Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 University Post-acute Rehab during CMS and state inspections, most recent first.
Three residents did not have required care plans developed for their specific needs, including anticoagulant monitoring and the use of bed and wheelchair alarms. Staff confirmed the absence of these care plans despite facility policy requiring comprehensive, person-centered plans for all residents with measurable objectives and timetables.
Two residents experienced medication administration errors when one received fewer lidocaine patches than prescribed and another was given finasteride without the required use of gloves. These incidents, observed during medication passes, resulted in a medication error rate of 6.45%, exceeding the regulatory limit.
Surveyors found that medications requiring refrigeration were stored at temperatures below the recommended range, and that opened multi-dose medications and glucose test strips in a medication cart were not labeled with the date of opening. Staff, including the DON and an LPN, confirmed that these items should have been dated and removed if outdated, in accordance with manufacturer instructions and facility policy.
The facility did not provide alternate meal options with protein and calorie content equivalent to the main entrée when residents selected items like grilled cheese sandwiches or cheese quesadillas. These alternatives contained significantly less protein than the main entrée, and additional protein sources were not offered at the time, contrary to facility policy and staff statements.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including rust and unpainted wall patches in the kitchen, incomplete labeling of food items, expired foods in the refrigerator, improper storage of wet equipment, dumpsters left open, and lack of temperature monitoring for tuna salad made from room temperature ingredients. These failures had the potential to contribute to the growth of microorganisms and foodborne illness for residents consuming facility-prepared meals.
Staff did not follow infection control protocols when providing high-contact care to two residents on Enhanced Barrier Precautions, including not wearing gowns, not changing gloves, and not performing hand hygiene between residents. Additionally, a resident's oxygen tubing was not labeled with a start date, and staff could not confirm when it was last changed, contrary to facility policy.
A resident with respiratory failure and moderate cognitive impairment did not receive oxygen therapy as ordered by the physician, receiving only one liter per minute via nasal cannula instead of the prescribed two liters. Facility leadership confirmed that physician orders were not followed, which did not meet professional standards of quality.
A resident's buprenorphine patch administration was documented on the wrong controlled drug count sheet by an LPN, resulting in inaccurate counts on two prescription records. The error was not identified during the shift change inventory, leading to discrepancies in the controlled medication documentation.
A resident's medications were administered twice at a day program due to a failure to check the Medication Administration Record (MAR) before administration. The resident, with conditions including epilepsy and parkinsonism, had medications stored in a locked cabinet at the program. The Program Support Trainer (PST) administered the medications first, and later, the Individual Success Coordinator (ISC) mistakenly administered them again from the resident's lunch bag, leading to a medication error.
A facility failed to discard expired medications and those without expiration dates, mixing them with non-expired ones in the medication storage room. This was confirmed by a Licensed Nurse and the Director of Nursing, who acknowledged the oversight and the facility's policy requiring immediate removal and disposal of outdated medications.
A resident's grievance regarding the reimbursement of a co-pay for lost hearing aids was not resolved in a timely manner by the facility. Despite the facility's policy requiring prompt grievance resolution, the Social Service Director was unaware of the co-pay receipt, leading to confusion and concern from the resident's family. The Administrator acknowledged the delay in reimbursement, resulting in a deficiency in honoring the resident's grievance rights.
A resident with end-stage kidney disease and malnutrition did not receive a prescribed nutrient supplement, Novasource Renal, due to it running out, and a pain medication, Gabapentin, was missed during a medication pass. The DON confirmed the necessity of the supplement and acknowledged the oversight in medication administration.
A resident with expressive aphasia was not provided with a communication board, as required by their care plan, leading to frustration and communication difficulties. Despite the resident's diagnosis following a stroke, staff failed to coordinate and provide necessary communication tools, with the Director of Staff Development and Director of Nursing acknowledging the oversight.
A facility failed to follow Enhanced Barrier Precautions, as a nurse did not wear required PPE while caring for a resident with multiple wounds and high infection risk, and a CNA did not wear full PPE during personal care. The Infection Preventionist confirmed the need for proper PPE use, which was not followed.
