Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 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.
Food storage and kitchen sanitation deficiencies were identified when wet sheet pans and a muffin pan with food residue were found in clean storage, raw meats were stored together on the same refrigerator level in a way that did not match the facility’s posted storage guide, the ice machine had white and black buildup on internal parts, and the resident microwave had food splashes and chipped interior lining. The DM, RD, and MD confirmed the findings, and facility policies required clean, dry utensils and equipment, proper raw food separation, and food-contact surfaces kept clean and in good repair.
The facility failed to follow infection control practices for residents on EBP when a CNA transferred a resident and another CNA changed soiled linens without the required gown and gloves. Staff also found adult briefs and flooring materials stored on a dusty linen room floor, a resident’s IUC drainage bag touching the floor, and two residents’ tracheostomy humidification devices on the floor. The DON, ADON, IPN, and RT staff confirmed these findings and stated the items should not have been handled or positioned that way.
Surveyors found the facility’s medication error rate was 10.34% after three errors were observed during med administration. An LPN applied a lidocaine patch to the wrong knee for one resident, failed to give another resident ordered losartan because it was not available, and gave a resident the wrong dose of Vitamin D. The DON stated nurses were expected to follow PO, and the facility policy required meds to be given safely and as prescribed.
Unlabeled prescription meds were found in the med room and skilled treatment cart, including injectable Lidocaine, Triamcinolone acetonide, Folic acid, Nystatin ointment, Collagenase Santyl, and Mupirocin. An LPN and the DON confirmed the items lacked resident-specific pharmacy labels. Expired silver wound dressings were also found in the treatment cart, and the LPN confirmed they had expired and should have been discarded.
Dumpster Lid Left Open: Surveyors observed one of one outside garbage dumpster not securely closed with the lid during two observations, including one with bags of trash inside. The DM confirmed the lid should be closed securely to prevent pest and rodent infestation, and the MD stated maintenance was responsible for monitoring the dumpster area and that the bin needed to be closed with the lid.
A resident with BPH, stool incontinence, and a urinary catheter had a physician-ordered B&BTP, but the care plan did not include a focus, goal, or intervention for that program. The resident reported embarrassment during exercises and frustration with staff communication about bowel and bladder care, and both an LPN and the DON confirmed the B&BTP was not care planned.
Failure to notify MD when a resident’s BP medication was unavailable. A resident with a history of stroke and HTN missed a scheduled dose of losartan when an LPN found the medication was not available, but the MD was not informed. The MD stated she expected notification so she could determine whether alternative orders were needed, and the DON stated nurses were expected to notify the physician when a medication was unavailable.
Failure to use ordered eye patch during meals. A resident with ptosis, glaucoma, and left facial droop had a physician order and care plan intervention for an eye patch on the left eye during lunch to help with double vision and self-feeding. During dining observation, the resident ate lunch without the eye patch, had tremors, and spilled a lot of food; RNA/CNA and CNA staff confirmed the patch was not worn, and the resident said he did not know where it was.
Failure to Maintain Resident Grooming and Hygiene: A resident with TBI and abnormal posture, who required moderate assistance with personal hygiene and could not participate in the treatment plan, was observed in bed with a sweaty smell and scattered white flakes on the scalp, hair, ears, face, and neck. An LN confirmed the condition and stated there was no documented evidence it was reported to the MD; the DON stated residents should be clean, smell free, and flake free.
Two residents with IUCs had abnormal catheter findings that were not managed as expected. One resident had foul-smelling urine and creamy-white-brownish encrustation in the tubing, with no evidence of regular flushing documented, and the DON confirmed the tubing should have been changed to prevent infection. Another resident had visible creamy-white sediment in the tubing and collection chamber, and staff confirmed the physician was not notified even though the care plan and facility policy required unusual urine appearance and sediment to be reported.
A resident with hydrocephalus, brain tumor, oropharyngeal dysphagia, and malnutrition was ordered a CCHO diet with MM5 texture and mildly thick liquids, but was served MM5 breaded fish and fried rice that were dry, sticky, and without sauce. The RD confirmed the foods were not moist, and the DM stated MM5 items must pass the fork test and spoon tilt test and be moistened as needed.
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.
