Nursing homes › California › Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento, CA 95838 · 9169228855 · 128 certified beds
Per CMS filings, this facility is affiliated with Windsor, a group operating 23 facilities in 1 states. Group record: average rating 2.4/5, 7 abuse citation icons, 1 facilities on the Special Focus list, $484,622 in federal fines. This facility rates below its group average (2.4/5).
All-time on record: 52 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2024-12-20 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Health | corrected 2024-12-27 |
| 2024-12-20 | Keep residents' personal and medical records private and confidential. | E | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide activities to meet all resident's needs. | E | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide and implement an infection prevention and control program. | E | Health | corrected 2024-12-27 |
| 2024-12-20 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Health | corrected 2024-12-27 |
| 2024-12-20 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Reasonably accommodate the needs and preferences of each resident. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Ensure each resident receives an accurate assessment. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide care or services that was trauma informed and/or culturally competent. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | 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 | Health | corrected 2024-12-27 |
| 2024-12-20 | 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 | Health | corrected 2024-12-27 |
| 2024-12-20 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Health | corrected 2024-12-27 |
| 2024-12-20 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2024-12-27 |
| 2024-10-03 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2024-10-04 |
| 2024-08-22 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2024-09-06 |
| 2024-08-22 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2024-09-06 |
| 2024-07-23 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2024-08-05 |
| 2024-07-11 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-07-12 |
| 2024-05-08 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2024-05-08 |
| 2023-12-20 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | complaint | corrected 2023-12-29 |
| 2023-11-16 | Observe each nurse aide's job performance and give regular training. | E | Health | corrected 2023-12-25 |
| 2023-11-16 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | E | Health | corrected 2023-12-25 |
| 2023-11-16 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2023-12-25 |
| 2023-11-16 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | E | Health | corrected 2023-12-25 |
| 2023-11-16 | 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 | Health | corrected 2023-12-25 |
| 2023-11-16 | Ensure each resident receives an accurate assessment. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Post nurse staffing information every day. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Keep all essential equipment working safely. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Health | corrected 2023-12-25 |
| 2023-11-16 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | Health | corrected 2023-12-25 |
| 2023-10-10 | Respond appropriately to all alleged violations. | D | complaint | corrected 2023-10-19 |
| 2023-08-01 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2023-08-23 |
| 2023-07-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2023-08-25 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| WINDSOR HAYSAC HOLDINGS LLC | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 06/01/2010 |
| 9560 PICO LLC | 5% Or Greater Indirect Ownership Interest | Organization | NO PERCENTAGE PROVIDED | since 06/30/2023 |
| ANTELOPE HOLDINGS I, LLC | 5% Or Greater Indirect Ownership Interest | Organization | NO PERCENTAGE PROVIDED | since 06/30/2023 |
| PICO AR LLC | 5% Or Greater Indirect Ownership Interest | Organization | NO PERCENTAGE PROVIDED | since 06/30/2023 |
| WINDSOR OXFORD HOLDING COMPANY, LLC | 5% Or Greater Indirect Ownership Interest | Organization | NO PERCENTAGE PROVIDED | since 04/01/2011 |
| ROBIN, AARON | 5% Or Greater Indirect Ownership Interest | Individual | NO PERCENTAGE PROVIDED | since 06/30/2023 |
| TRESS, AVROHOM | 5% Or Greater Indirect Ownership Interest | Individual | NO PERCENTAGE PROVIDED | since 06/30/2022 |
| ROBIN, AARON | Corporate Officer | Individual | NOT APPLICABLE | since 08/14/2023 |
| SHAW, PAMELA | Corporate Officer | Individual | NOT APPLICABLE | since 06/30/2023 |
| TRESS, AVROHOM | Corporate Officer | Individual | NOT APPLICABLE | since 08/14/2023 |
| SHAW, PAMELA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 06/30/2023 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 555717. Corrections: data@carerecords.org.