A resident with dementia was subjected to abuse when another resident threw water at her, despite her care plan indicating cognitive impairments and the need for prompt attention. Staff interviews confirmed the incident and acknowledged the inappropriateness of the action, highlighting a failure to protect the resident from harm.
The facility failed to protect a resident with dementia from abuse when another resident threw water at her. Despite the facility's policy on abuse prevention, staff confirmed the incident, and the affected resident's care plan noted her cognitive and physical impairments.
Failure to Develop and Implement Required Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with specific care needs. For one resident with a history of heart failure and blood clots, who was receiving Apixaban for DVT prophylaxis, there was no care plan addressing anticoagulant monitoring, despite documentation of the medication being administered multiple times. Both a licensed nurse and the Minimum Data Set Coordinator confirmed the absence of a care plan for anticoagulation, acknowledging its importance due to the resident's risk for bleeding. Another resident, re-admitted for surgical aftercare and with severe cognitive impairment, was observed using both bed and wheelchair alarms. Certified Nursing Assistants and a licensed nurse verified the use of these alarms and stated that alarms were expected to be in use at all times. However, review of the medical record revealed no care plan for the use of either alarm, and staff confirmed that such a care plan should have been in place, especially following the resident's re-admission from the hospital. A third resident, with a memory problem and a history of joint replacement, was also found to be using a bed alarm to prevent falls. Staff interviews and record reviews confirmed the presence of the bed alarm but revealed that no care plan had been developed for its use. The Director of Nursing and other staff acknowledged the importance of care plans for summarizing health conditions and interventions, and confirmed the lack of a care plan for this resident's bed alarm. Facility policy requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident, which were not in place for these three residents.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, resulting in a calculated error rate of 6.45% during observed medication administration. For one resident, a licensed nurse administered only two lidocaine 5% patches for lower back pain, despite the physician's order specifying three patches. Review of the Medication Administration Record (MAR) confirmed the discrepancy, and the nurse acknowledged the error during an interview. The facility's policy required medications to be administered according to physician orders and for staff to verify the correct dosage before administration. In a separate incident, another licensed nurse administered finasteride 5 mg to a different resident without wearing gloves, contrary to the physician's order and the medication's safety data sheet, which indicated the need for gloves due to potential reproductive toxicity. The nurse admitted to being unaware of the special handling requirements and did not use gloves during administration. The Director of Nursing confirmed that the medication was not administered per the physician's orders. Both incidents were observed and documented during the survey, contributing to the facility's medication error rate exceeding the regulatory threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified several deficiencies related to the storage and labeling of medications and biologicals. During an observation, the medication refrigerator was found to be at 32°F, which is below the recommended storage range of 36°F to 46°F for medications such as insulin and nemolizumab. The Director of Staff Development/Infection Preventionist and the DON both acknowledged that storing these medications at temperatures outside the manufacturer’s guidelines could compromise their effectiveness. Facility policy also required medications to be stored within the specified temperature range. Additionally, an opened inhaler used by a resident was found in a medication cart without a date indicating when it was opened. The LPN and DON confirmed that the inhaler should have been labeled with the date it was removed from its protective pouch, as the manufacturer’s instructions specify discarding the product within six weeks of opening. Facility policy required the date of opening to be recorded on multi-dose containers to ensure medications are not used beyond their effective period. A further deficiency was observed when an opened, undated bottle of glucose test strips was found in the same medication cart. The LPN was unable to determine the expiration date due to the missing open date, and the manufacturer’s label indicated the strips should be used within three months of opening. Facility policies required that the date of opening be recorded on multi-dose containers and that outdated or deteriorated medications be immediately removed from stock.
Failure to Provide Nutritionally Equivalent Alternate Meal Options
Penalty
Summary
The facility failed to provide alternative meal options with equivalent protein and calorie content to the main entrée when residents selected alternatives such as grilled cheese sandwiches or cheese quesadillas. During meal service observations, these alternatives were prepared with significantly less protein—approximately 9 to 15 grams—compared to the 21 grams provided in the main entrée. The grilled cheese sandwich consisted of two slices of bread and one slice of cheese, while the quesadilla was made with two corn tortillas and one-fourth cup of shredded cheese. These alternatives were chosen by residents, including one who requested no pork or chicken. Interviews with the Registered Dietician confirmed that alternate meals should match the protein content of the main entrée, and the Dietary Supervisor acknowledged that additional items like yogurt, soup, cottage cheese, or beans could be added to increase nutritional value, but these were not provided at the time. Review of the facility's menu policy indicated that missing food groups should be supplemented to meet residents' nutritional needs, but this was not consistently implemented during the observed meal services.
