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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 57 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 35% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. The latest standard survey recorded 27 findings, above the CA average of 15.4. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Families often praise the admissions team, specifically Tania, for being exceptionally helpful, compassionate, and professional during the transition process. While many reviewers highlight high-quality medical care from Dr. Hourani and a clean environment, there are serious, recurring allegations regarding nighttime neglect, wound care mismanagement, and communication breakdowns with families.
Quality Themes
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Concerns
Rating Trends
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Distribution · 60 analyzed
The owner uses templated, polite responses for positive reviews that fail to acknowledge specific details mentioned by reviewers. For negative reviews, they provide a standardized redirection to private channels due to privacy regulations.
Personalized based on this facility's data
Key Review Excerpts
“Windsor Gardens saved my wife’s life. Under the direction of care of the incredible Dr. Hourani, the staff gave my wife wonderful care and comfort.”
“I was a patient at this facility which for a 34 year old can be an unpleasant experience, but the staff here made it bearable and were extremely kind and helpful.”
“I’m I current resident here they do not take care of patients at nighttime I have my call button pressed since 245AM it is now 627am and still no help”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 16 measures
9
measures
6
measures
1
measures
Residents whose bladder or bowel control got worse
Residents vaccinated for the flu
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility has significant concerns with families filing 55 complaint-triggered deficiencies across 108 total violations. The most recurring problems involve medication management errors, inadequate care planning and treatment, and issues with resident rights and dignity. While all deficiencies show correction dates, the persistent pattern of medication errors and care quality issues across multiple recent surveys suggests ongoing operational challenges that families should carefully evaluate before placement.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Nutrition and Dietary Deficiencies
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.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
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.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Federal Penalties
Fine
Jan 23, 2024
$37,882
Payment Denial
Nov 4, 2023
18-day denial
Windsor Gardens Convalescent Hospital
for profit
Windsor
23 facilities nationwide
Chain avg rating: 2.3/5 · Rank 9 of 19
Owners
Antelope Holdings II, LLC
Owner · Organization
Antelope Holdings III, LLC
Owner · Organization
9560 Pico LLC
Owner (parent company) · Organization
Pico Ar LLC
Owner (parent company) · Organization
Robin, Aaron
Owner (parent company)
Tress, Avrohom
Owner (parent company)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
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Google Reviews
57 reviews from families & visitors
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