The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited March 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Windsor Country Drive Care Center
Registered name: Country Drive Post Acute
FREMONT, CA · Medicare-certified · 126 beds
In good standing
For-profitChain member
Data as of July 1, 2026
3 of 5 overall
Windsor Country Drive Care Center in Fremont has an overall rating of 3 out of 5 stars, with 3-star health inspections and 4-star staffing and quality measures. It reported 3.75 nurse hours per resident per day versus the 4.1 federal benchmark, had $0 in fines in the last 24 months, and recent inspection citations included pressure ulcer care, enough nursing staff on every shift, and food safety/handling.
Facility ratings
Health inspections
Staffing
3.7471 hrs/resident/day
Quality measures
Last inspection: February 23, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.7471.
Staffing detail
- Registered nurses
- 0.69
- Licensed practical nurses
- 0.68
- Nurse aides
- 2.38
- Weekend nursing
- 3.61
Hours per resident per day.
Total staff turnover: 32%
Registered nurse turnover: 19%
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
3.8%3.8%No change
Residents with a fall causing major injury
1.2%2.5%Worsening
Residents with pressure ulcers (bedsores)
10.2%8.7%Improving
Residents with a urinary tract infection
0%1.3%Worsening
Residents who lost too much weight
5.3%7.1%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
0%7.4%Worsening
Residents whose ability to walk got worse
13.1%9.9%Improving
Long-stay residents on antianxiety or sleep medication
3.9%9.7%Worsening
Short-stay residents newly given an antipsychotic
0.5%0%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
22.5%29.4%Worsening
Residents with depressive symptoms
0%65.8%Worsening
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
—89.2%—
Long-stay residents given the pneumonia vaccine
86.7%87.7%Improving
Short-stay residents given the seasonal flu vaccine
—63.4%—
Short-stay residents given the pneumonia vaccine
42.5%72.8%Improving
What the inspectors found
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited May 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to give residents clear notice of their rights, rules, services, and charges. Cited February 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 572 — 42 CFR §483.10 — S/S: E
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 August 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 5 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of WINDSOR · 23 homes · 2.4 stars avg
- Occupancy
- 112.1 residents on an average day (89% of 126 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 58 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.