Inspection citations
7’23
11’24
12’26
30 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Feb 20, 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. | Routine |
| Feb 20, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 20, 2026 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Feb 20, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Feb 20, 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 |
| Feb 20, 2026 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 20, 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 20, 2026 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Feb 20, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 20, 2026 | E · potential | Dispose of garbage and refuse properly. | Routine |
| Feb 20, 2026 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Jan 30, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 18, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Oct 18, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 18, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 18, 2024 | E · potential | Keep all essential equipment working safely. | Routine |
| Jul 9, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jul 9, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jun 12, 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 12, 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 |
| Jun 12, 2024 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Complaint |
| Apr 18, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jan 16, 2024 | D · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| May 19, 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 |
| May 19, 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 |
| May 19, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| May 19, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| May 19, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| May 19, 2023 | E · 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 |
| May 19, 2023 | E · 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
Sacramento Post-Acute
5255 Hemlock Street, Sacramento, CA 95841 · (916) 331-4590
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056073
- Certified beds
- 99
- Legal owner
- Oleander Holdings, LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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