Deficiencies in Food Storage, Preparation, and Sanitation
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During observations, surveyors noted rust-colored stains under the hand wash sink and unpainted patches on several walls in the kitchen and dry storage areas. The Maintenance Manager confirmed these issues, and the Registered Dietician stated that such surfaces needed to be smooth and cleanable to prevent cross-contamination. Additionally, food items were found with incomplete labeling, such as containers of spices without dates and resident food items in the refrigerator lacking names and dates, contrary to facility policy and posted instructions. Expired foods were found in the reach-in refrigerator, including feta cheese and a plate of lettuce and tomato, both past their use-by dates. The Dietary Supervisor acknowledged these items should have been discarded. A wet steam table pan was also found stored wet on a ready-to-use shelf, which the Registered Dietician explained could lead to bacterial growth if not properly air-dried. The FDA Food Code and facility policy require air-drying of equipment and utensils before use. Further deficiencies included the outside garbage dumpster being left propped open on two occasions, which the Registered Dietician and Dietary Supervisor stated could attract pests. Additionally, tuna salad was prepared from room temperature tuna without monitoring or logging the cool-down process to ensure it reached 41 degrees Fahrenheit within four hours, as required by the FDA Food Code and facility policy. These failures had the potential to lead to the growth of microorganisms and foodborne illness for the 50 residents consuming facility-prepared meals.
Failure to Follow Infection Control Policies for Enhanced Barrier Precautions and Oxygen Tubing
Penalty
Summary
Staff failed to follow infection control policies for three residents. For one resident on Enhanced Barrier Precautions (EBP) due to IV therapy and risk of infection, a CNA provided incontinent care wearing only gloves and not a gown, as required by posted signage and facility policy. The CNA did not change gloves or perform hand hygiene after caring for this resident and proceeded to provide care to another resident, touching the environment and the resident without proper infection control measures. Both the CNA and other staff confirmed knowledge of the EBP requirements, which include wearing gowns and gloves for high-contact care and changing gloves and performing hand hygiene between residents. Additionally, a resident using oxygen therapy had a nasal cannula that was not labeled with a start date, contrary to facility policy and staff expectations that oxygen tubing be labeled and changed weekly to prevent bacterial accumulation. The nurse was unable to determine how long the cannula had been in use. These lapses were observed and confirmed through staff interviews and record reviews, demonstrating a failure to implement and follow established infection prevention and control protocols.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute and chronic respiratory failure with hypoxia, COPD, and pneumonia did not receive oxygen therapy as ordered by the physician. The resident, who had moderate cognitive impairment, was admitted with a physician order for oxygen at two liters per minute via nasal cannula every shift for shortness of breath. However, during an observation, the resident was found to be receiving only one liter of oxygen per minute instead of the prescribed two liters. The Director of Staff Development/Infection Preventionist confirmed that the resident was receiving less oxygen than ordered and acknowledged that physician orders should be followed. The Director of Nursing also stated that oxygen is considered a medication and must be administered according to physician orders. Review of the facility's policy indicated that medications are to be administered as prescribed and in accordance with good nursing practices. This failure to follow the physician's order for oxygen administration constituted a breach of professional standards of quality.
Inaccurate Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for one resident. During an inspection of a medication cart, two controlled drug count sheets for a resident's buprenorphine patch were found to have inaccurate counts. A licensed nurse administered a buprenorphine patch to the resident but documented the administration on the wrong count sheet, which was associated with a different prescription. This resulted in both count sheets reflecting incorrect medication counts. The error was not detected during the routine inventory count conducted by nurses at shift change. Interviews with nursing staff and the Director of Nursing confirmed the documentation error and the resulting discrepancies in the controlled medication records. The facility's policy requires that two licensed nurses conduct a physical inventory of all controlled medications at each shift change and document the results on the accountability record. Any discrepancies are to be reported immediately to the Director of Nursing. In this instance, the required procedures were not followed, leading to inaccurate recordkeeping for the resident's controlled medication.
