Federal inspection record · CMS data as of October 1, 2026
Windsor Care Center Of Sacramento
501 Jessie Avenue, Sacramento, CA · (916) 922-8855
- Certified beds
- 128
- Residents per day
- 0
- Ownership
- For-Profit
- Chain
- Windsor
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 30, 1997
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
-
Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
Not ratednot rated
CMS did not rate quality measures here, so they do not move the star.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Windsor Care Center Of Sacramento carries 100 inspection points. That is fewer than 40% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
50 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Resident Rights8E
- E
Keep residents' personal and medical records private and confidential.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- 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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Keep residents' personal and medical records private and confidential.
Quality of Life and Care7E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide care or services that was trauma informed and/or culturally competent.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide enough food/fluids to maintain a resident's health.
Nutrition and Dietary7E
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Freedom from Abuse, Neglect, and Exploitation6D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Pharmacy Service6D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 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 limited.
- 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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- 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.
Resident Assessment and Care Planning5D
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
Nursing and Physician Services4F
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- E
Observe each nurse aide's job performance and give regular training.
- D
Post nurse staffing information every day.
- 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.
Environmental4E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Keep all essential equipment working safely.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Infection Control2E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Inspection history
2024-12-20
15 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2023-11-16
16 health deficiencies · 8 fire-safety deficiencies
Top issue: Environmental (3 deficiencies)
2021-12-09
19 health deficiencies · 2 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days2.2 pts better | 0 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.5 pts better | 0 | 1.5 | 1.7 |
·
Who owns and runs it
7 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Windsor Haysac Holdings LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 2 facilities |
| Antelope Holdings I, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 16 facilities |
| Robin, Aaron | Corporate Officer · Individual | 0% | 29 facilities |
| Shaw, Pamela | Corporate Officer · Individual | 0% | 39 facilities |
| Shaw, Pamela | Operational/Managerial Control · Individual | 0% | 39 facilities |
| Tress, Avrohom | Corporate Officer · Individual | 0% | 30 facilities |
| Windsor Oxford Holding Company, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 3 facilities |
·
Fire safety
16 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems8F
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the use of electrical equipment.
- D
Have proper medical gas storage and administration areas.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
Smoke4F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- C
Inspect, test, and maintain automatic sprinkler systems.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Emergency Preparedness4D
- C
Conduct testing and exercise requirements.
- D
List the names and contact information of those in the facility.
- D
Provide emergency officials' contact information.
- C
Address subsistence needs for staff and patients.
·
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Advanced Health Care of Sacramento
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