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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 Sacramento Post-acute during CMS and state inspections, most recent first.
A resident with prior pelvic fractures and hip pain, requiring substantial/maximal assistance for transfers, was transferred from bed to a shower chair by CNA students and their instructor after CNA staff had instructed them to wait for help and provided a gait belt. The instructor and students proceeded without calling for assistance, and multiple accounts from the resident, a witness, and staff described the resident slipping to the floor onto her knees, complaining of pain, and showing redness and discoloration on her lower legs, with a male student lifting her from the floor before any nurse was notified. The gait belt was later found unused on a table, and although the resident reported being dropped and expressed anxiety about falling again, facility leadership acknowledged there was no documented fall assessment, IDT review, or formal investigation, contrary to the facility’s written accident/incident policy requiring prompt investigation and reporting of all such events.
The facility failed to maintain food safety and sanitation standards, affecting 62 residents. Expired food items were found, and the kitchen had cleanliness issues, including unclean equipment and residue on surfaces. Temperature monitoring in storage areas was inadequate, with no logs for the dry storage room and missing thermometers in the freezer. The ice maker also had residue, indicating poor maintenance.
The facility failed to maintain the reach-in meat freezer in safe operating condition, with observed cracks on door seals and ice buildup near the fan. This was confirmed by the RD, and the facility's manual indicated the need for proper maintenance. The FDA Food Code 2022 requires equipment to be kept in repair, impacting food safety for 62 residents.
The facility failed to meet professional standards of care for three residents. A resident did not receive ordered suprapubic catheter and coccyx skin care, another resident's physician was not notified of high gastrostomy tube residuals, and a third resident received restorative nursing services without active orders. These deficiencies were confirmed through interviews and record reviews.
The facility failed to maintain infection control practices, as a resident's nephrostomy bag was observed touching the floor without a placement date, and two residents' CAM respiratory equipment lacked replacement dates. The Infection Preventionist and Respiratory Therapist confirmed these lapses, which were against the facility's policies.
A resident on hospice care with severe cognitive impairment suffered a significant skin tear during a brief change by a CNA, who allegedly handled him roughly. Despite the resident's distress and the severity of the injury, the incident was not reported to the appropriate authorities as required by the facility's policy.
A resident on hospice care sustained a degloving injury allegedly due to rough handling by a CNA. The facility failed to follow its policy for investigating abuse allegations, lacking interviews with the resident, witnesses, and staff, and did not document a thorough investigation. This placed the resident at risk for further harm.
A resident with a hydrocodone allergy was mistakenly given Norco instead of Percocet, leading to an unmonitored allergic reaction for 20 hours. The error was not reported immediately by the LPN, contrary to facility policy, resulting in a delay in addressing the resident's adverse effects.
A resident with a hydrocodone allergy was mistakenly given Norco, leading to itching and shortness of breath. The error occurred due to a nurse's distraction while preparing medications. The facility lacked a care plan addressing this medication error, contrary to its policy requiring defined goals and objectives for resident care.
A resident with a hydrocodone allergy was mistakenly given Norco, a medication containing hydrocodone, instead of the prescribed Percocet. The error occurred when a licensed nurse became distracted during medication preparation. The resident experienced itching and shortness of breath, and the error was confirmed by the facility's Infection Preventionist.
A resident with paralysis and PTSD was unable to reach the call light, which was hanging off the bed. This was confirmed by a CNA and the ADON, who acknowledged that the call light should have been within easy reach, as per the facility's policy.