Medication Administration Error at Day Program
Penalty
Summary
The facility failed to safely administer medications according to professional standards of care for a resident, leading to the administration of the resident's noon medications twice. The resident, who had been readmitted to the facility with diagnoses including epilepsy, parkinsonism, and gastro-esophageal reflux disease, attended a social enrichment day program once a week. The facility had agreed with the day program to store the resident's medication bubble packs in a locked cabinet at the day program. However, on a particular day, the Program Support Trainer (PST) administered the resident's lunchtime medications from the locked cabinet and documented it in the Medication Administration Record (MAR). Later, the Individual Success Coordinator (ISC) mistakenly administered the same set of medications again, having found them in the resident's lunch bag. The ISC did not check the MAR before administering the medications, leading to the duplication. The day program's Medication Error Report Form confirmed that the ISC realized the error only after attempting to document the administration in the MAR, where it was already recorded by the PST. The facility's policy and procedure on medication administration emphasized that medications should be administered in accordance with the written orders of the attending physician, and the day program's procedures required staff to ensure accurate administration of medications.
Expired and Unlabeled Medications Found in Storage
Penalty
Summary
The facility failed to properly manage the storage of medications, leading to expired medications being mixed with non-expired ones in the medication storage room. During a check conducted by a Licensed Nurse (LN 3), it was observed that three tubes of TRIPLE ANTIBIOTIC+PAIN RELIEF ointment, which had expired in January 2024, were found mixed with non-expired ointments. Additionally, three containers of Calmoseptine ointment were available for use without any expiration dates. This oversight was confirmed during an observation and interview with LN 3, who acknowledged that the medications should have been checked for expiration dates and discarded if expired or lacking expiration dates. The Director of Nursing (DON) confirmed in an interview that expired medications and those without expiration dates should have been removed from stock and disposed of according to the facility's policy. The facility's policy from April 2008 clearly states that outdated medications should be immediately removed and disposed of properly. The failure to adhere to this policy increased the potential for medication errors and placed residents at risk for ineffective drug therapy.
Failure to Timely Reimburse Resident's Hearing Aid Co-Pay
Penalty
Summary
The facility failed to resolve a grievance for a resident who had lost their hearing aids within the facility. The resident, who had a cognitive communication deficit, had brought the hearing aids upon admission, and they were reported missing by the resident's family. The family decided to replace the hearing aids using the resident's personal insurance due to their importance for the resident's daily life, incurring a co-pay of approximately $100. However, this co-pay was not reimbursed by the facility in a timely manner, leading to confusion and concern from the resident's family about if and when they would receive the refund. The facility's grievance policy, dated January 2010, required prompt efforts to resolve grievances, with a response from the Administrator or designee within three working days. Despite this policy, the Social Service Director (SSD) was unaware of the co-pay receipt, which was reportedly given to him shortly after the hearing aids were replaced. The Administrator acknowledged that the co-pay should have been reimbursed and stated there was no reason to delay the payment. The lack of timely reimbursement and communication regarding the grievance process resulted in a deficiency in honoring the resident's right to voice grievances without reprisal.
Failure to Administer Prescribed Medications and Supplements
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident with end-stage kidney disease and unspecified protein-calorie malnutrition, who was on hemodialysis therapy. During a medication administration observation, it was noted that a nutrient supplement, Novasource Renal, was not administered as ordered by the physician because it had run out. The resident had a physician order for this supplement to be given twice daily, but it had not been administered since the morning of June 2, 2024. The Director of Nursing acknowledged that the supplement was medically necessary for dialysis patients and should have been ordered in advance. Additionally, the facility failed to administer Gabapentin, a pain medication prescribed for nerve pain, during the morning medication pass. The licensed nurse responsible for the administration acknowledged missing the medication. The Director of Nursing confirmed that the Gabapentin should have been administered as prescribed. These failures placed the resident at risk for ineffective pain control and nutritional imbalance.
