★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
Not ratedQuality measures
Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Findings, latest cycle24
Findings with harm or immediate jeopardy, 3 cycles3
Fines, 3 years$37,882
Beds98
Inspection findings
Inspectors recorded 89 findings in the last three inspection cycles.
Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Apr 16, 2026 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm isolated | Corrected: Apr 20, 2026 |
| Apr 16, 2026 | Infection control | 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. (F0887) | No harm, but a risk of harm pattern | Corrected: Apr 22, 2026 |
| Apr 16, 2026 | Infection control | Develop and implement policies and procedures for flu and pneumonia vaccinations. (F0883) | No harm, but a risk of harm isolated | Corrected: Apr 22, 2026 |
| Apr 16, 2026 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Apr 20, 2026 |
| Apr 16, 2026 | Resident assessment and care planning | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F0842) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Apr 16, 2026 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Apr 23, 2026 |
| Apr 16, 2026 | Food and nutrition | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (F0802) | No harm, but a risk of harm isolated | Corrected: Apr 23, 2026 |
| Apr 16, 2026 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Apr 16, 2026 | Pharmacy and medications | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F0756) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Apr 16, 2026 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated | Corrected: Apr 24, 2026 |
| Apr 16, 2026 | Quality of life and care | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (F0740) | No harm, but a risk of harm isolated | Corrected: Apr 27, 2026 |
| Apr 16, 2026 | Quality of life and care | 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. (F0700) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Apr 16, 2026 | Quality of life and care | 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. (F0693) | No harm, but a risk of harm isolated | Corrected: Apr 20, 2026 |
| Apr 16, 2026 | Quality of life and care | Provide enough food/fluids to maintain a resident's health. (F0692) | No harm, but a risk of harm isolated | Corrected: Apr 21, 2026 |
| Apr 16, 2026 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Apr 16, 2026 | Quality of life and care | Assist a resident in gaining access to vision and hearing services. (F0685) | No harm, but a risk of harm isolated | Corrected: Apr 27, 2026 |
| Apr 16, 2026 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated | Corrected: Apr 24, 2026 |
| Apr 16, 2026 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm pattern | Corrected: Apr 27, 2026 |
| Apr 16, 2026 | Resident assessment and care planning | Ensure each resident receives an accurate assessment. (F0641) | No harm, but a risk of harm isolated | Corrected: Apr 24, 2026 |
| Apr 16, 2026 | Abuse, neglect and exploitation | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. (F0605) | No harm, but a risk of harm pattern | Corrected: Apr 20, 2026 |
| Apr 16, 2026 | Resident rights | 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. (F0584) | No harm, but a risk of harm isolated | Corrected: Apr 18, 2026 |
| Apr 16, 2026 | Resident rights | Keep residents' personal and medical records private and confidential. (F0583) | No harm, but a risk of harm isolated | Corrected: Apr 27, 2026 |
| Apr 16, 2026 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated | Corrected: Apr 27, 2026 |
| Apr 16, 2026 | Resident rights | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (F0561) | No harm, but a risk of harm isolated | Corrected: Apr 17, 2026 |
| Aug 14, 2025 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 18, 2025 |
| Aug 14, 2025 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm pattern · from a complaint | Corrected: Aug 18, 2025 |
| Jul 29, 2025 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 30, 2025 |
Earlier inspections (62)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Mar 2, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Food and nutrition | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (F0805) | No harm, but a risk of harm pattern | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Food and nutrition | 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. (F0803) | No harm, but a risk of harm pattern | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Pharmacy and medications | 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. (F0758) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Pharmacy and medications | Ensure each resident’s drug regimen must be free from unnecessary drugs. (F0757) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Quality of life and care | 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. (F0693) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Quality of life and care | Assist a resident in gaining access to vision and hearing services. (F0685) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Resident assessment and care planning | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F0657) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Resident assessment and care planning | Ensure each resident receives an accurate assessment. (F0641) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Resident assessment and care planning | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F0636) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Mar 2, 2025 | Resident rights | Ensure that residents are fully informed and understand their health status, care and treatments. (F0552) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2025 |
