Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Double Tree Post Acute Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was struck in the head by another resident with intact cognition, resulting in pain and dizziness that required hospital evaluation. The incident occurred without staff present, and both individuals confirmed their involvement. Facility policy affirms the right to be free from abuse, but this right was not upheld in this case.
A resident with a history of aggression and alcohol-induced psychotic disorder was pushed by a visitor during an altercation. Despite documented aggressive behavior, there was no person-centered care plan addressing the risk, and the incident was witnessed by an LPN. Facility policy requires protection from abuse by anyone, but the resident was not safeguarded from physical abuse.
A resident was involved in a physical altercation with a visitor, during which both parties pushed each other. Although staff intervened and documented the event, the allegation of abuse was not reported to the state department within the required 2-hour window. Interviews with staff and review of facility policy confirmed that the delay was due to a lack of recognition that the incident was reportable.
A facility failed to protect a resident from physical abuse when a staff member witnessed an altercation between two residents. One resident, diagnosed with anxiety disorder, hit another resident with hemiplegia during a dispute over cigarettes on the smoking patio. Both residents confirmed the altercation, and facility policies on abuse prevention and residents' rights were not upheld.
A resident with Type 2 Diabetes Mellitus experienced dangerously high glucose levels due to the failure of LNs to follow physician orders and administer insulin correctly. The resident's blood sugar levels were not documented accurately, and symptoms of hyperglycemia were reported. Interviews revealed a lack of adherence to facility policies and procedures.
The facility failed to manage an emergency kit (e-kit) properly, which was found unsealed and undocumented in the medication storage room. A nurse could not confirm when the e-kit was opened or replaced, and it lacked required pharmacist signatures. The Director of Nursing and a registered pharmacist acknowledged the e-kit should have been sealed, labeled, and documented according to the facility's policy.
A LTC facility failed to maintain a medication error rate below 5% for two residents. A nurse did not administer insulin and Glipizide as per physician orders for one resident, and administered lactobacillus without verifying the strength for another. The DON acknowledged these errors, which were contrary to the facility's medication administration policy.
A resident in an LTC facility experienced significant medication errors when an LPN failed to administer Humulin R insulin and glipizide according to physician orders. The insulin was not given despite a high blood sugar reading, and the glipizide was administered after breakfast instead of 30 minutes before. These actions led to the resident experiencing symptoms of high blood sugar.
The facility failed to properly store and label medications, including latanoprost, glucose test strips, and insulin lispro, leading to potential medication errors. Expired Tuberculin vials and an unlabeled polyethylene glycol bottle were found, and the medication refrigerator was out of the required temperature range.
The facility failed to maintain the walk-in freezer in a safe condition, affecting 115 residents. Ice buildup was observed on the walls, ceiling, and food boxes, attributed to temperature fluctuations and old equipment. The Dietary Manager, Maintenance Supervisor, Registered Dietician, and Director of Nursing were aware of the issue, which posed risks to food quality and safety. Despite facility policies emphasizing safe food storage, the problem persisted.
Two residents with malnutrition diagnoses did not receive their prescribed supplement drinks as indicated on their meal tray tickets. The Dietary Supervisor and CNA acknowledged the omissions, and the RD and DON confirmed the importance of accurate meal trays to meet nutritional needs.
The facility failed to protect four residents from abuse, resulting in two separate altercations where two residents sustained skin tears. Despite the facility's abuse prevention policy, the incidents were confirmed as abuse by the Social Services Director and a Licensed Nurse.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when one resident with severe cognitive impairment was struck in the head by another resident with intact cognition. The incident was confirmed through clinical record review, interviews, and documentation. The resident who was hit reported pain and dizziness following the altercation and was sent to the hospital for evaluation. The altercation took place in a room without staff present, and both residents acknowledged their involvement in the incident during interviews. The facility's policy states that residents have the right to be free from abuse, including physical abuse. Despite this, the facility failed to protect this right, resulting in one resident experiencing pain and ongoing discomfort after being hit. The event was documented in the residents' clinical records and confirmed by the DON, who acknowledged the residents' rights as outlined in facility policy.