Food Storage and Kitchen Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During kitchen observations, several clean and ready-to-use storage areas contained wet sheet pans and a muffin baking pan with brown food residue. The Dietary Manager confirmed the pans were wet and should have been air-dried before storage, and confirmed the brown substances on the muffin pan were food crumbs that should have been cleaned before being put away. Facility policies on dishwashing and sanitation stated that dishes are to be air dried before stacking and storing and that utensils and equipment shall be kept clean. In the walk-in refrigerator, several containers and pans of thawing raw meat were stored at the same level on the bottom rack, including raw bacon, raw chicken, raw pork, and raw ground beef. A pan of raw sausage patties and a pan of raw bacon were stacked together and placed on top of the other raw meat containers. The Registered Dietitian and Dietary Manager confirmed the arrangement was not correct. The facility’s posted food storage guidance identified different storage levels for produce, cooked and ready-to-eat foods, fish and eggs, raw beef and pork, raw ground meats, and raw poultry, and the FDA Food Code was cited regarding separation and protection from contamination. The ice machine was observed with white powdery buildup on the water curtain and significant black substances on the bottom of the evaporator unit, and the Maintenance Director confirmed the machine was not clean. He stated he was responsible for monthly cleaning and sanitizing and that the last cleaning had been completed earlier that month, but also acknowledged he might not have been cleaning and scrubbing enough. The RD stated ice is food and the ice machine should be clean and well maintained. In addition, the microwave designated for residents’ food had orange and red splashes on the interior and chipping interior metal coating, and the Maintenance Director confirmed it was not clean and later stated the microwave needed to be replaced. Facility policy stated utensils and equipment are to be kept clean, maintained in good repair, and free from chipped areas.
Infection Control Failures With PPE, Storage, Catheter Bag, and Respiratory Equipment
Penalty
Summary
The facility failed to follow infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP). During observation, one CNA transferred a resident from bed to wheelchair without wearing the complete PPE required by the resident’s EBP signage, and another CNA changed soiled linens in the resident’s room without wearing the required EBP PPE. Both CNAs confirmed they did not follow the PPE requirements, and the Infection Prevention Nurse stated staff were expected to follow PPE requirements for residents on EBP. The facility also had infection control concerns in linen storage area #2. During observation, adult briefs were stored on the floor and three elongated packages of vinyl plank flooring materials covered with whitish to creamy-like substances were found on the dusty floor of the linen storage room. The DON confirmed the findings and stated the adult briefs should be stored off the floor, the flooring materials should not have been stored in the linen storage area, and the linen storage floor should be kept clean. Additional observations showed a resident with an indwelling urinary catheter had a urine drainage bag sagging and touching the floor while the resident wheeled himself out of the room. The ADON confirmed the bag was touching the floor and emptied it, measuring 300 milliliters of urine. Two residents’ tracheostomy humidification equipment was also observed touching the floor. The Respiratory Therapy Supervisor, IPN, LN, and DON all confirmed the equipment should not be on the floor, and the facility policy identified respiratory therapy equipment as semi-critical items that should be free from microorganisms.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5% after surveyors identified three medication errors during observation of medication administration, resulting in a 10.34% error rate. Two of the 23 sampled residents involved were Resident 76 and Resident 11. During a medication pass, LN 5 applied a lidocaine 5% transdermal patch to Resident 76’s left knee even though the physician’s order directed application to the right knee. LN 5 later confirmed the order required the patch on the right knee and stated she should have contacted the physician to update the order. The DON stated licensed nurses were expected to follow physician orders. During the same observation, LN 5 administered Resident 76’s medications without losartan, which was ordered daily for hypertension, and LN 5 stated the medication was not available for administration. The MAR showed the resident did not receive the scheduled dose. In a separate medication observation, LN 5 administered one tablet of Vitamin D 10 mcg to Resident 11, while the physician’s order called for cholecalciferol 1000 units, one tablet by mouth daily for supplement. LN 5 stated that two and a half tablets should have been administered to match the order, and the DON stated licensed nurses were expected to follow physician orders. The facility policy stated medications are to be administered safely and as prescribed, and that the medication label is checked three times to verify the right resident, medication, dosage, time, and route.