Failure to Safely Supervise Transfer and Investigate Alleged Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate and sufficient supervision during a transfer and to ensure the environment was free from accident hazards for a cognitively intact resident with significant prior pelvic fractures and hip pain. The resident had a history of a serious pelvic ring and pubic ramus fracture following a fall and required substantial/maximal assistance for bed-to-chair transfers per the MDS. On the morning in question, CNA 1 informed a CNA instructor that the resident preferred a bed bath due to hip pain and instructed the instructor to call him for assistance before attempting the first out-of-bed transfer. Despite this, the CNA instructor and CNA students proceeded to transfer the resident from bed to a shower chair without calling CNA 1 for help. According to CNA 1, he left his gait belt in the room for the instructor to use and then left to care for another resident. He later heard a commotion and, upon returning, heard the resident repeatedly saying she had been dropped. CNA 1 observed redness on the resident’s lower legs and heard complaints of leg and back pain, and he saw the gait belt lying on a table across the room, leading him to suspect it had not been used during the transfer. The resident reported that three female students and their instructor attempted to transfer her, that she warned them she was going to fall, and that the instructor reassured her they had her before her legs buckled and she fell onto her knees on the floor. The resident stated the group could not lift her, and a male student entered and picked her up from the floor to the shower chair before CNA 1 arrived. An anonymous witness reported being present in the room and stated that four CNA students and the instructor were assisting with the resident’s shower and that, when the resident complained of pain, the instructor told the group to hurry with the transfer. The witness stated the resident slipped toward the ground, yelled that she was being dropped, and ended up on the floor on her legs, with one leg bent backward on her knee. The witness further stated there were no staff present and that no nurse was notified before the resident was picked up from the floor by the male student. Documentation on the shower sheet noted slight redness and discoloration at the resident’s lower legs, signed by CNA 1 and an LVN. Facility leadership, including the DSD and DON, acknowledged conflicting accounts about whether the resident fell, confirmed that the resident and at least one CNA student reported a fall, and stated that no fall assessment, IDT meeting, or documented investigation was completed, despite facility policy requiring investigation and reporting of all accidents and incidents. A physician progress note documented that the resident expressed anxiety about being in the facility because she reported being dropped during a transfer that morning and stated she was scared of falling again. During a record request, the facility was unable to provide any documentation that an investigation of the alleged fall had been conducted, even though the facility’s written policy on accidents and incidents required prompt investigation and reporting of all such events by the nurse supervisor/charge nurse or department director, including specific data elements on an incident/accident report form.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner, affecting 62 residents who received food from the kitchen. During an inspection, expired food items, specifically bread crumb containers, were found on the kitchen shelf. The Registered Dietitian (RD) confirmed the expiration of these items, which was against the facility's policy that no food should be kept longer than its expiration date. Additionally, the facility's kitchen was found to have several cleanliness issues. An unclean appliance attachment cap with dark residue was observed on the steam table, and the oven top was covered in dust-like particles. A metal wire rack used for storing clean water pitchers was also found with dark residue. Pans with hard black residue were available for use, and the RD acknowledged that this buildup could affect food quality and safety. The facility's policy required all equipment to be clean and maintained in good repair, which was not adhered to. The facility also failed to monitor temperatures in storage areas adequately. The dry storage room had no documented temperature monitoring, and the freezer section of the refrigerator lacked a thermometer and temperature logs. The ice maker's dispensing mechanism was found with dark residue, indicating inadequate cleaning. These findings were contrary to the facility's policies, which required regular temperature checks and maintenance of cleanliness in all equipment and storage areas.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the reach-in meat freezer in safe operating condition, as observed during a survey. The freezer was found with two cracks on the door seals, each under 1/2 inch in length, and ice buildup was noted near the fan at the top of the freezer. These observations were confirmed by the Registered Dietitian during an interview. The facility's freezer installation and operations manual, although undated, indicated that door gaskets should be cleaned with a mild soap solution to extend their life. Additionally, the FDA Food Code 2022 specifies that equipment should be maintained in a state of repair, with components such as doors and seals kept intact and adjusted according to the manufacturer's specifications. The failure to maintain the freezer in proper condition decreased the facility's potential to ensure food safety and quality for 62 residents who consumed meals prepared by the facility.
