Cycle 1
Health 2025-03-02 · Fire 2025-03-02
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Los Angeles, CA
Windsor Gardens Convalescent Hospital
2-star overall rating with 2-star inspections with $37,882 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
915 S. Crenshaw Blvd., Los Angeles, CA
(323) 937-5466
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Windsor
Operator or chain grouping
Approved since
1972-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,330
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.70
Baseline 20.38% · Performance 21.11% · Measure score 0.70 · Achievement 0.70 · Improvement 0
Healthcare-associated infections
0
Baseline 7.18% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 45.05% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.90
Baseline 3.81 hours · Performance 3.62 hours · Measure score 1.90 · Achievement 1.90 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.84% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 23.08% · Lower 95% interval 8.74% |
| Discharge to community | 34.08% |
50.57%
16.5 pts worse
|
Worse than the National Rate · Eligible stays 68 · Observed rate 19.12% · Lower 95% interval 23.14% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96.61% |
95.27%
1.3 pts better
|
Numerator 57 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 11 · Denominator 33 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 11 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 59 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.94% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 18.9% |
8.2%
10.7 pts better
|
Numerator 24 · Denominator 127 |
| Staff flu vaccination coverage | 14.56% |
42%
27.4 pts worse
|
Numerator 15 · Denominator 103 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 15 · Denominator 33 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 20 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.57% |
25.2%
23.4 pts better
|
Numerator 17 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.3
0.5 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 4.5 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.2% |
98.5%
13.3 pts worse
|
93.4%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 84.5% · Q3 90.0% · Q4 90.0% · 4Q avg 85.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.8% |
98.2%
15.4 pts worse
|
95.5%
12.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
1.6%
1.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
6.8%
2.9 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 3.0% · Q3 8.2% · Q4 13.0% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
4.1%
2.5 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.4% · Q3 7.1% · Q4 5.6% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
13.7%
4.4 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 10.0% · Q3 7.9% · Q4 11.5% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
14.2%
4.3 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 15.0% · Q3 7.5% · Q4 6.8% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.9% |
11.0%
4.1 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.1% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
10.7%
6 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.3% · Q3 3.3% · Q4 9.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
10.9%
5.9 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.2% · Q3 2.9% · Q4 2.9% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.7%
3.3 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 12.0% · Q3 6.1% · Q4 5.4% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.0% |
94.0%
51 pts worse
|
81.7%
38.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 39.7% · Q3 45.3% · Q4 50.0% · 4Q avg 43.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
11.2%
4.1 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 8.3% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.8% |
93.2%
45.4 pts worse
|
79.7%
31.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
23.2%
2.7 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 31.2% · Expected 28.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
34 health deficiencies
Top issue: Resident Rights (9 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2021-05-07 · Fire 2021-05-07
45 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-02-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-08
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-07
C · Minimal harm
2024-02-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-07
D · Potential for more than minimal harm
2021-05-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-08-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-03-02
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-02
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F693 · Quality of Life and Care Deficiencies
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.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-12
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-11-05
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-10-30
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-08-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-18
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-07-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-02
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-06
E · Potential for more than minimal harm
2024-04-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-22
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-03-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-08
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
G · Actual harm
2024-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-03-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-08
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-02-08
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-03-07
D · Potential for more than minimal harm
2024-01-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-23
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-20
D · Potential for more than minimal harm
2024-01-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-20
D · Potential for more than minimal harm
2023-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-02
G · Actual harm
2023-11-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-04
G · Actual harm
2023-11-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-08-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-09
D · Potential for more than minimal harm
2023-06-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-09
D · Potential for more than minimal harm
2023-06-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-09
D · Potential for more than minimal harm
2023-06-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-04-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-05
G · Actual harm
2023-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-04-27
F · Potential for more than minimal harm
2021-05-07
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2021-06-03
F · Potential for more than minimal harm
2021-05-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2021-06-03
E · Potential for more than minimal harm
2021-05-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F693 · Quality of Life and Care Deficiencies
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.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-06-03
D · Potential for more than minimal harm
2021-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-03
Penalties and ownership
What sits behind the stars
$37,882
2024-01-23
Fine
Fine · fine $37,882
Fine
$0
2023-11-04
Payment Denial
Payment Denial · denial start 2023-12-15 · 18 days
18 day denial
Ownership
Antelope Holdings Ii, LLC
5% Or Greater Direct Ownership Interest · Organization
Antelope Holdings Iii, LLC
5% Or Greater Direct Ownership Interest · Organization
9560 Pico LLC
5% Or Greater Indirect Ownership Interest · Organization
Hourani, Jameel
Operational/Managerial Control · Individual
Mekonnen, Gedyon
Operational/Managerial Control · Individual
Newgen Administrative Services, LLC
Operational/Managerial Control · Organization
Pico Ar LLC
5% Or Greater Indirect Ownership Interest · Organization
Robin, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Robin, Aaron
Corporate Director · Individual
Robin, Aaron
Corporate Officer · Individual
Shaw, Pamela
Operational/Managerial Control · Individual
Tress, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Tress, Avrohom
Corporate Director · Individual
Tress, Avrohom
Corporate Officer · Individual
Nearby options
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Alcott Rehabilitation Hospital
Los Angeles, CA
4-star overall rating with 3-star inspections with $20,279 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Sunray Healthcare Center
Los Angeles, CA
0-star overall rating with 0-star inspections with Special Focus status with $135,093 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The Rehabilitation Center On Pico
Los Angeles, CA
1-star overall rating with 1-star inspections with $193,710 in total fines with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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