Unlabeled Medications and Expired Wound Dressings Found in Medication Storage
Penalty
Summary
Prescription medications were found stored without resident-specific pharmacy labels in the medication room and in the skilled treatment cart. During observation, multiple unlabeled items were identified, including Lidocaine Injection 200 mg/20 mL, Triamcinolone acetonide injectable suspension 200 mg/5 mL, and a prescription box of Folic acid 1 mg in the medication room. In the treatment cart, unlabeled prescription tubes included Nystatin ointment 100,000 units, Triamcinolone acetonide cream 0.5%, two tubes of Collagenase Santyl ointment 250 units, and Mupirocin ointment 2%. LN 7 and LN 6 both stated the medications lacked resident labels, and the DON stated prescription medications must have a pharmacy label with the resident's name because otherwise the owner of the medication could not be identified. Expired wound care products were also found in the skilled treatment cart. Four pieces of Advanced Antimicrobial Ag (Silver) Advantage dressing were observed stored with active medications, and LN 6 confirmed they had expired on 1/1/26 and should have been discarded and removed from the cart. The DON stated LNs were expected to remove and discard expired medications and products from treatment carts. The facility policy on medication labeling and storage stated that medication labels must include the resident's name and that missing or improper labels should be handled through the dispensing pharmacy, and that discontinued, outdated, or deteriorated medications or biologicals require contact with the dispensing pharmacy for return or destruction instructions.
Dumpster Lid Left Open
Penalty
Summary
The facility failed to provide a clean environment for residents and visitors when one of one garbage dumpster outside the kitchen was not securely closed with the lid. During an observation of the dumpster area on 2/17/26 at 7:59 a.m., surveyors noted the garbage bin was not securely covered by the lid. The Dietary Manager confirmed at 8:44 a.m. that the garbage bin should be closed securely to prevent pest and rodent infestation and stated maintenance usually checked the area every morning and afternoon. A second observation on 2/17/26 at 4:00 p.m. again found the same garbage bin not securely covered, with bags of trash inside. The Maintenance Director later stated the maintenance department was responsible for monitoring the dumpster area and that the garbage bin needed to be closed with the lid. Facility policy required waste to be properly contained in dumpsters or compactors with lids, and the FDA Food Code stated outside receptacles used with food residue must have tight-fitting lids, doors, or covers.
Missing Care Plan for Bowel and Bladder Toileting Program
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 38, whose Bowel and Bladder Toileting Program (B&BTP) was ordered but not included as a care plan focus with measurable objectives. Resident 38 was admitted in early 2026 with benign prostatic hyperplasia and stool incontinence, and the order summary showed a urinary catheter order on 1/27/26 and a B&BTP order on 1/30/26 with no end date. However, the care plan report initiated 1/27/26 did not contain a care plan focus, goal, or intervention for the B&BTP. During interview, Resident 38 stated he felt embarrassed by stool incontinence while in the gym for exercises and had not fully participated because of the urinary catheter bag and tubing. He also stated he was frustrated with staff's lack of communication and concern related to his bowel and bladder care. LN 3 confirmed there was no care plan focus for the B&BTP and stated a care plan was important to monitor progress, for re-evaluation, and for quality of care. The DON also confirmed there was no care plan focus for the B&BTP and stated staff were expected to carry out physician orders, provide communication, and develop the care plan.
Failure to Notify Physician When Blood Pressure Medication Was Unavailable
Penalty
Summary
The facility failed to ensure that one of 23 sampled residents received treatment and care in accordance with professional standards of practice when a nurse did not notify the physician that the resident’s blood pressure medication was unavailable. Resident 76 was admitted in 2/2025 with diagnoses that included stroke and high blood pressure, and the physician’s orders included losartan potassium 25 mg by mouth daily for hypertension. During a medication pass observation on 2/17/26, LN 5 stated that Resident 76’s losartan was not available to administer, and the MAR showed that the scheduled dose was not given that day. During interviews, the MD stated that she was not notified about the missed losartan dose and expected nurses to inform her when a medication was unavailable so she could determine whether alternative orders were needed. The DON also stated that nurses were expected to notify the physician if a medication was not available so the physician could decide whether to give the medication when it arrived or adjust the administration time. The facility’s Medication Administration policy stated that medications are to be administered in a safe and timely manner, and as prescribed, but the facility-provided policies did not include guidance for staff on what to do when a medication was unavailable.