Resident Not Protected from Physical Abuse by Visitor
Penalty
Summary
A resident with a diagnosis of alcohol-induced psychotic disorder and intact cognition was involved in an altercation with a visitor, during which the visitor pushed the resident. Prior to the incident, the resident had exhibited verbal and physical aggression toward both visitors and staff, as documented in the SBAR communication tool. Despite this history, there was no documented evidence of a person-centered care plan addressing the resident's potential risk of aggression. The incident was witnessed by a licensed nurse, and the facility's policy states that residents must be free from abuse by anyone, including visitors. The failure to implement appropriate care planning and protective measures resulted in the resident not being protected from physical abuse by a visitor.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident and a visitor was reported to the appropriate authorities within the required 2-hour timeframe. On the evening of 7/1/25, a resident became verbally aggressive and pushed a visitor, who then pushed the resident in response. Staff intervened and calmed the situation. The incident was documented in the facility's records, and the primary care clinician was notified the same evening. However, the initial report to the state department was not faxed until the following day, more than 2 hours after the incident occurred and was recognized as a potential abuse situation. Interviews with facility staff, including licensed nurses and the Director of Nursing (DON), confirmed awareness of the requirement to report abuse allegations within 2 hours. The DON stated that the delay in reporting was due to not recognizing the incident as a reportable event at the time. Review of facility policy and federal regulations further confirmed the obligation to immediately report all suspected abuse, neglect, or mistreatment. The failure to report the incident in a timely manner constituted noncompliance with both facility policy and federal requirements.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a staff member witnessed an altercation between two residents. Resident 1, who had intact cognition and was diagnosed with anxiety disorder and muscle weakness, was seen hitting Resident 2, who also had intact cognition and was diagnosed with hemiplegia and reduced mobility. The incident occurred on the smoking patio, where Resident 1 confronted Resident 2 over a dispute involving cigarettes. The Director of Nursing was informed of the incident by a janitor who witnessed the altercation, and the Social Services Director confirmed the event through video observation. Interviews with both residents confirmed the physical altercation, with Resident 1 admitting to hitting Resident 2 in the face, and Resident 2 attempting to retaliate. Progress notes and communication forms documented the incident, including Resident 1's admission of hitting Resident 2 and Resident 2's account of being struck in the head. The facility's policies on abuse prevention and residents' rights emphasize the commitment to protecting residents from abuse and ensuring they are treated with respect and dignity, which was not upheld in this instance.
Failure to Manage Diabetes Leads to Hyperglycemia
Penalty
Summary
The facility failed to properly manage a resident's Type 2 Diabetes Mellitus, leading to dangerously high glucose levels and symptoms of hyperglycemia. The Licensed Nurses (LNs) did not follow physician orders, resulting in the resident not receiving the prescribed morning insulin. The resident's blood sugar level was recorded at 466 mg/dl, which was above the sliding scale order, yet the LN did not notify the physician or administer the necessary insulin. Throughout the day, the resident continued to experience high blood sugar levels, with readings reaching as high as 577 mg/dl. Despite these critical levels, the LNs failed to document the readings accurately and did not administer the correct insulin dosage as per the physician's orders. The resident complained of symptoms such as headache, dizziness, and thirst, indicating the severity of the hyperglycemia. Interviews with the LNs revealed a lack of understanding and adherence to the facility's policies and procedures regarding insulin administration and changes in a resident's condition. The Director of Nursing acknowledged the failure to follow physician orders and the potential harm caused by untreated hyperglycemia. The facility's documentation system also had limitations, as it could not record non-numerical values for blood sugar levels, further complicating the situation.