| Feb 12, 2025 | Resident rights | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. (F0573) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 27, 2025 |
| Jan 24, 2025 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 27, 2025 |
| Nov 5, 2024 | Resident rights | 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. (F0578) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 6, 2024 |
| Oct 30, 2024 | Resident rights | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. (F0626) | No harm, but a risk of harm isolated · from a complaint | Corrected: Oct 31, 2024 |
| Aug 15, 2024 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 28, 2024 |
| Aug 1, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 5, 2024 |
| Jul 18, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 25, 2024 |
| Jul 18, 2024 | Nursing and physician services | 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. (F0727) | No harm, but a risk of harm widespread · from a complaint | Corrected: Jul 25, 2024 |
| Jul 18, 2024 | Quality of life and care | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F0690) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 25, 2024 |
| Jul 18, 2024 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 25, 2024 |
| Jul 18, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 25, 2024 |
| Jul 2, 2024 | Quality of life and care | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (F0744) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 22, 2024 |
| Jul 2, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 22, 2024 |
| Jun 7, 2024 | Administration | Administer the facility in a manner that enables it to use its resources effectively and efficiently. (F0835) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 6, 2024 |
| Jun 7, 2024 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 6, 2024 |
| Apr 22, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 10, 2024 |
| Apr 22, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 10, 2024 |
| Apr 22, 2024 | Resident rights | 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. (F0585) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 10, 2024 |
| Apr 22, 2024 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm pattern · from a complaint | Corrected: May 10, 2024 |
| Mar 8, 2024 | Pharmacy and medications | 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. (F0758) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 29, 2024 |
| Mar 8, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 29, 2024 |
| Mar 8, 2024 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 29, 2024 |
| Mar 6, 2024 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 20, 2024 |
| Mar 6, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Mar 20, 2024 |
| Feb 23, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 15, 2024 |
| Feb 8, 2024 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Nursing and physician services | Post nurse staffing information every day. (F0732) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Quality of life and care | Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Quality of life and care | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (F0676) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Resident assessment and care planning | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (F0644) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Resident rights | 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. (F0578) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Resident rights | Ensure that residents are fully informed and understand their health status, care and treatments. (F0552) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 7, 2024 |
| Feb 8, 2024 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 7, 2024 |
| Jan 23, 2024 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 20, 2024 |
| Jan 23, 2024 | Food and nutrition | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (F0806) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 20, 2024 |
| Jan 23, 2024 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 20, 2024 |
| Jan 23, 2024 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 20, 2024 |
| Jan 5, 2024 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 20, 2024 |
| Jan 5, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 20, 2024 |
| Dec 4, 2023 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 2, 2024 |
| Nov 4, 2023 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | Actual harm to a resident isolated · from a complaint | Corrected: Dec 4, 2023 |
| Nov 4, 2023 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | Actual harm to a resident isolated · from a complaint | Corrected: Dec 4, 2023 |
Fines and payment denials
Federal fines in the last three years: $37,882 (1). Payment denials: 1.
| Date | Type | Amount |
|---|---|---|
| Jan 23, 2024 | Fine | $37,882 |
| Nov 4, 2023 | Payment denial | 18 days |
Staffing
| Nurse staff hours per resident per day | 3.87 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.31 | California median: 0.52 |
| Nurse staff hours on weekends | 3.68 | California median: 3.85 |
| Nursing staff who left within a year | 37.4% | California median: 36.0% |
About this home
| Beds | 98 |
| Residents per day, average | 90.6 |
| Ownership | For-profit, limited liability company |
| Legal business name | Windsor Gardens Convalescent Hospital Inc. |
| Chain | Windsor (22 homes) |
| In Medicare/Medicaid since | Jun 1, 1972 |
Questions to ask when you call
- What was corrected after the last inspection?
- How many staff work at night and on weekends?
- Does anyone on staff speak my relative's language?
- May I visit at any time, without an appointment?
Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov
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