★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures
Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Findings, latest cycle24
Findings with harm or immediate jeopardy, 3 cycles3
Fines, 3 years$8,824
Beds136
Medicare has flagged this home for abuse: an inspection found that a resident was harmed by abuse, or there were repeated findings of possible abuse.
Inspection findings
Inspectors recorded 77 findings in the last three inspection cycles.
Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| May 14, 2026 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm isolated | Corrected: Jun 4, 2026 |
| May 14, 2026 | Building and environment | Keep all essential equipment working safely. (F0908) | No harm, but a risk of harm pattern | Corrected: Jun 4, 2026 |
| May 14, 2026 | Food and nutrition | Dispose of garbage and refuse properly. (F0814) | No harm, but a risk of harm pattern | Corrected: Jun 4, 2026 |
| May 14, 2026 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Jun 4, 2026 |
| May 14, 2026 | Food and nutrition | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (F0805) | No harm, but a risk of harm pattern | Corrected: Jun 4, 2026 |
| May 14, 2026 | Food and nutrition | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (F0803) | No harm, but a risk of harm isolated | Corrected: Jun 4, 2026 |
| May 14, 2026 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm pattern | Corrected: Jun 4, 2026 |
| May 14, 2026 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated | Corrected: Jun 4, 2026 |
| May 14, 2026 | Resident assessment and care planning | Ensure each resident receives an accurate assessment. (F0641) | No harm, but a risk of harm isolated | Corrected: Jun 4, 2026 |
| May 14, 2026 | Resident assessment and care planning | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. (F0640) | No harm, but a risk of harm isolated | Corrected: Jun 4, 2026 |
| May 14, 2026 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 4, 2026 |
| Mar 30, 2026 | Abuse, neglect and exploitation | Protect each resident from the wrongful use of the resident's belongings or money. (F0602) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 2, 2026 |
| Mar 11, 2026 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 27, 2026 |
Earlier inspections (64)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Feb 6, 2026 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 10, 2026 |
| Feb 6, 2026 | Resident rights | 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. (F0584) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 10, 2026 |
| Feb 5, 2026 | Resident rights | 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. (F0584) | No harm, but a risk of harm isolated · from a complaint | Corrected: Feb 6, 2026 |
| Jan 29, 2026 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 30, 2026 |
| Jan 20, 2026 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 26, 2026 |
| Jan 13, 2026 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 26, 2026 |
| Nov 24, 2025 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 25, 2025 |
| Nov 24, 2025 | Resident rights | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. (F0628) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 25, 2025 |
| Nov 24, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 25, 2025 |
| Nov 13, 2025 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 16, 2025 |
| Nov 13, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 16, 2025 |
| Jul 21, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 1, 2025 |
| Jul 21, 2025 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm isolated · from a complaint | Corrected: Aug 1, 2025 |
| Jun 19, 2025 | Resident rights | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 3, 2025 |
| Jun 12, 2025 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 20, 2025 |
| Jun 5, 2025 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 6, 2025 |
| Jun 4, 2025 | Nursing and physician services | 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. (F0726) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 13, 2025 |
| Jun 4, 2025 | Quality of life and care | Provide safe, appropriate pain management for a resident who requires such services. (F0697) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 13, 2025 |
| May 6, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 12, 2025 |
| Apr 17, 2025 | Quality of life and care | Provide appropriate foot care. (F0687) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 25, 2025 |
| Apr 17, 2025 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 25, 2025 |
| Apr 8, 2025 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Apr 9, 2025 |
| Feb 27, 2025 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Building and environment | Keep all essential equipment working safely. (F0908) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Food and nutrition | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. (F0808) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Food and nutrition | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (F0802) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Quality of life and care | Provide safe, appropriate pain management for a resident who requires such services. (F0697) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Quality of life and care | Provide activities to meet all resident's needs. (F0679) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm pattern | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Feb 27, 2025 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated | Corrected: Mar 19, 2025 |
| Jan 14, 2025 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 31, 2025 |
| Jan 2, 2025 | Quality of life and care | Provide safe, appropriate pain management for a resident who requires such services. (F0697) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jan 23, 2025 |
| Nov 12, 2024 | Abuse, neglect and exploitation | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600) | No harm, but a risk of harm isolated · from a complaint | Corrected: Nov 25, 2024 |
| Jun 27, 2024 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 26, 2024 |
| Mar 13, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Mar 13, 2024 |
| Feb 16, 2024 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm isolated | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Building and environment | Keep all essential equipment working safely. (F0908) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Food and nutrition | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (F0806) | No harm, but a risk of harm isolated | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Food and nutrition | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F0804) | No harm, but a risk of harm widespread | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Pharmacy and medications | 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. (F0758) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm widespread | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Quality of life and care | Provide safe, appropriate dialysis care/services for a resident who requires such services. (F0698) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Quality of life and care | Provide safe, appropriate pain management for a resident who requires such services. (F0697) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Resident assessment and care planning | Ensure services provided by the nursing facility meet professional standards of quality. (F0658) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Resident assessment and care planning | Assure that each resident’s assessment is updated at least once every 3 months. (F0638) | No harm, but a risk of harm isolated | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Resident rights | 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. (F0584) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Feb 16, 2024 | Resident rights | Keep residents' personal and medical records private and confidential. (F0583) | No harm, but a risk of harm pattern | Corrected: Mar 12, 2024 |
| Dec 22, 2023 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Dec 17, 2023 |
| Dec 22, 2023 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Dec 22, 2023 |
| Nov 17, 2023 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | Actual harm to a resident isolated · from a complaint | Corrected: Dec 17, 2023 |
| Oct 20, 2023 | Resident assessment and care planning | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F0842) | No harm, but a risk of harm isolated · from a complaint | Corrected: Oct 27, 2023 |
| Oct 20, 2023 | Food and nutrition | Dispose of garbage and refuse properly. (F0814) | No harm, but a risk of harm isolated · from a complaint | Corrected: Oct 27, 2023 |
| Oct 20, 2023 | Quality of life and care | Provide care and assistance to perform activities of daily living for any resident who is unable. (F0677) | No harm, but a risk of harm isolated · from a complaint | Corrected: Oct 27, 2023 |
Fines and payment denials
Federal fines in the last three years: $8,824 (1). Payment denials: 0.
| Date | Type | Amount |
|---|---|---|
| Feb 16, 2024 | Fine | $8,824 |
Staffing
| Nurse staff hours per resident per day | 3.88 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.90 | California median: 0.52 |
| Nurse staff hours on weekends | 3.62 | California median: 3.85 |
| Nursing staff who left within a year | 23.6% | California median: 36.0% |
About this home
| Beds | 136 |
| Residents per day, average | 129.2 |
| Ownership | For-profit, limited liability company |
| Legal business name | Windsor Elk Grove Care and Rehabilitation LLC |
| Chain | Windsor (22 homes) |
| In Medicare/Medicaid since | Jan 1, 1967 |
Questions to ask when you call
- What was corrected after the last inspection?
- How many staff work at night and on weekends?
- Does anyone on staff speak my relative's language?
- May I visit at any time, without an appointment?
Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov