Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WINDSOR GARDENS CONVALESCENT HOSPITAL
LOS ANGELES, CA · 98 certified beds · Last Life Safety survey March 2, 2025
CMS Certification Number 056194 · first certified June 1972
Ownership
Operated by WINDSOR · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CA
8 citations — more than 5% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (March 2026 to August 2026). Most CA facilities have been surveyed by August 2027. This facility’s last Life Safety survey was March 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 8 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 8 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 7, 2021 | 2 |
| February 8, 2024 | 3 |
| March 2, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-03-02 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2021-05-07 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2024-02-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-03-02 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2024-02-08 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2025-03-02 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 1 | 2024-02-08 |
What the citations cover
- Smoke Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 1
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 2, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 7, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 7, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 7, 2025) |
February 8, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 7, 2024) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (March 7, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (March 7, 2024) |
May 7, 2021 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 1, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 1, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.