General Information: WINDSOR GARDENS CARE CENTER OF FULLERTON
Nursing home name WINDSOR GARDENS CARE CENTER OF FULLERTON
Address245 E WILSHIRE AVENUE
FULLERTON, CA 92832
Phone number (714) 871-6020
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 99
Total number of residents 94
Perc of occupied beds 94
Sprinkler status Yes
Number of Facility Reported Incidents2
Number of Substantiated Complaints0
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: WINDSOR GARDENS CARE CENTER OF FULLERTON
Overall rating 3
3
Nursing Home Staffing 3
3
Registered Nurses only 3
3
Health Inspections 2
2
Quality Measures 5
5
Nursing Home Staffing Info: WINDSOR GARDENS CARE CENTER OF FULLERTON
National AverageCalifornia AverageWINDSOR GARDENS CARE CENTER OF FULLERTON
Overall staff rating NA NA 3
3
Registered Nurses only rating NANA 3
3
Total Number of Residents NA NA 94
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.49 hours 3.72 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.8 hours 1.52 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.88 hours 0.62 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.92 hours 0.9 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.69 hours 2.2 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.14 hours 0.21 hours
Health Survey: WINDSOR GARDENS CARE CENTER OF FULLERTON
Heath Survey Summary on 2013-03-14
Total Number of Health Deficiencies 12
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-06-06
Total Number of Health Deficiencies 11
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-02-18
Total Number of Health Deficiencies 20
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Health Survey Details: WINDSOR GARDENS CARE CENTER OF FULLERTON
Inspection Results: 03/14/2013
Corrected Deficiency Scope and Severity
04/14/2013 Allow residents to self-administer drugs if determined safe. Isolated/Minimal harm or potential for actual harm
04/14/2013 Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated/Minimal harm or potential for actual harm
04/14/2013 Reasonably accommodate the needs and preferences of each resident. Isolated/Minimal harm or potential for actual harm
04/14/2013 Provide activities to meet the interests and needs of each resident. Isolated/Minimal harm or potential for actual harm
04/14/2013 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
04/14/2013 Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
04/14/2013 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. Isolated/Minimal harm or potential for actual harm
04/14/2013 Ensure residents maintain acceptable nutritional status. Isolated/Minimal harm or potential for actual harm
04/14/2013 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
04/14/2013 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
04/14/2013 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated/Minimal harm or potential for actual harm
04/14/2013 Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern/Minimal harm or potential for actual harm
Inspection Results: 06/06/2012
Corrected Deficiency Scope and Severity
06/23/2012 Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated/Minimal harm or potential for actual harm
06/23/2012 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
06/23/2012 Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated/Minimal harm or potential for actual harm
06/23/2012 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
06/23/2012 Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
06/23/2012 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
06/23/2012 At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated/Minimal harm or potential for actual harm
06/23/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
06/23/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
06/23/2012 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
06/23/2012 Keep all essential equipment working safely. Isolated/Minimal harm or potential for actual harm
Inspection Results: 02/18/2011
Corrected Deficiency Scope and Severity
03/21/2011 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. Isolated/Minimal harm or potential for actual harm
03/21/2011 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated/Minimal harm or potential for actual harm
03/21/2011 Reasonably accommodate the needs and preferences of each resident. Pattern/Potential for minimal harm
03/21/2011 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern/Potential for minimal harm
03/21/2011 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
03/21/2011 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
03/21/2011 Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated/Minimal harm or potential for actual harm
03/21/2011 Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
03/21/2011 Ensure residents maintain acceptable nutritional status. Isolated/Minimal harm or potential for actual harm
03/21/2011 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
03/21/2011 Hire sufficient dietary support personnel. Isolated/Minimal harm or potential for actual harm
03/21/2011 Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Isolated/Minimal harm or potential for actual harm
03/21/2011 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. Pattern/Potential for minimal harm
03/21/2011 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
03/21/2011 At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated/Minimal harm or potential for actual harm
03/21/2011 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
03/21/2011 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated/Minimal harm or potential for actual harm
03/21/2011 Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern/Potential for minimal harm
03/21/2011 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
03/21/2011 Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread /Minimal harm or potential for actual harm

Fire Safety Survey: WINDSOR GARDENS CARE CENTER OF FULLERTON
Fire Safety Survey Summary on 2013-03-22
Total Number of Fire SafetyDeficiencies 3
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-06-13
Total Number of Fire SafetyDeficiencies 8
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-02-28
Total Number of Fire SafetyDeficiencies 5
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey: WINDSOR GARDENS CARE CENTER OF FULLERTON
Fire Safety Survey Results: 03/22/2013
Corrected Deficiency Severity
04/08/2013 Smoke barrier doors that can resist smoke for at least 20 minutes. Isolated/Minimal harm or potential for actual harm
04/08/2013 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
04/08/2013 Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Results: 06/13/2012
Corrected Deficiency Severity
06/26/2012 Properly constructed linen or trash chutes. Isolated/Minimal harm or potential for actual harm
06/26/2012 Portable fire extinguishers. Isolated/Minimal harm or potential for actual harm
06/26/2012 Properly installed hallway dispensers for alcohol-based hand rub. Isolated/Minimal harm or potential for actual harm
06/26/2012 Properly installed electrical wiring and equipment. Widespread/Potential for minimal harm
06/26/2012 Exits that are accessible at all times. Isolated/Minimal harm or potential for actual harm
06/26/2012 Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Isolated/Minimal harm or potential for actual harm
06/26/2012 Emergency lighting that can last at least 1 1/2 hours. Isolated/Minimal harm or potential for actual harm
06/26/2012 A fire alarm system that can be heard throughout the facility. Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Results: 02/28/2011
Corrected Deficiency Severity
03/14/2011 Corridor and hallway doors that block smoke. Isolated/Minimal harm or potential for actual harm
03/14/2011 Exits that are accessible at all times. Pattern/Minimal harm or potential for actual harm
03/14/2011 Portable fire extinguishers. Isolated/Minimal harm or potential for actual harm
03/14/2011 Properly sized and located linen or trash receptacles. Isolated/Minimal harm or potential for actual harm
03/14/2011 Properly installed electrical wiring and equipment. Widespread/Potential for minimal harm

Resident Complaints: WINDSOR GARDENS CARE CENTER OF FULLERTON
Date Complaint Substantiated: 01/10/2014
CorrectedCategoryDeficiencySeverity
01/24/2014Keep accurate, complete and organized clinical records on each resident that meet professional standards. D
01/24/2014Store, cook, and serve food in a safe and clean way. D
Date Complaint Substantiated: 08/15/2013
CorrectedCategoryDeficiencySeverity
08/29/2013Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. E
08/29/2013Operate and provide services according to Federal, State, and local laws and professional standards. E

Quality Measures: WINDSOR GARDENS CARE CENTER OF FULLERTON
Quality Measures National Average California Average WINDSOR GARDENS CARE CENTER OF FULLERTON
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 11.7% 15.3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.9% 4.3%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 6.2% 8.5%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 5.8% 3.7%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 45.3% 75.7%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 3.3% 2.5%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 5.3% 1.6%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 1.8% 0.0%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 2.1% 0.5%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 1.6% 2.1%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 92.3% 98.9%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.6% 93.7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.5% 14.0%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 16.9% 22.3%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 0.9% 0.4%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 81.1% 62.0%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 79.8% 55.6%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.0% 0.7%

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