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Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento, CA 95838 (opens Google Maps) · Sacramento County · (916) 922-8855· 128 certified beds · avg — residents/day · certified since Dec 30, 1997 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: WINDSOR (22 facilities, chain avg rating 2.4★)
2/5
Health inspection rating (on-site)
inspected Dec 20, 2024
1
Serious findings on record
most recent May 8, 2024
$0
Fines, last 3 years
—
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, isolated · May 8, 2024 · F-0600 · triggered by a complaint
The 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.
▲ Actual harm, isolated · May 8, 2024 · F-0600 · triggered by a complaint
The 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.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 8, 2024 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 51 inspection findings. Open the full record below to read every finding.
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. F-0725
The facility did not keep residents' personal and medical information private and confidential. F-0583
The 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. F-0677
View all 51 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 20, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725 |
| Dec 20, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Dec 20, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0677 |
| Dec 20, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679 |
| Dec 20, 2024 | E · Potential for more than minimal harm, pattern | The 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. · F-0880 |
| Dec 20, 2024 | E · Potential for more than minimal harm, pattern | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0550 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0558 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · F-0699 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0758 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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. · F-0761 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Dec 20, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0600 |
| Oct 3, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0600 |
| Aug 22, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0600 |
| Aug 22, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0656 |
| Jul 23, 2024 | D · Potential for more than minimal harm, isolated | The 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 · F-0600 |
| Jul 11, 2024 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| May 8, 2024 | ▲ G · Actual harm, isolated | The 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 · F-0600 |
| Dec 20, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint · F-0806 |
| Nov 16, 2023 | E · Potential for more than minimal harm, pattern | The facility did not observe each nurse aide's job performance or provide regular training as required. · F-0730 |
| Nov 16, 2023 | E · Potential for more than minimal harm, pattern | The 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. · F-0805 |
| Nov 16, 2023 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Nov 16, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · F-0813 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The 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. · F-0677 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · F-0908 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The 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. · F-0919 |
| Nov 16, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · F-0921 |
| Oct 10, 2023 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Aug 1, 2023 | D · Potential for more than minimal harm, isolated | The 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 · F-0600 |
| Dec 9, 2021 | E · Potential for more than minimal harm, pattern | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Dec 9, 2021 | E · Potential for more than minimal harm, pattern | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · F-0726 |
| Dec 9, 2021 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The 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. · F-0550 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · F-0557 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The 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. · F-0558 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' personal and medical information private and confidential. · F-0583 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The 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. · F-0761 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806 |
| Dec 9, 2021 | D · Potential for more than minimal harm, isolated | The 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. · F-0880 |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 15).
All citationsSerious citations (G–L)
2021
All citations: 12
Serious citations (G–L): 0
2023
All citations: 17
Serious citations (G–L): 0
2024
All citations: 22
Serious citations (G–L): 1
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 12 | 0 | E |
| 2023 | 17 | 0 | E |
| 2024 | 22 | 1 | G ▲ |
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)
Nurse staffing (from payroll records, adjusted for how much care residents need)
What these staffing numbers mean →
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: Not reported
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: Not reported
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: Not reported
California average: 3.90
U.S. average: 3.50
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | — | 4.31 | 3.95 | — |
| Registered Nurse hours | — | 0.61 | 0.69 | — |
| Weekend total nurse staffing | — | 3.90 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | — | 0.51 | 0.48 | — |
| Total nursing staff turnover (%) | — | 36.7 | 45.8 | — |
| RN turnover (%) | — | 38.1 | 42.9 | — |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 —, RN —, weekend —.Comparing with Medicare Care Compare? Care Compare shows the raw figure (— here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Costs & payment
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Windsor Care Center of Sacramento. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
- Request the room type, effective date and itemized daily rate in writing.
- Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
- Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Understand who pays for care · How we handle price evidence · Report an incorrect price
Who owns this facility
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Antelope Holdings I, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 06/30/2023 |
| Robin, Aaron | Individual | 5% or Greater Indirect Ownership Interest | — | 06/30/2023 |
| Tress, Avrohom | Individual | 5% or Greater Indirect Ownership Interest | — | 06/30/2022 |
| Windsor Haysac Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/01/2010 |
| Windsor Oxford Holding Company, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 04/01/2011 |
| Robin, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2023 |
| Shaw, Pamela | Individual | Corporate Officer | NOT APPLICABLE | 06/30/2023 |
| Shaw, Pamela | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/30/2023 |
| Tress, Avrohom | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2023 |
All 9 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain Windsor — 22 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
- Windsor Gardens Convalescent Hospital — Los Angeles, CA · overall 1/5
- Windsor the Ridge Rehabilitation Center — Salinas, CA · overall 5/5
- Alta Gardens Care Center — Garden Grove, CA · overall 3/5
- Cheviot Hills Post Acute — Los Angeles, CA · overall 2/5
- Citrus Grove Post Acute — Riverside, CA · overall 3/5
- Coastal Post Acute — Salinas, CA · overall 4/5
- Country Drive Post Acute — Fremont, CA · overall 3/5
- Delta Oaks Post Acute — Stockton, CA · overall 1/5abuse
Listed by state, then facility name — not a ranking. Showing 8 of the 21 others, continuing from this facility's own place in that list.
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
Also worth asking anywhere
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the plan of correction for the findings in your most recent state inspection?"
- "Can I visit again unannounced, at a mealtime or on a weekend?"
Nearby facilities (12 closest of 46 within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| North Pointe Care Center | 0.0 mi | Sacramento, CA | ★★☆☆☆ | 1/5 | abuse |
| Advanced Health Care of Sacramento | 3.2 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Gramercy Court | 3.8 mi | Sacramento, CA | ★★★★☆ | 2/5 | abuse |
| Sherwood Healthcare Center | 4.5 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Woodside Healthcare Center | 4.8 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Arden Park Post Acute | 4.9 mi | Sacramento, CA | ★★★☆☆ | 2/5 | abuse |
| Mission Carmichael Healthcare Center | 4.9 mi | Carmichael, CA | ★★★☆☆ | 3/5 | |
| McKinley Park Care Center | 5.0 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| Mid-Town Oaks Post-Acute | 5.1 mi | Sacramento, CA | ★★★☆☆ | 2/5 | |
| Asbury Park Nursing and Rehabilitation Center | 5.3 mi | Sacramento, CA | ★★★☆☆ | 2/5 | |
| Saylor Lane Healthcare Center | 5.4 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| College Oak Nursing and Rehabilitation Center | 5.4 mi | Sacramento, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Other facilities in the same county
CMS records place this facility in Sacramento, CA — 37 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
- Acc Care Center — Sacramento, CA · overall 5/5
- American River Center — Carmichael, CA · overall 4/5
- Bridgewood Post Acute — Sacramento, CA · overall 3/5abuse
- Bruceville Terrace - D/P SNF of Methodist Hospital — Sacramento, CA · overall 3/5abuse
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 555717.
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