Delta Oaks Post Acute
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 62 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (1/5 stars)
- Above-median deficiencies (27 vs median 13.0)
Bottom 25% in CA · Below recommended RN staffing · Above recommended total nurse staffing · Worst in WINDSOR chain · No penalties on record · Abuse citation
What this means for your family
This facility's recent reviews show a dangerous trend of medical neglect and poor hygiene. If you choose this facility, you must perform daily, unannounced visits to check for skin integrity and ensure call lights are being answered promptly.
Google Reviews
Google Reviews
62 reviews on Google“Families considering Delta Oaks Post Acute should exercise extreme caution due to frequent and severe allegations of medical neglect, including untreated wounds, sepsis, and failure to respond to call lights. While some reviewers praise the friendliness of the reception and certain nursing staff, there is a significant pattern of reports regarding poor hygiene, lack of therapy services, and inadequate staffing.”
Quality Themes
Tap a score for detailsStrengths
- Friendly reception and administrative staff
- Attentive CNAs in certain units
- Recent lobby and dining area renovations
Concerns
- Severe medical neglect and wound mismanagement (mentioned by 4 reviewers)
- Unresponsive call lights and difficulty reaching staff (mentioned by 5 reviewers)
- Poor facility hygiene and strong odors of urine (mentioned by 4 reviewers)
- Inadequate staffing levels (mentioned by 3 reviewers)
- Discrepancies in advertised rehabilitation/gym services (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 65 analyzed
How They Respond to Reviews
The owner uses highly standardized, template-based responses that follow a consistent structure of expressing concern and requesting an offline conversation. While they address the reviewer by name, they do not provide specific solutions or address the unique details of the complaints.
Questions for Your Tour
- 1It is wonderful to see the recent renovations in the lobby and dining area; could you tell us more about the meal program and how residents participate in group dining?
- 2We noticed the administrative team is very welcoming; how do you ensure that communication remains just as consistent between the nursing staff and family members?
- 3With the recent focus on facility updates, what specific steps are being taken to ensure the highest standards of cleanliness and hygiene in the resident rooms?
- 4How does the nursing team manage medication administration and monitor for any changes in a resident's skin health or wound care?
- 5What is the protocol for responding to call lights, and how do you ensure staff are available to assist residents promptly during the night?
- 6Can you walk us through the specific rehabilitation and gym services currently available to residents working on their mobility?
Personalized based on this facility's data
Key Review Excerpts
“The employees at this location neglected my relative to the point that there were 3 separate times having pneumonia, had sepsis, had maggots in a wound, multiple bed sores, and did not follow thru with ANY of the agreed to contact and care plan for my relative.”
“I'm very thankful with this facility. I love how we were able to work together to help my mom get better and reached the goals we had put . One of the many goals we had put for my mom was to get off the ventilador and then trache . It was met and my mom was eventually able to breathe on her own”
“The first six months after a stroke are the most important. If anything is going to come back it’s within those first six months. I feel like this place does the bare minimum. No therapy no nothing.”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
5
measures
7
measures
5
measures
Residents vaccinated for the flu
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents whose walking got worse
Residents who lost too much weight
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility shows a concerning pattern of frequent family complaints triggering federal investigations, with 58 complaint-driven deficiencies indicating serious ongoing issues. The most recurring problems involve safety hazards and accident prevention, medication management, and infection control practices. While the facility corrects cited deficiencies, the persistent pattern of complaints across multiple years suggests underlying care quality issues that families should carefully investigate before placement.
Mar 5, 2026Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Feb 17, 2026Complaint2
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Dec 30, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Dec 4, 2025Complaint1
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Nov 24, 2025Complaint1
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Oct 2, 2025Routine15
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Ownership & Operations
Who Operates This Facility
Delta Oaks Post Acute
for profit
Chain Affiliation
Windsor
23 facilities nationwide
Chain avg rating: 2.3/5 · Rank 17 of 19 (Worst)
Ownership & Management
Owners
Windsor Norcal 13 Holdings LLC
Owner · Organization
Antelope Holdings I, LLC
Owner (parent company) · Organization
Tress, Avrohom
Owner (parent company)
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
62 reviews from families & visitors
Medicare data downloads
Original nursing home datasets
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