California ›Elk Grove

Elk Grove Post Acute

9461 Batey Avenue, Elk Grove, CA 95624 · Sacramento County · 136 certified beds · avg 130 residents/day · certified since Jan 1, 1967

Abuse citation flag (CMS)

Part of chain: WINDSOR (22 facilities, chain avg rating 2.4★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5
Health inspection rating (on-site)
3
Serious findings on record
$8,824
Fines, last 3 years
3.81
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Mar 13, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 13, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 22, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 17, 2023 (Past Non-Compliance)

▲ Actual harm, one-off · Nov 17, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 17, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (77)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 14, 2026E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 14, 2026E · Potential for harm, repeatedThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
May 14, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 14, 2026E · Potential for harm, repeatedThe facility did not dispose of garbage and refuse properly.
May 14, 2026E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
May 14, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 14, 2026D · Potential for harm, one-offThe facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
May 14, 2026D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 14, 2026D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 14, 2026D · Potential for harm, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
May 14, 2026D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Mar 30, 2026D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Mar 11, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 6, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 6, 2026D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Feb 5, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jan 29, 2026D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jan 20, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 13, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 24, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 24, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Nov 24, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 13, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 13, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jul 21, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jul 21, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jun 19, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 12, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 5, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 4, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Jun 4, 2025D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
May 6, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Apr 17, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Apr 17, 2025D · Potential for harm, one-offThe facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint
Apr 8, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 27, 2025E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Feb 27, 2025E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Feb 27, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 27, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Feb 27, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Feb 27, 2025D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Feb 27, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 27, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Feb 27, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Feb 27, 2025D · Potential for harm, one-offThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Jan 14, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 2, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Nov 12, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 27, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Mar 13, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 16, 2024F · Potential for harm, facility-wideThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Feb 16, 2024F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not keep residents' personal and medical information private and confidential.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 16, 2024E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not provide safe and appropriate pain management for a resident who needed it.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 16, 2024E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Feb 16, 2024D · Potential for harm, one-offThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Feb 16, 2024D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Feb 16, 2024D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Dec 22, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 22, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Nov 17, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 20, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Oct 20, 2023D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly. · from a complaint
Oct 20, 2023D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (16 → 10).

YearCitationsSerious (G–L)Worst severity that year
202362G ▲
2024181G ▲
2025340E
2026190E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $8,824.

DateTypeAmount / length
Feb 16, 2024Fine$8,824

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.814.313.95bottom 28% in California; top 48% in the U.S.
Registered Nurse hours0.860.610.69top 15% in California; top 23% in the U.S.
Weekend total nurse staffing3.653.903.50bottom 43% in California; top 35% in the U.S.
Weekend RN hours (not acuity-adjusted)0.770.510.48top 13% in California; top 13% in the U.S.
Total nursing staff turnover (%)23.236.745.8top 13% in California; top 5% in the U.S.
RN turnover (%)20.038.142.9top 19% in California; top 13% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.79, RN 0.85, weekend 3.63. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Antelope Holdings I, LLCOrganization5% or Greater Indirect Ownership Interest—06/30/2023
Antelope Realty Holdings I, LLCOrganization5% or Greater Direct Ownership Interest—07/26/2024
Robin, AaronIndividual5% or Greater Indirect Ownership Interest—06/30/2023
Tress, AvrohomIndividual5% or Greater Indirect Ownership Interest—06/30/2023
Windsor Norcal 13 Holdings LLCOrganization5% or Greater Direct Ownership Interest—01/04/2007
Chow, KellyIndividualOperational/Managerial ControlNOT APPLICABLE11/06/2023
Chow, KellyIndividualADP of the SNFNOT APPLICABLE11/06/2023
Feliciano, LarryIndividualOperational/Managerial ControlNOT APPLICABLE01/16/2017
Feliciano, LarryIndividualADP of the SNFNOT APPLICABLE01/16/2017
Newgen Administrative Services, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE06/30/2023
Newgen Administrative Services, LLCOrganizationADP of the SNFNOT APPLICABLE03/19/2025
Robin, AaronIndividualCorporate OfficerNOT APPLICABLE08/14/2023
Shaw, PamelaIndividualOperational/Managerial ControlNOT APPLICABLE06/30/2023
Shaw, PamelaIndividualTrustee of the SNFNOT APPLICABLE06/30/2023
Shaw, PamelaIndividualADP of the SNFNOT APPLICABLE06/30/2023
Tress, AvrohomIndividualCorporate OfficerNOT APPLICABLE08/14/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Asbury Park Nursing and Rehabilitation Center11.5 miSacramento, CA★★★☆☆2/5
Greenhaven Healthcare Center11.7 miSacramento, CA★★★☆☆2/5abuse
Rancho Seco Care Center11.7 miGalt, CA—/5abuseSFF
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Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 055308.