to respond. If the resident's request is something you can fulfill, complete the task within five minutes if possible.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Windsor Gardens Convalescent Hospital
915 S.
Crenshaw Blvd.
Los Angeles, CA 90019
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WINDSOR GARDENS CONVALESCENT HOSPITAL in LOS ANGELES, CA for a deficiency under regulatory tag F-F0658 during a complaint investigation conducted on 2025-08-14.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of WINDSOR GARDENS CONVALESCENT HOSPITAL.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-08-18.
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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.