NursingHomeGrade

WINDSOR CARE CENTER OF SACRAMENTO

501 JESSIE AVENUE, SACRAMENTO, CA 95838

Operator

WINDSOR HAYSAC HOLDINGS · 2 facilities

Provider number (CCN)
555717
Certification
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified beds
128
Phone
(916) 922-8855
CMS data as of
August 1, 2026
F
●
stable

Deficiencies 0% over tracking period

What the records show

CMS rates WINDSOR CARE CENTER OF SACRAMENTO 2 out of 5 stars overall, with 2 of 5 for health inspections, 1 of 5 for staffing, 5 of 5 for quality measures. Federal inspectors cited 51 health deficiencies across the last three survey cycles, most recently surveyed in 2024, 1 at actual-harm level or higher. CMS lists no fines or payment denials for this facility in the covered period.

Facility Assessment Inspectors recorded 1 citation at the actual-harm level or worse in the last three survey cycles.

Reviews, Ratings and Official Records

This page reviews WINDSOR CARE CENTER OF SACRAMENTO using federal government records — CMS star ratings, health-inspection findings, staffing data and enforcement actions. NursingHomeGrade does not collect, host or publish resident or family testimonials, and no star rating below is a consumer review score.

Partial-data grade: missing RN staffing. Missing components add no positive points. RN staffing data not reported — review the inspection and enforcement records below.

Ratings and Grade Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 Not reported

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 51
Outstanding 0
Actual harm or worse (G–L) 1
CMS Ratings
Federal five-star ratings published by CMS. These are regulatory ratings, not consumer review scores.
Overall: ★★☆☆☆ (2/5)
Health inspection: ★★☆☆☆ (2/5)
Quality: ★★★★★ (5/5)
Staffing: ★☆☆☆☆ (1/5)
NursingHomeGrade Score
 27/100

Loaded into NursingHomeGrade on September 5, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

CMS scores each facility from one to five stars — one is in the bottom fifth of facilities in its state on health inspections, five is in the top tenth. Our own A–F grade is a separate 0–100 score built from staffing hours, inspection citations, and the severity and correction status of those citations, weighted as described in our grading methodology.

Inspection Records Covered

Source records: CMS Care Compare profile for provider 555717 ↗ · the federal files we load and when.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

1 actual harm issue found among 51 total deficiencies. 51 corrected.

Most recent inspection (December 20, 2024)

E Potential harm — pattern F0921 Status: Corrected

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

F Potential harm — widespread F0725 Status: Corrected

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0758 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0761 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

E Potential harm — pattern F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

E Potential harm — pattern F0679 Status: Corrected

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0699 Status: Corrected

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

E Potential harm — pattern F0583 Status: Corrected

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0558 Status: Corrected

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

Inspection cycle 2 (November 16, 2023)

D Potential harm — isolated F0908 Status: Corrected

Keep all essential equipment working safely.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0919 Status: Corrected

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0921 Status: Corrected

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 27, 2024

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 4, 2024

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

E Potential harm — pattern F0730 Status: Corrected

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

E Potential harm — pattern F0805 Status: Corrected

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

E Potential harm — pattern F0813 Status: Corrected

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0677 Status: Corrected

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected September 6, 2024

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0657 Status: Corrected

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

D Potential harm — isolated F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 25, 2023

Inspection cycle 3 (July 23, 2024)

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 5, 2024

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

G Actual harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 8, 2024

D Potential harm — isolated F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 19, 2023

D Potential harm — isolated F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 23, 2023

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

E Potential harm — pattern F0726 Status: Corrected

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0806 Status: Corrected

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 29, 2023

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0806 Status: Corrected

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0761 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0641 Status: Corrected

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0557 Status: Corrected

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0558 Status: Corrected

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

D Potential harm — isolated F0583 Status: Corrected

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2022

Fines and Enforcement Actions

CMS lists no fines and no payment denials for WINDSOR CARE CENTER OF SACRAMENTO in the enforcement records covering the last three years, as published in the file processed August 1, 2026.

Ownership and Contact Information

Facility name
WINDSOR CARE CENTER OF SACRAMENTO
Legal business name
WINDSOR SACRAMENTO ESTATES, LLC
Address
501 JESSIE AVENUE, SACRAMENTO, CA 95838
Phone
(916) 922-8855
Provider number (CCN)
555717
Ownership type
For profit - Limited Liability company
Operator
WINDSOR HAYSAC HOLDINGS · 2 facilities
Medicare/Medicaid certified since
December 30, 1997
Official record
CMS Care Compare profile ↗
Details verified against CMS data dated
August 1, 2026

The federal nursing-home files publish no email address for certified facilities, so none is listed here. We do not guess or construct contact addresses. Contact details above are reproduced from CMS Provider Information; call the facility to confirm before relying on them.

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C

SACRAMENTO POST-ACUTE

5255 HEMLOCK STREET, SACRAMENTO, CA 95841

56/100 score 0.47 hrs RN staffing 12 deficiencies

Sources and Methodology

The NursingHomeGrade score is our own calculation from these federal files — it is not a CMS rating and not a consumer review score. See exactly how the score is calculated · full methodology · source files and load dates.

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