Failure to Use Ordered Eye Patch During Meals
Penalty
Summary
The facility failed to provide treatment and services to maintain or improve a resident’s ability to carry out activities of daily living when Resident 61 did not wear his ordered eye patch during lunch. Resident 61’s admission record listed diagnoses including ptosis of the left eyelid, glaucoma, and left facial droop. His physician’s order directed restorative nursing staff to have him wear an eye patch on his left eye during lunch time or as tolerated, and his care plan identified him as at risk of decline in self-feeding due to incoordination, with an intervention for him to wear the eye patch during lunch time or as tolerated. During a dining observation, Resident 61’s lunch was served while his hands tremored and he spilled a lot of his food, and no eye patch was applied to his left eye. RNA/CNA 2 confirmed he was not wearing the eye patch, and later CNA 1 also confirmed he ate lunch without it. Resident 61 stated the eye patch was not applied when he ate lunch and that he did not know where it was. The ADON reviewed the record and confirmed the order for use of the eye patch in dining, stating it should be applied to manage double vision and strengthen the weaker eye. The OT also confirmed the eye patch was used to help with double vision and to strengthen focus during mealtime and reduce food spillage.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide quality care and dignity to maintain good grooming for one resident who was unable to perform activities of daily living independently. The resident had diagnoses including traumatic brain injury and abnormal posture, and the physician’s order indicated the resident could not understand rights and responsibilities or participate in the treatment plan. The MDS showed the resident required moderate assistance with personal hygiene. During observations on 2/17/26 and 2/19/26, the resident was lying in bed and appeared stiff, with a sweaty smell and scattered white flakes on the scalp, hair strands, ears, face, and neck. During a concurrent observation, interview, and record review, an LN inspected the resident’s head, face, ears, neck, hair strands, and scalp and confirmed the sweaty smell and scattered flakes. The LN also confirmed there was no documented evidence that the resident’s sweaty and flaky condition was reported to the physician. The DON stated residents should be clean, smell free, and flake free, and that the sweaty smell and flaky condition should have been reported to the MD for proper treatment.
Failure to Monitor and Report Abnormal IUC Findings
Penalty
Summary
Provide appropriate catheter care and monitoring for residents with indwelling urinary catheters was not maintained for two residents. Resident 67 had diagnoses including urine retention, neuropathic bladder, and benign prostatic hyperplasia, and had an order for indwelling urinary catheter irrigation with normal saline as needed for clogging. The care plan directed staff to provide catheter care every shift and to monitor and report signs and symptoms of UTI, including pain, burning, blood-tinged urine, cloudiness, no output, and foul-smelling urine. During observation, Resident 67’s IUC tubing had a foul odor of urine and creamy-white-brownish encrustation, and the resident stated, “It hurts when I pee.” A nurse confirmed the findings and stated the tubing had last been flushed on 6/7/25 and had not been flushed since then, with no documented evidence of regular flushing. The DON confirmed the encrusted tubing should be changed to prevent infection. Resident 1 was admitted with diagnoses including bladder dysfunction and infection due to an indwelling urethral catheter. The physician order directed irrigation of the IUC with normal saline as needed for clogging, and the care plan directed staff to notify the physician of signs and symptoms of UTI such as sedimentation. During observation, Resident 1’s IUC drainage bag contained urine with visible creamy-white sediment in the tubing and collection chamber, and a nurse stated the urine was expected to be yellow with no sediment and that the physician should be notified to rule out infection. Record review showed no documented evidence that the physician was notified of the encrustation. Staff interviews confirmed that cloudy urine, sediment, and foul-smelling urine were expected to be identified and reported, and the facility policy required unusual urine appearance to be reported immediately.
MM5 Foods Served Dry and Sticky to Resident With Dysphagia
Penalty
Summary
The facility failed to ensure that Minced and Moist level 5 (MM5) food was prepared in a form designed to meet individual needs for one resident. Resident 9 had diagnoses including hydrocephalus, brain tumor, oropharyngeal dysphagia, and moderate protein-calorie malnutrition. The resident was ordered a CCHO diet with MM5 texture and mildly thick liquids, and the record noted the resident required assistance with eating and had chewing and swallowing problems. During a lunch observation, Resident 9 was seen eating with CNA assistance and received MM5 breaded fish and MM5 fried rice. The observed MM5 breaded fish and fried rice were dry and without sauce. The breaded fish was sticky when scooped with a spoon, and it stuck to the spoon instead of sliding down easily and smoothly. The RD confirmed the fish and fried rice were dry and sticky, and stated MM5 foods should be moist and not sticky. The DM stated MM5 foods should pass the fork test and spoon tilt test, and that dry MM5 foods needed sauce to moisten them. Facility documents for breaded fish and fried rice also stated they were to be minced to 4 mm by 15 mm and moistened with gravy or sauce, and the diet manual stated MM5 fish should be moistened throughout and rice should be soft, not sticky, and served with a thick sauce.
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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What surveyors actually found near you
We read the 730 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 | ★★★★★ | 17 | 0 |
| College Oak Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 14 | 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 | ★★★★★ | 6 | 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 July 2026) and official state health department websites.