The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
Windsor Elk Grove Care and Rehabilitation Center
Registered name: Elk Grove Post Acute
Elk Grove, CA · Medicare-certified · 136 beds
Needs attention
Abuse citationFor-profitChain member
Data as of July 1, 2026
3 of 5 overall
Windsor Elk Grove Care and Rehabilitation Center has an overall rating of 3 out of 5 stars. Its health inspection rating is 2 out of 5 stars, staffing is 4 out of 5 stars, quality measures are 5 out of 5 stars, reported nurse staffing is below the federal benchmark (3.79 vs. 4.1 hours per resident day), and it has a recent abuse citation; there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
3.7916 hrs/resident/day
Quality measures
Last inspection: May 14, 2026Penalties, last 24 months: $0recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.7916.
Staffing detail
- Registered nurses
- 0.85
- Licensed practical nurses
- 0.64
- Nurse aides
- 2.30
- Weekend nursing
- 3.63
Hours per resident per day.
Total staff turnover: 23%
Registered nurse turnover: 20%
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
11.5%10.3%Improving
Residents with a fall causing major injury
2.9%3%No change
Residents with pressure ulcers (bedsores)
3.4%5.6%Worsening
Residents with a urinary tract infection
0%3%Worsening
Residents who lost too much weight
12.8%3.2%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
2.5%5.1%Worsening
Residents whose ability to walk got worse
8.8%20.8%Worsening
Long-stay residents on antianxiety or sleep medication
10.5%8.6%Improving
Short-stay residents newly given an antipsychotic
0.6%0.6%No change
Residents with a long-term catheter
0.9%1.5%Worsening
Residents with new or worsening incontinence
3.1%10.7%Worsening
Residents with depressive symptoms
2.1%3.2%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
—98.1%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—99%—
Short-stay residents given the pneumonia vaccine
99.6%97.6%Worsening
What the inspectors found
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: F
The home failed to make food and drinks appealing and served them at a safe, appetizing temperature. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 804 — 42 CFR §483.60 — S/S: F
The home failed to properly label and securely store medications and biologicals. Cited May 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — S/S: E
The home failed to ensure residents received food prepared in a form that met their individual needs. Cited May 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 805 — 42 CFR §483.60 — 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 11 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 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $8,824 in total fines.
- $8,824
Federal fine
Feb 16, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of WINDSOR · 23 homes · 2.4 stars avg
- Occupancy
- 130.2 residents on an average day (96% of 136 beds)
- Medicare history
- Certified for 59 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.