Nursing home report card · Sacramento, CA
Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento, CA 95838
Call this home: (916) 922-8855
View this home on Medicare.gov ↗
Quick summary
Below-average Medicare rating
Overall rating is 2 of 5 stars. Its health-inspection rating is 2 of 5. Read the dated inspection findings and separate staffing and care ratings below.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Dec 20, 2024
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Below-average Medicare rating
Based on problems found during health inspections.
Below-average Medicare rating
Based on staffing levels and related measures.
Among the lowest Medicare ratings
Based on reported health and care results.
Among the highest Medicare ratings
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 555717
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Caused actual harm · isolated case
May 8, 2024 · Inspection rule 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Could have caused harm · pattern case
Dec 20, 2024 · Inspection rule 0921
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Could have caused harm · isolated case
Dec 20, 2024 · Inspection rule 0550
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 2 stars
- Health inspection rating: 2 stars
- Staffing rating: 1 stars
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; California averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Caused actual harm1 citation
- Could have caused harm50 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 51
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Limited Liability company.
- We do not have individual owner names for this home.
Other homes in this group: All Windsor nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
December 20, 202416 findings
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0699 · code D
Provide care or services that was trauma informed and/or culturally competent.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0558 · code D
Reasonably accommodate the needs and preferences of each resident.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0921 · code E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0725 · code F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0583 · code E
Keep residents' personal and medical records private and confidential.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0679 · code E
Provide activities to meet all resident's needs.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is…
October 3, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
August 22, 20242 findings
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
July 23, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
July 11, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
May 8, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
December 20, 20231 finding
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
November 16, 202314 findings
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0730 · code E
Observe each nurse aide's job performance and give regular training.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0805 · code E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0813 · code E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Nursing and Physician Services problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0732 · code D
Post nurse staffing information every day.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0677 · code D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code D
Ensure medication error rates are not 5 percent or greater.
- Environmental problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0908 · code D
Keep all essential equipment working safely.
- Environmental problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0919 · code D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- Environmental problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0921 · code D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
October 10, 20231 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0610 · code D
Respond appropriately to all alleged violations.
August 1, 20231 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
December 9, 202112 findings
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Nursing and Physician Services problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0726 · code E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0557 · code D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0558 · code D
Reasonably accommodate the needs and preferences of each resident.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0583 · code D
Keep residents' personal and medical records private and confidential.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code D
Provide enough food/fluids to maintain a resident's health.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- No fines or penalties appear in the records we have.
Other homes in this chain
Windsor · other locations in California
- North Long Beach Post Acute · Long Beach1 of 5 · 87 problems
- Windsor Gardens Convalescent Hospital · Los Angeles1 of 5 · 90 problems
- Delta Oaks Post Acute · Stockton1 of 5 · 115 problems
- River City Post Acute · Carmichael1 of 5 · 93 problems
- Oak Grove Post Acute · Stockton1 of 5 · 128 problems
- Terrace Post Acute · Van Nuys1 of 5 · 88 problems
- Hampton Post Acute · Stockton1 of 5 · 133 problems
- South Coast Post Acute · Santa Ana2 of 5 · 96 problems
Related topics
Questions about Windsor Care Center of Sacramento
What is Windsor Care Center of Sacramento's Medicare star rating?
Has Windsor Care Center of Sacramento been fined?
Does Windsor Care Center of Sacramento have a Medicare abuse warning?
How does Windsor Care Center of Sacramento compare with other nursing homes in California?
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