01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-16 | 26 | 2025-03-02 | 3 |
| Cycle 2 | 2025-03-02 | 25 | 2024-02-08 | 2 |
| Cycle 3 | 2024-02-08 | 39 | 2021-05-07 | 3 |
CMS CCN 0561942026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Gardens Convalescent Hospital
915 S. Crenshaw Blvd. · Los Angeles, CA 90019 · Los Angeles County
Certified beds98CMS provider file
Recent citation rows98current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
98 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 24 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-16 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-272026-04-16 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-04-272026-04-16 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-182026-04-16 · HEALTHF0605Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-16 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-04-242026-04-16 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-272026-04-16 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-04-242026-04-16 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2026-04-272026-04-16 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2026-04-212026-04-16 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-16 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2026-04-272026-04-16 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-04-242026-04-16 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0802Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Correction field: Deficient, Provider has date of correction · 2026-04-232026-04-16 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-04-232026-04-16 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-172026-04-16 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-04-202026-04-16 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2026-04-222026-04-16 · HEALTHF0887Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-222026-04-16 · HEALTHF0919Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Correction field: Deficient, Provider has date of correction · 2026-04-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-01-23 | Fine | $37,882 | 0 |
| 2023-11-04 | Payment Denial | $0 | 18 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ANTELOPE HOLDINGS II, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 06/30/2023
- ANTELOPE HOLDINGS III, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 06/30/2023
- ROBIN, AARONIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST50% · since 06/30/2023
- TRESS, AVROHOMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST50% · since 06/30/2023
- ROBIN, AARONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/09/2023
- TRESS, AVROHOMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/09/2023
- ROBIN, AARONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/14/2023
- TRESS, AVROHOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/14/2023
- NEWGEN ADMINISTRATIVE SERVICES, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/30/2023
- HOURANI, JAMEELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/1995
- MEKONNEN, GEDYONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/05/2024
- SHAW, PAMELAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/30/2023
- NEWGEN ADMINISTRATIVE SERVICES, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/27/2025
- HOURANI, JAMEELIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/01/1995
- MEKONNEN, GEDYONIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/05/2024
- SHAW, PAMELAIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/30/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.84per resident day
RN hours0.26per resident day
Weekend nurse hours3.65per resident day
Staff turnover51.9%CMS reported field
06 / LOCAL RECORDS
Open the Los Angeles ledger →Other published facilities nearby
Alcott Rehabilitation Hospital121 beds · CMS overall 5/562 citation rowsAlden Terrace Convalescent Hospital210 beds · CMS overall 5/556 citation rowsAlexandria Care Center177 beds · CMS overall 1/5137 citation rowsAlta View Post Acute99 beds · CMS overall 1/568 citation rowsAlvarado Care Center72 beds · CMS overall 2/585 citation rowsAngels Nursing Health Center49 beds · CMS overall 5/554 citation rowsArarat Convalescent Hospital42 beds · CMS overall 4/545 citation rowsAvalon Villa Care Center131 beds · CMS overall 1/5172 citation rows