Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
6’23
18’24
34’25
19’26
77 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| May 14, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 14, 2026 | D · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| May 14, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| May 14, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| May 14, 2026 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| May 14, 2026 | D · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| May 14, 2026 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| May 14, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 14, 2026 | E · potential | Dispose of garbage and refuse properly. | Routine |
| May 14, 2026 | E · potential | Keep all essential equipment working safely. | Routine |
| May 14, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Mar 30, 2026 | D · potential | Protect each resident from the wrongful use of the resident's belongings or money. | Complaint |
| Mar 11, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 6, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Feb 6, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 5, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Jan 29, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jan 20, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 13, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 24, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 24, 2025 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Complaint |
| Nov 24, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 13, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 13, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 21, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 21, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 19, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jun 12, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 5, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 4, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jun 4, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| May 6, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 17, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Apr 17, 2025 | D · potential | Provide appropriate foot care. | Complaint |
| Apr 8, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 27, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 27, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Feb 27, 2025 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 27, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Feb 27, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Feb 27, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Feb 27, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 27, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Feb 27, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 27, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Feb 27, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Feb 27, 2025 | D · potential | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Routine |
| Feb 27, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 27, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 27, 2025 | E · potential | Keep all essential equipment working safely. | Routine |
| Feb 27, 2025 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Jan 14, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 2, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Nov 12, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 27, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Complaint |
| Mar 13, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 16, 2024 | E · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Feb 16, 2024 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Feb 16, 2024 | D · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Feb 16, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 16, 2024 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Feb 16, 2024 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Feb 16, 2024 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Feb 16, 2024 | F · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 16, 2024 | E · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Feb 16, 2024 | F · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Feb 16, 2024 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Feb 16, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 16, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 16, 2024 | E · potential | Keep all essential equipment working safely. | Routine |
| Feb 16, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Dec 22, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 22, 2023 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 17, 2023 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 20, 2023 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Oct 20, 2023 | D · potential | Dispose of garbage and refuse properly. | Complaint |
| Oct 20, 2023 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Elk Grove Post Acute
9461 Batey Avenue, Elk Grove, CA 95624 · (916) 685-9525
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055308
- Certified beds
- 136
- Legal owner
- Windsor Elk Grove Care and Rehabilitation LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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