Inspection citations
29’23
14’24
13’25
2’26
58 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 3, 2026 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Feb 10, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 9, 2025 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Dec 4, 2025 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Dec 4, 2025 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Dec 4, 2025 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Dec 4, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 4, 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 |
| Dec 4, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 4, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Dec 4, 2025 | E · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Nov 24, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Sep 5, 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 18, 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. | Complaint |
| Jan 24, 2025 | D · potential | Prepare residents for a safe transfer or discharge from the nursing home. | Complaint |
| Dec 26, 2024 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Dec 19, 2024 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 29, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Nov 29, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Nov 15, 2024 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Nov 15, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Nov 15, 2024 | D · potential | Honor each resident's preferences, choices, values and beliefs. | Routine |
| Nov 15, 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 |
| Nov 15, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 15, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 18, 2024 | E · potential | Put firmly secured handrails on each side of hallways. | Complaint |
| Apr 2, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Feb 23, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 17, 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, 2023 | 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, 2023 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Nov 8, 2023 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Complaint |
| Oct 12, 2023 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Oct 12, 2023 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Oct 12, 2023 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Oct 12, 2023 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Oct 12, 2023 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Oct 12, 2023 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Oct 12, 2023 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Oct 12, 2023 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Oct 12, 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 |
| Oct 12, 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 |
| Oct 12, 2023 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Oct 12, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Oct 12, 2023 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Oct 12, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 12, 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 |
| Oct 12, 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 |
| Oct 12, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Oct 12, 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 |
| Oct 12, 2023 | F · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Oct 12, 2023 | E · 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 12, 2023 | 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 |
| Oct 12, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 12, 2023 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Oct 12, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 12, 2023 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Oct 12, 2023 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 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
Pioneer House
415 P Street, Sacramento, CA 95814 · (916) 442-4906
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555542
- Certified beds
- 50
- Legal owner
- Alister LLC
- Part of
- Cypress Healthcare Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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