Failure to Manage Emergency Kit in Medication Storage
Penalty
Summary
The facility failed to properly manage an emergency kit (e-kit) containing medications, which was observed to be unsealed in the north station medication storage room. A Licensed Nurse (LN) was unable to provide information on when the e-kit was opened or when it should have been replaced. The use of the e-kit was not logged in the e-kit logbook, and the contracted facility pharmacy was not contacted for a replacement. Additionally, the e-kit lacked the required pharmacist signatures on the white labels, indicating a failure in the verification and documentation process. Interviews with the Director of Nursing (DON) and a registered pharmacist (RPh) revealed that the e-kit should have been sealed, properly labeled with pharmacist signatures, and documented for any use. The facility's policy and procedure for emergency pharmacy services, dated 2007, requires that any medication or supply item removed from the e-kit be documented and communicated to the pharmacy. The failure to adhere to these procedures could lead to expired pharmaceutical products, decreased availability of medications in an emergency, or increased risk of drug diversion.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5% for two residents, leading to potential adverse health outcomes. For Resident 31, a Licensed Nurse (LN) did not administer Humulin Insulin as per the physician's order. The resident's blood sugar level was recorded at 466 mg/dl, which required a specific insulin dosage and notification to the Medical Doctor (MD), neither of which were carried out. Additionally, the same resident was given Glipizide after breakfast, contrary to the physician's order to administer it 30 minutes before a meal. For Resident 103, the LN administered lactobacillus without verifying the strength of the medication as per the physician's order. The order lacked specific strength details, and the LN failed to consult the medication label or seek clarification from the MD or charge nurse. This oversight could have led to improper dosing, as the label indicated a different serving size than what was administered. The Director of Nurses (DON) acknowledged these errors, confirming that the medications were not administered according to the prescriber's orders. The facility's policy and procedure for administering medications, which emphasizes adherence to prescriber orders and timing, was not followed in these instances, exposing residents to potential health risks.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of insulin and glipizide. Licensed Nurse (LN) 1 did not administer the resident's Humulin R insulin as per the physician's order. The resident's blood sugar level was recorded at 466 mg/dl at 6 a.m., but LN 1 did not administer the insulin dose required for such a high level, nor did they notify the physician. This oversight led to the resident experiencing symptoms of high blood sugar, including headache, dizziness, thirst, and general malaise. The facility's policy requires medications to be administered according to prescriber orders, which was not followed in this instance. Additionally, LN 1 administered the resident's glipizide 5 mg after breakfast, contrary to the physician's order to give it 30 minutes before a meal. LN 1 acknowledged the error, noting that the breakfast tray was delivered about thirty minutes before the medication was given. The Director of Nursing confirmed that LN 1 failed to administer the medication as ordered. The facility's policy emphasizes that medication administration times should be determined by resident need and benefit, not staff convenience, which was not adhered to in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Three unopened bottles of latanoprost ophthalmic solution were found in a medication cart instead of being refrigerated as per the manufacturer's instructions. Additionally, an opened glucose test strip bottle and an opened bottle of insulin lispro were found without open dates, making it impossible to determine their expiration dates. These oversights were acknowledged by the Licensed Nurse (LN) and the Director of Nursing (DON), who confirmed that staff were expected to follow the manufacturer's instructions and facility policies regarding medication storage and labeling. Further deficiencies were identified in the North Station Medication room, where two expired multidose vials of Tuberculin purified protein derivative were found. These vials had been opened beyond the 30-day usage period specified on the product label. Additionally, a prescription bottle of polyethylene glycol with electrolytes was found without a patient-specific prescription label, which could lead to medication errors. The DON acknowledged these issues and confirmed that medications should be properly labeled and expired medications removed. The temperature of the medication refrigerator in the North Station Medication room was also found to be out of range, recorded at 30 degrees Fahrenheit, which is below the required range of 36 to 46 degrees Fahrenheit. This issue persisted for 13 out of 30 days in September, as noted in the facility's temperature log. The DON acknowledged that the refrigerator's temperature was not within the required range, which is necessary for the safe storage of pharmaceutical products requiring refrigeration.