Failure to Provide Communication Board for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication board for a resident with expressive aphasia, which resulted in the resident experiencing frustration and impeded communication. The resident, who had a diagnosis of aphasia following a stroke, was observed to communicate using yes and no answers and attempted to write letters in the air, which was difficult to decipher. Despite the care plan indicating the need for a communication board and other tools to aid communication, none were available in the resident's room. Interviews with staff revealed a lack of communication and coordination regarding the resident's needs. The Director of Staff Development confirmed the absence of a communication board and acknowledged that it should have been provided. The Social Services Director believed a communication board was unnecessary due to the resident's ability to communicate with yes and no answers, and there was no request for a communication board from other staff members. The Director of Nursing also acknowledged the oversight, indicating that the communication board should have been provided as per the care plan.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precaution (EBP) guidelines, which are crucial for preventing the transmission of multi-drug resistant organisms. Specifically, a Licensed Nurse (LN 3) did not wear the required Personal Protective Equipment (PPE) when entering the room of a resident with a high risk of infection due to conditions such as sepsis, nephrostomy catheter breakdown, and diabetes. The resident also had multiple wounds, including gangrene and ulcers on the right foot. Despite the presence of an EBP sign and PPE supplies at the room entrance, LN 3 entered without the proper PPE, handled the resident's nephrostomy bag, and used a pillow from the floor, potentially spreading infection. Additionally, a Certified Nursing Assistant (CNA 1) failed to wear the full required PPE while changing another resident's undergarments. The Infection Preventionist confirmed that LN 3 should have worn a gown and gloves during wound dressing changes and nephrostomy care. LN 3 acknowledged the oversight and admitted to not wearing a gown in an Enhanced Precaution room, indicating a lack of compliance with infection control protocols.
Resident Abuse Incident Involving Water Throwing
Penalty
Summary
The facility failed to protect a resident from abuse when another resident threw water at her. The incident involved a resident with dementia and cognitive communication deficits, who was unable to make healthcare decisions. The resident's care plan noted her impaired cognitive function and the need for prompt attention to her needs. Despite these considerations, the facility did not prevent the incident where her roommate threw water at her while she was lying in bed. The interdisciplinary team noted the incident, and staff interviews confirmed that the water was thrown, with the resident's gown found to be damp. Interviews with facility staff, including a Licensed Nurse, the Director of Nursing, and Certified Nurse Assistants, revealed a consensus that throwing water at a resident is inappropriate and disrespectful. The staff expressed concerns about the safety and well-being of residents when such actions occur. The facility's policy on abuse reporting and investigation, dated December 2022, emphasizes ensuring resident safety and well-being, yet this incident highlights a failure to uphold these standards, as evidenced by the staff's acknowledgment of the inappropriate behavior and the resident's experience of being disrespected and potentially harmed.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from abuse when Resident 2 threw water at her. Resident 1, who has dementia and cognitive communication deficits, was admitted to the facility in 2021. The incident occurred on 5/15/24, when Resident 2, upset with Resident 1 for grabbing the privacy curtain, threw water at her while she was lying in bed. This was confirmed by multiple staff members, including a Licensed Nurse, the Director of Nursing, and two Certified Nurse Assistants, who all stated that no one should throw water at another resident. Resident 1's gown was found to be mildly damp, and she reported the incident to CNA 2, who confirmed the wetness and Resident 2's admission of throwing the water. Resident 1's care plan and interdisciplinary team notes indicated that she has impaired cognitive function and physical mobility, and her mood was generally calm according to weekly nurse progress notes. The facility's policy on abuse reporting and investigation, dated December 2022, emphasizes ensuring the safety and well-being of residents. Despite this policy, the facility's failure to prevent Resident 2 from throwing water at Resident 1 compromised Resident 1's right to be free from harm and abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 707 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saylor Lane Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Mckinley Park Care Center | 1 mi | ★★★★★ | 31 | 0 |
| Mid-town Oaks Post-acute | 1.1 mi | ★★★★★ | 27 | 0 |
| Sherwood Healthcare Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Pioneer House | 2.5 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for University Post-acute Rehab.
100% money-back within 48 hours.
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.