WINDSOR GARDENS CONVALESCENT HOSPITAL

Los Angeles · CA · For profit - Limited Liability company · WINDSOR chain · 98 certified beds · CCN 056194 · WINDSOR GARDENS CONVALESCENT HOSPITAL INC


WINDSOR GARDENS CONVALESCENT HOSPITAL operates 98 certified beds in LOS ANGELES, California. Its Medicare and Medicaid certification dates to 1972-06-01. It averages 92.0 residents a day.

What harm was found in the violations cited at WINDSOR GARDENS CONVALESCENT HOSPITAL?

CMS lists 90 health-inspection deficiencies for WINDSOR GARDENS CONVALESCENT HOSPITAL, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-04-16.

Survey dateTagDeficiencySeverity
2026-04-16F0605, F0656, F0812, F0880, F0887Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.E
2026-04-16F0561, F0580, F0583, F0584, F0641, F0684, F0685, F0689, F0692, F0693, F0700, F0740, F0755, F0756, F0761, F0802, F0842, F0883, F0919Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Keep residents' personal and medical records private and confidential. / Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. / Ensure each resident receives an accurate assessment. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Assist a resident in gaining access to vision and hearing services. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / 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. / Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Make sure that a working call system is available in each resident's bathroom and bathing area.D
2025-08-14F0558Reasonably accommodate the needs and preferences of each resident.E
2025-08-14F0658Ensure services provided by the nursing facility meet professional standards of quality.D
2025-07-29F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D
2025-03-02F0803, F0805, F0812Ensure 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E
2025-03-02F0552, F0558, F0636, F0641, F0657, F0677, F0685, F0686, F0690, F0693, F0757, F0758, F0759, F0760, F0880Ensure that residents are fully informed and understand their health status, care and treatments. / Reasonably accommodate the needs and preferences of each resident. / 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. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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. / 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. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / 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. / Ensure medication error rates are not 5 percent or greater. / Ensure that residents are free from significant medication errors. / Provide and implement an infection prevention and control program.D
2025-02-12F0573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.D
2025-01-24F0760Ensure that residents are free from significant medication errors.D
2024-11-05F0578Honor 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.D
2024-10-30F0626Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.D
2024-08-15F0695Provide safe and appropriate respiratory care for a resident when needed.D
2024-08-01F0880Provide and implement an infection prevention and control program.D
2024-07-18F0727Have 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.F
2024-07-18F0656, F0684, F0690, F0755Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D
2024-07-02F0609, F0744Timely 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.D
2024-06-07F0658, F0835Ensure 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.D
2024-04-22F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.E
2024-04-22F0585, F0656, F0755Honor 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. / 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.D
2024-03-08F0755, F0758Provide 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.E
2024-03-08F0558Reasonably accommodate the needs and preferences of each resident.D
2024-03-06F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-03-06F0760Ensure that residents are free from significant medication errors.D
2024-02-23F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D
2024-02-08F0578, F0656, F0732Honor 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. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Post nurse staffing information every day.E
2024-02-08F0550, F0552, F0644, F0676, F0686, F0695, F0761Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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 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. / Provide safe and appropriate respiratory care for a resident when 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.D
2024-01-23F0658, F0684, F0806, F0919Ensure 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. / Make sure that a working call system is available in each resident's bathroom and bathing area.D
2024-01-05F0755, F0761Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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.D
2023-12-04F0610Respond appropriately to all alleged violations.D
2023-11-04F0600, F0684Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide appropriate treatment and care according to orders, resident’s preferences and goals.G
2023-08-25F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D

Why was WINDSOR GARDENS CONVALESCENT HOSPITAL fined?

DateTypeAmount
2024-01-23Fine$37,882

Has WINDSOR GARDENS CONVALESCENT HOSPITAL had payment denied by Medicare?

Payment denial startLength in days
2023-12-1518

How is WINDSOR GARDENS CONVALESCENT HOSPITAL staffed relative to the CA average?

MeasureThis facilityCA average
Total nurse staffing hours per resident per day3.840864.51570
Total nursing staff turnover (%)51.936.7
Average number of residents per day92.087.9

Who owns WINDSOR GARDENS CONVALESCENT HOSPITAL, and what chain is it in?

WINDSOR GARDENS CONVALESCENT HOSPITAL is registered with CMS as For profit - Limited Liability company, operates under the legal business name WINDSOR GARDENS CONVALESCENT HOSPITAL INC and belongs to the WINDSOR chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTANTELOPE HOLDINGS II, LLC, ANTELOPE HOLDINGS III, LLCsince 06/30/2023
5% OR GREATER INDIRECT OWNERSHIP INTERESTROBIN, AARON, TRESS, AVROHOMsince 06/30/2023
CORPORATE DIRECTORROBIN, AARON, TRESS, AVROHOMsince 08/09/2023
CORPORATE OFFICERROBIN, AARON, TRESS, AVROHOMsince 08/14/2023
OPERATIONAL/MANAGERIAL CONTROLNEWGEN ADMINISTRATIVE SERVICES, LLC, HOURANI, JAMEEL, MEKONNEN, GEDYON, SHAW, PAMELAsince 02/01/1995
ADP OF THE SNFNEWGEN ADMINISTRATIVE SERVICES, LLC, HOURANI, JAMEEL, MEKONNEN, GEDYON, SHAW, PAMELAsince 02/01/1995

Were you or a family member harmed at WINDSOR GARDENS CONVALESCENT HOSPITAL?