Federal Nursing-Home Survey Record
WINDSOR GARDENS CONVALESCENT HOSPITAL
Does WINDSOR GARDENS CONVALESCENT HOSPITAL have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), WINDSOR GARDENS CONVALESCENT HOSPITAL (CCN 056194), in LOS ANGELES, CA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 21 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $37,882 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
CMS has $37,882 in civil money penalties on file against this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$37,882
CMS has $37,882 in civil money penalties on file against this facility. CMS also records 18 day(s) of payment denial.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 3 · CMS state average: 3.2
Deficiency timeline — full federal history
Reasonably accommodate the needs and preferences of each resident.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Reasonably accommodate the needs and preferences of each resident.
Provide and implement an infection prevention and control program.
Ensure that residents are free from significant medication errors.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Ensure each resident receives an accurate assessment.
Ensure medication error rates are not 5 percent or greater.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure that residents are fully informed and understand their health status, care and treatments.
Assist a resident in gaining access to vision and hearing services.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
39 citations from earlier inspection cycles — historical, not current (expand)
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Ensure that residents are free from significant medication errors.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Provide safe and appropriate respiratory care for a resident when needed.
Provide and implement an infection prevention and control program.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Ensure services provided by the nursing facility meet professional standards of quality.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Reasonably accommodate the needs and preferences of each resident.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that residents are free from significant medication errors.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Post nurse staffing information every day.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that residents are fully informed and understand their health status, care and treatments.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide safe and appropriate respiratory care for a resident when needed.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Document what happened
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