The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited November 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Windsor Post-Acute Center of Bakersfield
Registered name: BAKERSFIELD POST ACUTE
BAKERSFIELD, CA · Medicare-certified · 99 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
1 of 5 overall
Windsor Post-Acute Center of Bakersfield has a 1-star overall rating, with a 1-star health inspection rating, recent federal penalty/fines of $13,340, and nurse staffing of 4.01 hours per resident per day, just below the 4.1 federal benchmark. Staffing and quality measures are both 3 stars.
Facility ratings
Health inspections
Staffing
4.0143 hrs/resident/day
Quality measures
Last inspection: May 14, 2026Penalties, last 24 months: $13,340recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.0143.
Staffing detail
- Registered nurses
- 0.36
- Licensed practical nurses
- 1.09
- Nurse aides
- 2.56
- Weekend nursing
- 3.58
Hours per resident per day.
Total staff turnover: 39%
Registered nurse turnover: 38%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
10.9%3.8%Improving
Residents with a fall causing major injury
1.4%2.6%Worsening
Residents with pressure ulcers (bedsores)
2.8%2.2%Improving
Residents with a urinary tract infection
1.5%0%Improving
Residents who lost too much weight
1.7%0%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
5%5%No change
Residents whose ability to walk got worse
—14.8%—
Long-stay residents on antianxiety or sleep medication
14.5%12.5%Improving
Short-stay residents newly given an antipsychotic
0%1.4%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
4.6%10.4%Worsening
Residents with depressive symptoms
7.8%2.8%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—98.7%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The nursing home failed to develop and carry out a complete care plan that met each resident’s needs with clear steps and timelines. Cited October 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 656 — 42 CFR §483.21(b)(1) — S/S: G
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited November 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited August 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
The nursing home failed to post its nurse staffing information every day, so families could not easily see daily staffing levels. Cited August 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 732 — 42 CFR §483.35(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 22 health deficiencies.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $13,340 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $25,940 in total fines · 1 payment denial.
- 31 days
Medicare/Medicaid payment denial
Oct 17, 2024
- $13,340
Federal fine
Oct 17, 2024
- $12,600
Federal fine
Oct 26, 2023
Operator & ownership
Recent ownership change · Mar 1, 2023
Now operated by Bakersfield Post Acute, previously Windsor Post Acute Center of Bakersfield.
- Ownership
- For profit - Corporation
- Chain
- Part of PACS GROUP · 281 homes · 2.8 stars avg
- Occupancy
- 91.4 residents on an average day (92% of 99 beds)
- Medicare history
- Certified for 39 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.