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
17’23
25’24
11’25
18’26
71 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 11, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 5, 2026 | F · potential | Hire a qualified full-time social worker in a facility with more than 120 beds. | Complaint |
| Apr 2, 2026 | 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 |
| Apr 2, 2026 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Complaint |
| Mar 12, 2026 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Feb 26, 2026 | 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 |
| Feb 26, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Feb 26, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 26, 2026 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Feb 26, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Feb 26, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Feb 26, 2026 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 26, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Feb 26, 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 |
| Feb 26, 2026 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Feb 26, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 26, 2026 | E · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Feb 26, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 16, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 24, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 18, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 12, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 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 |
| Apr 24, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Apr 10, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 3, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 26, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 26, 2025 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Complaint |
| Feb 4, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Dec 26, 2024 | D · potential | Give the resident's representative the ability to exercise the resident's rights. | Complaint |
| Nov 27, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Nov 8, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Nov 8, 2024 | 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. | Routine |
| Nov 8, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 8, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Nov 8, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Nov 8, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Nov 8, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Nov 8, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Nov 8, 2024 | 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 |
| Nov 8, 2024 | 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 |
| Nov 8, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Nov 8, 2024 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Nov 8, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Nov 8, 2024 | D · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Nov 8, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 8, 2024 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Sep 5, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 18, 2024 | 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 6, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 26, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Apr 24, 2024 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Apr 24, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 20, 2024 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Complaint |
| Nov 29, 2023 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Nov 14, 2023 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Oct 30, 2023 | 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. | Complaint |
| Oct 29, 2023 | D · potential | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Complaint |
| Jun 9, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 9, 2023 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Jun 9, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jun 9, 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. | Routine |
| Jun 9, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 9, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 9, 2023 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 9, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 9, 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 |
| Jun 9, 2023 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Jun 9, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 9, 2023 | B · minimal | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Routine |
| Jun 9, 2023 | D · potential | Provide and implement an infection prevention and control program. | 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
Greenhaven Healthcare Center
455 Florin Road, Sacramento, CA 95831 · (916) 393-2550
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555098
- Certified beds
- 148
- Legal owner
- Bawitdaba LLC
- Part of
- Cypress Healthcare Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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