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
21’23
9’24
3’25
12’26
45 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jan 23, 2026 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Jan 23, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Jan 23, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jan 23, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jan 23, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jan 23, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jan 23, 2026 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Jan 23, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jan 23, 2026 | D · 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 |
| Jan 23, 2026 | D · potential | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Routine |
| Jan 23, 2026 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jan 23, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 22, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 9, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 9, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 24, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Oct 3, 2024 | J · harm | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Oct 3, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 3, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Oct 3, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Oct 3, 2024 | 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 |
| Oct 3, 2024 | 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 |
| Oct 3, 2024 | E · potential | Keep all essential equipment working safely. | Routine |
| Apr 17, 2024 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 28, 2023 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 17, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Aug 17, 2023 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Aug 17, 2023 | 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 |
| Aug 17, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Aug 17, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 17, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Aug 17, 2023 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Aug 17, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Aug 17, 2023 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Aug 17, 2023 | D · 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 |
| Aug 17, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Aug 17, 2023 | 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 |
| Aug 17, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Aug 17, 2023 | E · potential | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Routine |
| Aug 17, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 17, 2023 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Aug 17, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Aug 17, 2023 | E · potential | Keep all essential equipment working safely. | Routine |
| Aug 17, 2023 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Aug 17, 2023 | F · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
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
Double Tree Post Acute Care Center
7400 24th Street, Sacramento, CA 95822 · (916) 422-4825
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056177
- Certified beds
- 122
- Legal owner
- 7400 24th Street LLC
- Part of
- Bvhc, Llc
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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