Failure to Meet Professional Standards in Nursing Care
Penalty
Summary
The facility failed to ensure that nursing care met professional standards for three residents. For Resident 63, the nursing staff did not perform suprapubic catheter care and coccyx skin care as ordered. The resident was admitted with conditions including benign prostatic hyperplasia, diabetes mellitus type II, and moderate malnutrition, which increased the risk for complications. Despite orders to check the catheter every shift and apply barrier cream to the coccyx, documentation showed that care was not completed on multiple dates in September 2024. Interviews with staff confirmed the lack of documentation and care. Resident 36's medical record did not indicate that the physician was notified as ordered when the gastrostomy tube residual exceeded 250 ml. The resident, who had a history of stroke and was dependent on tube feeding, had orders to notify the physician if residuals were high. However, on several occasions in September 2024, there was no documented evidence that the physician was informed, as confirmed by the Assistant Director of Nursing during a record review. For Resident 53, restorative nursing services were provided without active prescriber orders. The resident, admitted with muscle weakness and hemiplegia, had a discontinued order for RNA services since September 2023. Despite this, RNA services continued to be provided, as confirmed by the Director of Nursing and the Director of Rehabilitation. The facility's policy required services to be provided in accordance with physician orders, which was not followed in this case.
Infection Control Deficiencies in Equipment Management
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by two specific incidents involving residents. In the first incident, a resident with a nephrostomy bag was observed with the antimicrobial privacy bag touching the floor, and the bag was not labeled with a placement date. This was confirmed by the Infection Preventionist, who acknowledged that the bag should be kept off the floor and dated to ensure timely replacement. The facility's policy on catheter care emphasized the importance of keeping catheter tubing and drainage bags off the floor to prevent urinary tract infections. In the second incident, two residents receiving tracheostomy care had their Continuous Air Mist (CAM) respiratory equipment not labeled with replacement dates. The Respiratory Therapist confirmed that the tracheostomy mask, corrugated tubing, and humidifier bottle for these residents were not dated, which was against the facility's expectations for equipment management. The Director of Nursing also confirmed that all parts of the CAM system should be labeled with replacement dates, as per the facility's policy on preventing ventilator-associated pneumonia.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged abuse involving a resident who was treated roughly during a brief change, resulting in a significant skin tear. The incident was reported anonymously, indicating that the resident acquired an avulsion injury to the right upper extremity when a CNA allegedly grabbed him by the arm. The resident expressed that the CNA was so strong that she tore the last piece of skin he had. Despite the severity of the incident, the Director of Nursing (DON) and the administrator did not report it, and there was an insistence on rewording documentation to avoid implications of physical abuse. The resident involved was on hospice care and had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5. He was able to make medical decisions and understand his rights and responsibilities. The resident was described as needing assistance with various activities of daily living. On the day of the incident, the wound nurse documented the resident's tearful and painful state, with the resident repeatedly questioning why the CNA treated him like a rag doll. The wound nurse also took pictures of the injury and notified the physician. Interviews with staff confirmed that the incident was reported to the charge nurse and the DON, but no further action was taken to report the incident to the appropriate authorities. The facility's policy required immediate reporting of suspected abuse to the administrator and other officials, but this protocol was not followed. The resident was unable to be interviewed later as he had expired.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its policy and procedure to investigate an allegation of abuse involving a resident who sustained a degloving injury to the right forearm and wrist. The incident was reported by an anonymous staff member, who indicated that the injury occurred during a brief change when a CNA allegedly handled the resident roughly. Despite the resident's claims of rough treatment, the facility did not initiate a proper investigation as per their policy. The resident, who was on hospice care and had severe cognitive impairment, was able to communicate and expressed distress over the incident, repeatedly questioning why the CNA treated him in such a manner. The wound nurse documented the resident's statements and the nature of the injury but did not record any further information or conduct a comprehensive investigation. The facility's investigation report, which was supposed to be documented in an IDT note, lacked essential elements such as interviews with the resident, witnesses, and staff, as well as observations of the resident's interactions with others. The facility's policy required a thorough investigation of all allegations, including interviews with relevant parties and documentation of findings. However, the investigation report did not meet these requirements, and there was no evidence of a five-day follow-up investigation report. The failure to conduct a proper investigation placed the resident at risk for further harm and did not comply with the facility's own procedures for handling allegations of abuse.
