Windsor Care Center of Sacramento
Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.
based on 66 Google reviews
Watch Windsor Care Center of Sacramento
Get an email when new inspections, ratings, or penalties are published for this facility.
We’ll only email you about this — no spam, unsubscribe anytime.
What this means for your family
This facility presents a high-risk environment due to a recent and significant pattern of documented neglect, theft, and failure to communicate medical emergencies. While some families still express gratitude for the nursing staff, the severity of the recent allegations regarding patient safety and physical well-being is too significant to ignore. If you choose this facility, you must implement frequent, unannounced visits and verify all medical communications personally.
Google Reviews
Google Reviews
66 reviews on Google“Families should exercise extreme caution when considering Windsor Care Center, as recent reviews are dominated by severe allegations of neglect, physical abuse, and theft. While some long-term residents' families have historically praised the compassionate nursing staff and rehabilitation outcomes, the most recent feedback highlights critical failures in patient safety, including unmonitored falls and lack of communication regarding hospital transfers.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate nursing and DON staff
- Effective physical therapy and rehab
- Dedicated activities staff
Concerns
- Severe neglect and physical abuse allegations (mentioned by 5 reviewers)
- Theft of resident belongings (mentioned by 3 reviewers)
- Understaffing leading to unmonitored falls (mentioned by 2 reviewers)
- Poor communication regarding medical emergencies (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 68 analyzed
How They Respond to Reviews
The owner provides personalized responses by addressing reviewers by name and acknowledging specific details in positive reviews. For negative reviews, they use a consistent template to express regret and attempt to move the conversation to a private channel.
Questions for Your Tour
- 1We've heard wonderful things about the compassion of your nursing and DON staff; how does that culture of care translate to the daily interactions with residents?
- 2With the physical therapy and rehab programs being a noted strength, could you walk us through how a resident's personalized therapy plan is managed?
- 3How does the facility ensure that residents are closely monitored and supported to prevent falls, especially during busy shifts?
- 4What is the protocol for communicating with family members immediately following a medical emergency or a change in a resident's condition?
- 5Could you tell us more about the daily activities organized by your staff and how they help keep residents engaged?
- 6What specific steps are being taken to improve the cleanliness of the resident rooms and common areas?
Personalized based on this facility's data
Key Review Excerpts
“My poor grandmother was mistreated and neglected. Left in her in feces and urine for days at a time. They steal things from the people in this place”
“My mother in law fell down. A nurse called said she was OK. 3 days later my husband received a call from a social worker at a local hospital that she was having hip surgery. We never received a call about her in the hospital.”
“The employees who work here love their residents. Many of the residents don’t have family to visit them especially on holidays. The staff go out of their way to show their love and care for each and every one of them.”
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 14 measures
9
measures
4
measures
1
measures
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
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 needing more daily help over time
Residents whose walking got worse
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed multiple complaints about resident protection and safety, triggering 15 investigations that revealed recurring deficiencies in abuse prevention, medication management, and food service. The facility shows persistent issues with protecting residents from abuse and neglect, appearing in complaints from 2023 through 2024. While all deficiencies report correction dates, the pattern of repeated violations in critical care areas suggests ongoing operational challenges that families should carefully evaluate.
Dec 20, 2024Complaint2
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Dec 20, 2024Routine20
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
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
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
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.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Oct 3, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Aug 22, 2024Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Jul 23, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Jul 11, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ownership & Operations
Who Operates This Facility
Windsor Care Center of Sacramento
for profit
Chain Affiliation
Windsor
23 facilities nationwide
Chain avg rating: 2.3/5 · Rank 12 of 19
Ownership & Management
Owners
Windsor Haysac Holdings LLC
Owner · Organization
Antelope Holdings I, LLC
Owner (parent company) · Organization
Windsor Oxford Holding Company, 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
66 reviews from families & visitors
Official Website
Visit windsorsacramento.com
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
Nearby Alternatives
Twin Rivers at Natomas
1.4 miAssisted Living · Sacramento, CA
The Woodlake
3.2 miAssisted Living · Sacramento, CA
Woodside Healthcare Center
4.9 miNursing Home · Sacramento, CA
The Chateau at River's Edge
5.1 miAssisted Living · Sacramento, CA
Cajucom Care Home #2
5.1 miAssisted Living · Sacramento, CA
Asbury Park Nursing & Rehabilitation Center
5.3 miNursing Home · Sacramento, CA