Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento, CA 95838
Windsor Care Center of Sacramento is a nursing home in Sacramento, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionDecember 20, 2024 (1 year ago)
- Health citations since December 9, 202150 (California average 50)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to not rated by CMS.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from not rated by CMS to 1 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to not rated by CMS.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 1 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on December 20, 2024
16 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 16 citations
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on December 27, 2024.
Citation F0583. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0583 2 times since 2021.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0677 2 times since 2023.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on December 27, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0880 2 times since 2021.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0921 2 times since 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0550 2 times since 2021.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0558 2 times since 2021.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0600 5 times since 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0641 3 times since 2021.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0684 2 times since 2021.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on December 27, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0755 2 times since 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 27, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0761 2 times since 2021.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 27, 2024.
CMS has cited this home for F0812 3 times since 2021.
Fire safety inspection on December 20, 2024
6 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 6 citations
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 23, 2025.
CMS has cited this home for K0345 2 times since 2023.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on January 27, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 23, 2025.
CMS has cited this home for K0918 3 times since 2021.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 30, 2024.
CMS has cited this home for K0920 2 times since 2021.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on January 30, 2025.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 31, 2024.
Health inspection on October 3, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 4, 2024.
Health inspection on August 22, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 6, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 6, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on July 23, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 5, 2024.
Health inspection on July 11, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 12, 2024.
CMS update of June 26, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of May 29, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on May 8, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.
Show the 1 citation
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on May 8, 2024.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 29, 2024
Ownership
CMS lists this home under a new chain.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on December 20, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on December 29, 2023.
CMS has cited this home for F0806 2 times since 2021.
Health inspection on November 16, 2023
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation F0730. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on December 25, 2023.
Citation F0805. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on December 25, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 25, 2023.
Citation F0813. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on December 25, 2023.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 25, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on December 25, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 25, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on December 25, 2023.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on December 25, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 25, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on December 25, 2023.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on December 25, 2023.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on December 25, 2023.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on December 25, 2023.
Fire safety inspection on November 16, 2023
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 31, 2023.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 31, 2023.
Citation E0030. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on December 31, 2023.
Citation E0031. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on December 31, 2023.
Citation K0343. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on December 31, 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on December 31, 2023.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on December 31, 2023.
Citation E0015. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on December 31, 2023.
Health inspection on October 10, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 19, 2023.
Health inspection on December 9, 2021
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 9, 2022.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2022.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 9, 2022.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on January 9, 2022.
Citation F0557. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS lists it as corrected on January 9, 2022.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on January 9, 2022.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on January 9, 2022.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on January 9, 2022.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on January 9, 2022.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 9, 2022.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on January 9, 2022.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 9, 2022.
Fire safety inspection on December 9, 2021
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 19, 2022.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 19, 2022.
CMS star ratings
- 1 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- not rated by CMS CMS quality measures star rating
Facts from CMS
- Phone
- (916) 922-8855
- Last standard health inspection
- December 20, 2024 (1 year ago)
- Certified beds
- 128
- Residents per day, on average
- Not listed by CMS
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Windsor Sacramento Estates, LLC
- Chain
- Windsor
- Takes part in
- Medicare and Medicaid
The same number of health citations as the California average (50).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- WINDSOR HAYSAC HOLDINGS LLC5% or greater direct ownership interest · 100% · since 06/01/2010
- ANTELOPE HOLDINGS I, LLC5% or greater indirect ownership interest · no percentage provided · since 06/30/2023
- WINDSOR OXFORD HOLDING COMPANY, LLC5% or greater indirect ownership interest · no percentage provided · since 04/01/2011
- SHAW, PAMELAOperational/managerial control · not applicable · since 06/30/2023
Questions
When was Windsor Care Center of Sacramento last inspected?
CMS lists December 20, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does Windsor Care Center of Sacramento have?
CMS lists 50 health citations since December 9, 2021. CMS also calls these deficiencies.
Has Windsor Care Center of Sacramento been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Windsor Care Center of Sacramento?
Its CMS overall star rating is 1 of 5.
Is Windsor Care Center of Sacramento a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.