Failure to Promptly Notify Physician and Monitor Resident After Medication Error
Penalty
Summary
The facility failed to promptly notify the physician or implement timely monitoring for a resident who was administered Norco, a narcotic medication containing hydrocodone and acetaminophen, despite having hydrocodone listed as an allergy. This oversight resulted in the resident not being monitored for an allergic reaction for approximately 20 hours. The resident, who was admitted in early 2023 with diagnoses including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia, experienced itching and shortness of breath after receiving the medication in error. The error occurred when a licensed nurse, while distracted during medication administration, mistakenly gave Norco instead of the prescribed Percocet. The nurse realized the mistake during a medication count but failed to report it immediately, only informing the charge nurse the following day. The facility's policy requires immediate reporting and monitoring of medication errors, but no documentation or monitoring was conducted on the day of the incident. The Infection Preventionist confirmed the lack of documentation and emphasized the expectation for immediate reporting to address any adverse effects.
Failure to Implement Care Plan for Medication Allergy
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was administered Norco, a narcotic medication containing hydrocodone, despite having hydrocodone listed as an allergy. This oversight occurred for a resident admitted in early 2023 with multiple diagnoses, including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia. The resident, who is his own responsible party, experienced itching and shortness of breath after receiving the medication, which was documented in the physician's progress notes. The incident was attributed to a licensed nurse who administered the narcotic by mistake, as she was distracted while preparing another resident's medications. A medication error report confirmed that the resident received Norco instead of the prescribed Percocet. During a review, it was found that there was no care plan addressing the medication error, which was confirmed by the Infection Preventionist. The facility's policy on care plans emphasizes the importance of having defined goals and objectives accessible to all disciplines, which was not adhered to in this case.
Medication Error: Administration of Norco to Resident with Hydrocodone Allergy
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications when a licensed nurse administered Norco, a narcotic medication containing hydrocodone and acetaminophen, to a resident who had hydrocodone listed as an allergy. This error occurred despite the resident's face sheet and order summary report clearly indicating the hydrocodone allergy. The resident, who was admitted in early 2023 with diagnoses including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia, experienced itching and shortness of breath after receiving the incorrect medication. The medication error was confirmed by the facility's Infection Preventionist and was documented in a medication error report. The licensed nurse involved admitted to the mistake, stating that she was distracted while preparing medications and inadvertently administered Norco instead of the prescribed Percocet. The facility's policy on medication errors defines such incidents as deviations from physician orders or professional standards and requires monitoring for adverse consequences and prompt notification of significant errors.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to maintain a resident's communication within the facility when the resident's call light was not within reach. Resident 1, who was admitted in 2023 with diagnoses including paralysis of the legs and lower body and post-traumatic stress disorder (PTSD), was observed on 4/18/24 stating that he was unable to reach the call light, which was hanging off the left side of the bed. This observation was confirmed by Certified Nursing Assistant 1 (CNA 1) and the Assistant Director of Nursing (ADON), both of whom acknowledged that the call light should have been within easy reach of the resident. The facility's policy, dated 9/2003, also indicated that the call light should be within easy reach of the resident when they are in bed or confined to a chair.
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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) |
|---|---|---|---|---|
| Manzanita Healthcare Center | 0.5 mi | — | 15 | 0 |
| College Oak Nursing And Rehabilitation Center | 1.1 mi | — | 13 | 1 |
| American River Center | 1.9 mi | — | 12 | 0 |
| Eskaton Village Care Center | 1.9 mi | — | 13 | 0 |
| Whitney Oaks Care Center | 2.4 mi | — | 5 | 0 |
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