WINDSOR GARDENS OF THE VALLEY
Address
13000 VICTORY BLVD,
NORTH HOLLYWOOD, CA 91606
(818) 985-5990
Nursing Home Ratings
Health Inspections | |
Quality Measures | |
Nursing Staff | |
R.N. Staff Only | |
Overall Rating |
Percent of Beds Occupied
Number of Residents and Certified Beds
- Residents: 95
- Certified Beds: 99
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Corporation
- Offers Both Resident and Family Counseling Services
- This Facility is Not Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Windsor Gardens of the Valley. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
Resident Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation Plus Extensive Services
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-16 | 9.8% |
Total Percent: | 9.8% |
Very High Rehabilitation Plus Extensive Services
- At least one rehabilitation discipline five days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-16 | 2.1% |
Total Percent: | 2.1% |
Medium Rehabilitation Plus Extensive Services
- Five days any combination of three rehabilitation disciplines
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-16 | 1.5% |
Total Percent: | 1.5% |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
ADL Index Range: 11-16 | 35.8% |
ADL Index Range: 6-10 | 23.8% |
ADL Index Range: 0-5 | 16.7% |
Total Percent: | 76.4% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 4.2% |
ADL Index Range: 6-10 | 1.0% |
ADL Index Range: 0-5 | 1.6% |
Total Percent: | 6.8% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 0.4% |
Total Percent: | 0.4% |
Extensive Services
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 2-16 - Isolation for active infectious disease | 0.06% |
Total Percent: | 0.06% |
Special Care Low
- Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score greater or equal to 5
- Respiratory failure and oxygen therapy while a resident
- Feeding tube where calories >= 51% or calories are in the range of 26-50% and fluid >= 501 mL)
- Ulcers: 2 or more stage II or 1 or more stage III or IV pressure ulcers
- Ulcers: 2 or more venous or arterial ulcers
- Ulcers: 1 stage II pressure ulcer and 1 venous or arterial ulcer with 2 or more skin care treatments
- Foot infection/diabetic foot ulcer/open lesions of foot with treatment
- Radiation therapy while a resident
- Dialysis while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-14 - No Signs of depression | 2.2% |
Total Percent: | 2.2% |
Behavioral Symptoms and Cognitive Performance
- Cognitive impairment BIMS score less than or equal to 9
- CPS great than or equal to 3
- Hallucinations or delusions
- Physical or verbal behavioral symptoms toward others
- Other behavioral symptoms
- Rejection of care or wandering
- Activities of Daily Living (ADL) score of 5 or less
ADL Index Range: 0-1 - Less restorative nursing | 0.5% |
Total Percent: | 0.5% |
Reduced Physical Function
- Urinary and/or bowel training program
- Passive and/or active range of motion (ROM)
- Amputation/prosthesis training
- Dressing or grooming training
- Eating or swallowing training
- Transfer training
- Splint or brace assistance
- Bed mobility and/or walking training
- Communication training
ADL Index Range: 11-14 - Less restorative nursing | 0.06% |
ADL Index Range: 6-10 - Less restorative nursing | 0.06% |
Total Percent: | 0.1% |
Rating Details For Windsor Gardens of the Valley
Nursing Staff -
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
Nursing Hours Per Resident Per Day | Reported | Expected |
Registered Nurse (RN) Hours | 1 Hour and 26 Minutes | 1 Hour and 27 Minutes |
Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 2 Hours and 41 Minutes | 49 Minutes |
Certified Nursing Assistant (CNA) Hours | 2 Hours and 41 Minutes | |
Total Licensed Nurse Hours | 4 Hours and 8 Minutes | 2 Hours and 15 Minutes |
Total Nurse Hours | 4 Hours and 8 Minutes | 4 Hours and 56 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for California are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
This Facility | California Average |
Long-Term Stay Preventive Actions
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 84% | 87% |
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 84% | 86% |
Long-Term Stay Deficiencies
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 10% | 8% |
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 11% | 10% |
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 15% | 12% |
Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 4% | 4% |
Percent of Long-Stay Residents Who Are More Depressed or Anxious | 4% | 9% |
Percent of Long-Stay Residents Who Were Physically Restrained | 9% | 7% |
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 6% | 5% |
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 69% | 58% |
Percent of Long-Stay Residents Who Lose Too Much Weight | 6% | 7% |
Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 6% | 8% |
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 10% | 11% |
Short-Term Stay Preventive Actions
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 85% | 83% |
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 82% | 81% |
Short-Term Stay Deficiencies
Percent of Short-Stay Residents Who Have Pressure Sores | 20% | 17% |
Percent of Short-Stay Residents Who Have Delirium | - | 2% |
Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 29% | 23% |
Health Inspection Details -
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 01/19/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Administration
Post Nurse Staffing Information.
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Quickly Tell the Resident's Doctor the Results of Lab Tests.
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Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Provide Needed Housekeeping and Maintenance.
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Have a Program to Keep Infection from Spreading.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Get Rid of Garbage Properly.
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Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
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Mistreatment
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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Nutrition and Dietary
1) Provide 3 Meals Daily at Regular Times; or 2) Serve Breakfast Within 14 Hours After Dinner; or 3) Offer a Snack at Bedtime Each Day.
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1) Provide 3 Meals Daily at Regular Times; or 2) Serve Breakfast Within 14 Hours After Dinner; or 3) Offer a Snack at Bedtime Each Day.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
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Properly Mark Drugs and Other Similar Products.
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Quality Care
Provide Activities to Meet the Needs of Each Resident.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene.
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Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
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Make Sure That Each Resident's Nutritional Needs Were Met.
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Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
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Give Proper Treatment to Residents with Feeding Tubes to Prevent Problems (Such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-Pharyngeal Ulcers) and Help Restore Eating Skills, if Possible.
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Make Sure That Each Resident's Nutritional Needs Were Met.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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Provide a Final Summary of the Resident's Health Status and a Summary of the Resident's Stay, when the Resident is Ready to Leave the Nursing Home.
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Resident Rights
Keep Each Resident's Personal and Medical Records Private and Confidential.
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Have a Private Telephone Available for Use.
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Provide Services to Meet the Needs and Preferences of Each Resident.
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Keep Each Resident's Personal and Medical Records Private and Confidential.
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Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
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Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Windsor Gardens of the Valley, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Formal Complaints | Degree of Harm | Residents Affected |
Environmental
Have a Program to Keep Infection from Spreading.
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Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
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Pharmacy Service
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Make Sure That Residents Are Safe from Serious Medication Errors.
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Quality Care
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Resident Rights
Provide Enough Notice Before Discharging or Transferring a Resident.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Windsor Gardens of the Valley had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 01/21/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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