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Complaint Investigation

Windsor Gardens Convalescent Hospital

August 14, 2025 · Los Angeles, CA · 915 S. Crenshaw Blvd.
Citations 2
CMS Rating 3/5
Beds 98
Provider ID 056194
Healthcare Facility
Windsor Gardens Convalescent Hospital
Los Angeles, CA  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0558
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINDSOR GARDENS CONVALESCENT HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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