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
6’21
5’23
33’24
3’25
23’26
70 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 24, 2026 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 24, 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 |
| Jun 11, 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. | Complaint |
| Mar 27, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 27, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 27, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 4, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 9, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Jan 9, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| Jan 9, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 9, 2026 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jan 9, 2026 | 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 |
| Jan 9, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jan 9, 2026 | G · harm | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jan 9, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jan 9, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jan 9, 2026 | E · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Jan 9, 2026 | 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 |
| Jan 9, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jan 9, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jan 9, 2026 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jan 9, 2026 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jan 9, 2026 | 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 26, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 29, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 2, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 13, 2024 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Sep 13, 2024 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Sep 13, 2024 | E · 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 |
| Sep 13, 2024 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Sep 13, 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 |
| Sep 13, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Sep 13, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Sep 13, 2024 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Sep 13, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Complaint |
| Sep 13, 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 |
| Sep 13, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Sep 13, 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 |
| Sep 13, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Sep 13, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Sep 13, 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 |
| Sep 13, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Sep 13, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Sep 13, 2024 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Sep 13, 2024 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Aug 1, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 1, 2024 | 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 |
| Jul 17, 2024 | 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 |
| Jul 10, 2024 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 10, 2024 | D · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jul 2, 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 |
| Jul 2, 2024 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 2, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 28, 2024 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Jun 28, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 11, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 20, 2024 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Complaint |
| Feb 20, 2024 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Complaint |
| Jan 3, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Dec 6, 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 6, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 13, 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 |
| Oct 13, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 13, 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 |
| Jul 9, 2021 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Jul 9, 2021 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jul 9, 2021 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 9, 2021 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jul 9, 2021 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jul 9, 2021 | D · potential | Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | 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
North Pointe Care Center
500 Jessie Avenue, Sacramento, CA 95838 · (916) 922-7177
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555400
- Certified beds
- 161
- Legal owner
- North Sacramento Healthcare, LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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