Windsor Manor Rehabilitation Center of Concord

    3806 Clayton Rd, Concord, CA, 94521
    4.1 · 52 reviews
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousCurrent/former resident
    1.0

    Understaffed, dirty, inconsistent, dangerous care

    I had a very mixed, mostly disappointing stay. Some nurses, CNAs, PT/OT and the social worker were kind and helpful, but the facility felt understaffed, disorganized and in parts dirty and smelly. My room arrived empty (no mattress, no chair, no towels), maintenance was slow, meals were inedible, meds (antibiotics/blood thinners) were missed, wound-care supplies and security were inadequate, and I even had to sit on a garbage can to eat. Because care and cleanliness were so inconsistent - despite a few excellent staff - I can't recommend this place until major changes are made.

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    Amenities

    4.06 · 52 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.4
    • Staff

      3.5
    • Meals

      1.5
    • Amenities

      2.0
    • Value

      1.0

    Pros

    • Some staff (CNAs and nurses) are caring and helpful
    • Effective, responsive communication from RJ Navarro (text-based)
    • Helpful social worker who assists with paperwork and follow-up
    • Strong PT/OT services reported (7 days/week in some cases)
    • Good wound care reported by some families
    • Clean facility reported by several reviewers
    • Friendly, team-oriented staff in many accounts
    • Smooth discharge process for some patients
    • Quick response to assisted living contacts in some cases
    • Supportive roommate interactions noted
    • Some reviewers highly recommend the facility
    • Successful state survey mentioned by at least one reviewer
    • Prompt assistance with equipment (wheelchairs) in some cases
    • Staff experienced with post-surgery and rehab in some reports
    • Follow-up contact after discharge by staff

    Cons

    • Chronic understaffing and short-staffed shifts
    • Perceived poor quality of nursing care in many reports
    • Unlicensed staff reportedly delivering therapy
    • Questionable or potentially fraudulent Medicare billing
    • Long delays providing basic items (room phone, towels, chairs)
    • Unpalatable, poor-quality food
    • Significant patient weight loss reported
    • Patients left bedbound or in diapers for extended periods
    • Facility providing custodial care rather than skilled nursing
    • Missing medications and wound-care supplies (e.g., PICC support)
    • Lack of cleaning supplies and poor housekeeping
    • Filthy, unkept rooms and common areas; strong odors reported
    • Maintenance delays (air mattress deflated, no regular mattress)
    • Items reportedly stolen from patients
    • Rude or unprofessional staff behavior reported
    • Long waits for diaper changes and unresponsiveness to call buzzers
    • Security concerns (unsecured doors)
    • Missed critical medications (antibiotics, blood thinners) and ER visits
    • COVID infections reported among residents
    • Small, cramped shared rooms with poor privacy
    • Disorganized administration and poor communication in some cases
    • High cost relative to perceived quality
    • Insurance limitations preventing transfer to better facility
    • Inconsistent quality and high variability between shifts/staff
    • Website misrepresentation of facility condition

    Summary review

    Overall sentiment in the reviews for Windsor Manor Rehabilitation Center of Concord is highly mixed but leans toward serious concerns about care consistency, staffing, and basic operational quality. Many reviewers report deeply troubling experiences—chronic understaffing, delays in basic services, missing medications and wound-care supplies, and what they describe as custodial rather than skilled nursing care. There are multiple accounts of residents being left bedbound or in diapers for long periods, long waits to be changed or assisted, missed antibiotics and blood thinners leading to ER visits, and significant weight loss tied to poor food and insufficient nursing attention. Housekeeping and maintenance problems are repeatedly cited: deflated air mattresses, no regular mattress, lack of towels or chairs on arrival, dirty rooms and strong odors, and delayed repairs. Some reviewers also allege theft of patient items and express security concerns such as unsecured doors.

    A persistent theme is inconsistency: some families praise individual staff members and specific teams (notably CNAs, certain nurses, the PT/OT teams, and wound-care personnel), while others report rude, inexperienced, or inattentive caregivers. Several reviews single out RJ Navarro and a helpful social worker for effective communication, follow-up, and assistance with paperwork, discharge coordination, and equipment—these positive experiences include smooth discharges, prompt responses, and supportive interactions. Conversely, other reviewers describe poor administrative responsiveness, disorganized management, and staff turnover or inexperience that they believe contribute to substandard care. This variability suggests that patient experience may depend heavily on the particular shift, team, or case manager assigned.

    Clinical and safety issues raised in multiple reviews are significant: non-licensed staff allegedly providing therapy, missing wound-care devices and medications (including insulin and PICC-line supports), and reports of missed critical doses. Several reviewers explicitly state they raised concerns with the Ombudsman or Medicare, and one review mentions questionable or fraudulent Medicare billing—this elevates the complaints from quality-of-care issues to potential regulatory and legal concerns. COVID outbreaks and infections were also mentioned, further underscoring infection control and safety worries for vulnerable patients.

    Dining and daily living support receive frequent criticism. Many describe the food as unpalatable or "slop," contributing to weight loss and dissatisfaction. There are reports of inadequate dining accommodations (no chairs at arrival, having to sit on a garbage can), and overall limited attention to residents' mealtime needs. By contrast, other reviewers report normal or acceptable meals and praise staff who assist with feeding and mobility. Recreational and visiting spaces receive mixed remarks: some appreciate spacious visiting areas (though parking is tight), while others say visiting areas are untidy and lacking adequate seating.

    Facility condition and cleanliness are contested: some reviewers expressly call the facility "clean" and praise good housekeeping, while a substantial number describe it as old, dirty, smelly, and misrepresented on the website. Maintenance and supplies problems—air mattresses, towels, basic wound supplies, and cleaning materials—are recurrently cited. Security and privacy concerns also appear (small shared rooms with curtains only, unsecured doors). Financial and insurance issues compound frustration for families: high costs, billing questions, and insurance constraints that prevent transfer to preferred facilities exacerbate trust issues.

    In summary, Windsor Manor Rehabilitation Center of Concord shows polarized experiences: there are clear pockets of high-quality, compassionate, and well-coordinated care—especially highlighted by individual caregivers, a few therapy teams, and specific staff members such as RJ Navarro and an involved social worker. However, a large portion of reviews report systemic problems (understaffing, inconsistent clinical care, supply and medication lapses, hygiene and maintenance failures, and potential billing irregularities) that create serious risk and dissatisfaction. Prospective residents and families should be aware of the variability in care, consider asking detailed, specific questions about current staffing levels, medication and wound-care protocols, infection control, recent state surveys, and billing practices, and seek references from recent family contacts. If safety-critical issues (missed meds, wound-care gaps, security, or water/air-mattress problems) are present, escalation to the facility administration, the state survey agency, and the long-term care Ombudsman may be warranted based on the reported patterns.

    Location

    Map showing location of Windsor Manor Rehabilitation Center of Concord

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