Windsor Gardens Convalescent Hospital
915 S. Crenshaw Blvd. · Los Angeles, CA · 90019 · 3239375466
98 certified beds For profit - Individual Chain: Windsor
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 3 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
RN staffing in the bottom 10% nationally
0.23 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.81 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.23 | 0.55–0.75 |
| Weekend hours / resident-day | 3.63 | ≈ weekday level |
| Nursing turnover / year | 51% | median 45% |
| Fines (3-yr window) | 1 · $37,882 |
Inspection citations (95 in the current record)
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Potential for harm · E August 14, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected August 18, 2025 · Resident Rights
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Potential for harm · D August 14, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 18, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 29, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 30, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 7, 2025 · Resident Rights
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Potential for harm · D March 2, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 7, 2025 · Resident Rights
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Potential for harm · D March 2, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected March 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 2, 2025
Ensure each resident receives an accurate assessment.
Corrected March 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 2, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 2, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
Assist a resident in gaining access to vision and hearing services.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
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 March 7, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
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 March 7, 2025 · Quality of Life and Care
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Potential for harm · D March 2, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected March 7, 2025 · Pharmacy Service
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Potential for harm · D March 2, 2025
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 March 7, 2025 · Pharmacy Service
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Potential for harm · D March 2, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected March 7, 2025 · Pharmacy Service
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Potential for harm · D March 2, 2025
Ensure that residents are free from significant medication errors.
Corrected March 7, 2025 · Pharmacy Service
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Potential for harm · E March 2, 2025
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 March 7, 2025 · Nutrition and Dietary
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Potential for harm · E March 2, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected March 7, 2025 · Nutrition and Dietary
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Potential for harm · E March 2, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 7, 2025 · Nutrition and Dietary
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Potential for harm · D March 2, 2025
Provide and implement an infection prevention and control program.
Corrected March 7, 2025 · Infection Control
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Potential for harm · D February 12, 2025 · found via complaint
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected February 27, 2025 · Resident Rights
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Potential for harm · D January 24, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected January 27, 2025 · Pharmacy Service
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Potential for harm · D November 5, 2024 · found via complaint
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 November 6, 2024 · Resident Rights
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Potential for harm · D October 30, 2024 · found via complaint
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected October 31, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 23, 2024 | Fine | $37,882 |
| November 4, 2023 | Payment Denial | 18 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056194 · certified since June 1, 1972. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.