WINDSOR GARDENS OF THE VALLEY

The information listed below provides an in-depth look into the type and quality of care offered at Windsor Gardens of the Valley. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

WINDSOR GARDENS OF THE VALLEY
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

96%

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

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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 ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation Plus Extensive Services

Rehabilitation 720 Minutes Per Week Minimum
  • 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: 11-169.8%
Total Percent:9.8%
 

Very High Rehabilitation Plus Extensive Services

Rehabilitation 500 Minutes Per Week Minimum
  • 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: 11-162.1%
Total Percent:2.1%
 

Medium Rehabilitation Plus Extensive Services

Rehabilitation 150 Minutes Per Week Minimum
  • 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: 11-161.5%
Total Percent:1.5%
 

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-1635.8%
ADL Index Range: 6-1023.8%
ADL Index Range: 0-516.7%
Total Percent:76.4%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-164.2%
ADL Index Range: 6-101.0%
ADL Index Range: 0-51.6%
Total Percent:6.8%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-160.4%
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 DayReportedExpected
Registered Nurse (RN) Hours1 Hour and 26 Minutes1 Hour and 27 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours2 Hours and 41 Minutes49 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 41 Minutes
Total Licensed Nurse Hours4 Hours and 8 Minutes2 Hours and 15 Minutes
Total Nurse Hours4 Hours and 8 Minutes4 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 FacilityCalifornia Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season84%87%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination84%86%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair10%8%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse11%10%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores15%12%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain4%4%
Percent of Long-Stay Residents Who Are More Depressed or Anxious4%9%
Percent of Long-Stay Residents Who Were Physically Restrained9%7%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder6%5%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder69%58%
Percent of Long-Stay Residents Who Lose Too Much Weight6%7%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection6%8%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased10%11%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season85%83%
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination82%81%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Pressure Sores20%17%
Percent of Short-Stay Residents Who Have Delirium-2%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain29%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 InspectorsDegree of HarmResidents Affected

Administration

Post Nurse Staffing Information.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Quickly Tell the Resident's Doctor the Results of Lab Tests.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Provide Needed Housekeeping and Maintenance.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Get Rid of Garbage Properly.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009

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.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
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.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009

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.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Properly Mark Drugs and Other Similar Products.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009

Quality Care

Provide Activities to Meet the Needs of Each Resident.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Make Sure That Each Resident's Nutritional Needs Were Met.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
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.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011
Make Sure That Each Resident's Nutritional Needs Were Met.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
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.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Have a Private Telephone Available for Use.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Provide Services to Meet the Needs and Preferences of Each Resident.
  • Inspection Date: 08/12/2008
  • Correction Date: 09/05/2008
Keep Each Resident's Personal and Medical Records Private and Confidential.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Inspection Date: 10/11/2009
  • Correction Date: 11/02/2009
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.
  • Inspection Date: 01/19/2011
  • Correction Date: 02/07/2011

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 ComplaintsDegree of HarmResidents Affected

Environmental

Have a Program to Keep Infection from Spreading.
  • Complaint Filed: 04/23/2008
  • Correction Date: 06/07/2008
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable.
  • Complaint Filed: 04/23/2008
  • Correction Date: 06/07/2008

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.
  • Complaint Filed: 05/19/2010
  • Correction Date: 07/28/2010
Make Sure That Residents Are Safe from Serious Medication Errors.
  • Complaint Filed: 05/19/2010
  • Correction Date: 07/28/2010

Quality Care

Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Complaint Filed: 09/23/2008
  • Correction Date: 10/20/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Complaint Filed: 05/19/2010
  • Correction Date: 08/10/2010

Resident Rights

Provide Enough Notice Before Discharging or Transferring a Resident.
  • Complaint Filed: 04/23/2008
  • Correction Date: 06/07/2008

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 InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 01/21/2011
  • Correction Date: 02/08/2011

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 08/20/2008
  • Correction Date: 09/05/2008

Furnishings and Decorations

Exits That Are Free from Obstructions and Can Be Used at All Times.
  • Inspection Date: 10/19/2009
  • Correction Date: 10/29/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 01/21/2011
  • Correction Date: 02/08/2011
Source: Medicare Nursing Home Compare; Department of Health Services of California - Licensing and Certification Program - Retrieved 2011