Ice Buildup in Walk-In Freezer Compromises Food Safety
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, affecting 115 residents who received facility-prepared foods. During an observation and interview with the Dietary Manager (DM), ice buildup was noted on the walls, ceiling, and boxes of food within the freezer. The DM acknowledged the issue, attributing it to temperature fluctuations caused by the door opening and closing. The Maintenance Supervisor (MS) also confirmed awareness of the ice buildup, suggesting it was due to old equipment and insulation issues, but was unaware of the potential impact on food quality. The Registered Dietician (RD) and the Director of Nursing (DON) both confirmed awareness of the ice buildup, with the RD noting the potential for ice burn and compromised food quality, and the DON highlighting the risk of contamination and food safety concerns. The facility's policy on preventing foodborne illness emphasized the importance of storing food to minimize contamination risks, and the Maintenance Director's job description included ensuring equipment is maintained in a safe and efficient manner. Despite these guidelines, the ongoing issue with the freezer's ice buildup was not adequately addressed, posing a risk to food safety and quality.
Failure to Provide Accurate Meal Trays
Penalty
Summary
The facility failed to ensure that the meal tray tickets for two residents, who were part of a sample of 25, were accurate and followed. Resident 100, admitted in January 2024, had diagnoses including muscle wasting and protein-calorie malnutrition. Resident 72, admitted in February 2024, had diagnoses including muscle weakness and protein-calorie malnutrition. During observations on September 30, 2024, it was noted that both residents' meal trays were missing the prescribed house supplement drinks, which were indicated on their meal tray tickets. The Dietary Supervisor and a Certified Nursing Assistant acknowledged the omissions, attributing the responsibility to the kitchen staff. Interviews with the Registered Dietician and the Director of Nursing confirmed that the residents were supposed to receive house supplement drinks to prevent weight loss. The Registered Dietician emphasized that not receiving the correct meal trays could potentially result in unmet nutritional needs. The Director of Nursing reiterated the expectation that meal trays should match the meal tray tickets and acknowledged the potential for continued weight loss if the supplements were not provided. The facility's policy on Food and Nutrition Services, revised in October 2017, mandates that food trays be inspected to ensure the correct meals are provided to each resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that four residents were free from abuse, resulting in two separate altercations. Resident 1 and Resident 2 were involved in a physical altercation where Resident 2 sustained a skin tear on his right arm. Resident 1, who had no cognitive impairment, claimed that Resident 2 hit him first, and Resident 2, who also had no cognitive impairment, stated that Resident 1 hit him first. A witness, Resident 5, confirmed seeing Resident 2 hit Resident 1 with a cane. The Social Services Director and Licensed Nurse 1 confirmed the incident as a form of abuse for both residents involved. In another incident, Resident 3 and Resident 4 were involved in a physical altercation where Resident 3 sustained a skin tear on her right arm. Resident 3, who had no cognitive impairment, reported that Resident 4 spit at her, leading her to hit Resident 4, who then hit her back. Resident 4, who had severe cognitive impairment and advanced dementia, was unable to recall the incident. The Social Services Director and Licensed Nurse 1 confirmed the altercation and the resulting injuries. The facility's policy on abuse prevention, which stipulates that residents have the right to be free from abuse, was not adhered to in these cases. The Administrator acknowledged the difficulty in determining the aggressor in each altercation but agreed that all four residents were victims of physical abuse. The incidents highlight a failure in the facility's responsibility to protect residents from abuse by anyone, including other residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capital Post Acute | 1 mi | — | 28 | 0 |
| City Creek Post Acute | 2.7 mi | — | 0 | 0 |
| Acc Care Center | 2.7 mi | — | 7 | 0 |
| Bridgewood Post Acute | 2.9 mi | — | 2 | 0 |
| Greenhaven Healthcare Center | 3.5 mi | — | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.