Independent research · Occupancy & availability
How full is this provider?
We separate historical occupancy, licensed or reported capacity, and openings that are confirmed today. These are different facts.
Occupancy alone is not a quality rating. An empty bed may be unstaffed or unsuitable for a particular resident. For agencies that deliver care at home, conventional bed occupancy does not apply.
Inspection citations
50 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Dec 20, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Dec 20, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Dec 20, 2024 | E · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Dec 20, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 20, 2024 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Dec 20, 2024 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Dec 20, 2024 | E · potential | Provide activities to meet all resident's needs. | Routine |
| Dec 20, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 20, 2024 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Dec 20, 2024 | F · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Dec 20, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 20, 2024 | D · potential | 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. | Routine |
| Dec 20, 2024 | D · potential | 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. | Routine |
| Dec 20, 2024 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 20, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 20, 2024 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Oct 3, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 22, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 22, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 23, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 11, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| May 8, 2024 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 20, 2023 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Complaint |
| Nov 16, 2023 | D · potential | 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. | Routine |
| Nov 16, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Nov 16, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Nov 16, 2023 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Nov 16, 2023 | E · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Nov 16, 2023 | D · potential | Post nurse staffing information every day. | Routine |
| Nov 16, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Nov 16, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Nov 16, 2023 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Nov 16, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 16, 2023 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Nov 16, 2023 | D · potential | Keep all essential equipment working safely. | Routine |
| Nov 16, 2023 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Nov 16, 2023 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Oct 10, 2023 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Dec 9, 2021 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Dec 9, 2021 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Dec 9, 2021 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Dec 9, 2021 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Dec 9, 2021 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Dec 9, 2021 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 9, 2021 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Dec 9, 2021 | E · potential | 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. | Routine |
| Dec 9, 2021 | D · potential | 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. | Routine |
| Dec 9, 2021 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Dec 9, 2021 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 9, 2021 | D · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Windsor Care Center of Sacramento
501 Jessie Avenue, Sacramento, CA 95838 · (916) 922-8855
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555717
- Certified beds
- 128
- Legal owner
- Windsor Sacramento Estates, LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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