Windsor Care Center of Sacramento
501 Jessie Avenue · Sacramento, CA · 95838 · 9169228855
128 certified beds For profit - Limited Liability company Chain: Windsor
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: not rated Quality measures: 5 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (52 in the current record)
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Potential for harm · D December 20, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 27, 2024 · Resident Rights
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Potential for harm · D December 20, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected December 27, 2024 · Resident Rights
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Potential for harm · E December 20, 2024
Keep residents' personal and medical records private and confidential.
Corrected December 27, 2024 · Resident Rights
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Potential for harm · D December 20, 2024
Ensure each resident receives an accurate assessment.
Corrected December 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · E December 20, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 27, 2024 · Quality of Life and Care
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Potential for harm · E December 20, 2024
Provide activities to meet all resident's needs.
Corrected December 27, 2024 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 27, 2024 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide care or services that was trauma informed and/or culturally competent.
Corrected December 27, 2024 · Quality of Life and Care
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Potential for harm · F December 20, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected December 27, 2024 · Nursing and Physician Services
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Potential for harm · D December 20, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 27, 2024 · Pharmacy Service
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Potential for harm · D December 20, 2024
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 limited.
Corrected December 27, 2024 · Pharmacy Service
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Potential for harm · D December 20, 2024
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.
Corrected December 27, 2024 · Pharmacy Service
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Potential for harm · D December 20, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 27, 2024 · Nutrition and Dietary
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Potential for harm · E December 20, 2024
Provide and implement an infection prevention and control program.
Corrected December 27, 2024 · Infection Control
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Potential for harm · E December 20, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected December 27, 2024 · Environmental
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Potential for harm · D December 20, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 27, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 3, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 4, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 22, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 6, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 23, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 11, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 12, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G May 8, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 8, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 20, 2023 · found via complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected December 29, 2023 · Nutrition and Dietary
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Potential for harm · D November 16, 2023
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.
Corrected December 25, 2023 · Resident Rights
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Potential for harm · D November 16, 2023
Ensure each resident receives an accurate assessment.
Corrected December 25, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555717 · certified since December 30, 1997. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.