Cedarwood Post Acute
Sacramento, California · CCN 055296
61 surveys since 2011. The first finding at harm level was recorded in 2016.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 184
- Surveys
- 61
- Harm or worse
- 1
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 51
- Ownership
- For profit - Limited Liability company
- Chain
- SPYGLASS HEALTHCARE
- County
- Sacramento
- Medicare-certified since
- 1969
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 1
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 252 for-profit facilities with fewer than 66 beds in California.
Last survey on record
Jun 17, 2026
145 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Annual nurse turnover | 37.5% | 36.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D3863.3% | E1728.3% | F58.3% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8805×
Provide and implement an infection prevention and control program.
- F5504×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F8124×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F6413×
Ensure each resident receives an accurate assessment.
- F7593×
Ensure medication error rates are not 5 percent or greater.
In the surveyor’s words
From the most serious findings on record at Cedarwood Post Acute, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF812Jun 17, 2026
Based on observation, interview and record review, the facility failed to store, handle, and prepare food in the facility kitchen in accordance with food standards when:Foods were not properly labeled with the use by or open dates;Proper hand hygiene was not followed by kitchen staff;Cold foods were not maintained at safe temperatures during food service and,Wet stainless steel pans were stacked before allowing to dry.These failures had the potential for residents to receive food outside the safe use by dates and for the spread of food borne illness in the kitchen to 42 residents receiving food from the kitchen service.1.During an observation on 6/14/26, at 8:08 a.m., in the kitchen freezer, frozen dessert puffs were in an open plastic bag with no open date or use by date.During an… […]
- No harm, potential for more than minimal, widespreadF812Jun 13, 2025
Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food properly in accordance with professional standards for food service safety for a census of 49 when: 1) Two metal bowls and 9 plate cover lids stored wet and stacked, 2) Two plastic cups had white film build up inside the cups, 3) Two thermometers missing inside freezers, 4) Open food items were not labeled with use by date, and, 5) Food items were not covered during resident food distribution of meal trays These failures increased the potential for food borne illness. Findings: 1.During a concurrent initial tour observation and interview on 6/10/25 at 8:20 a.m. […]
- No harm, potential for more than minimal, widespreadF658Aug 23, 2024
Based on observations, interviews and record reviews, the facility failed to assure professional standards of care were followed when: 1. Resident 15, 19, and 29's oxygen tubing (a device that delivers extra oxygen through a tube into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled, dated and changed. 2. Resident 11's physician order for 1:1 (one on one) feeding assistance with meals was not carried out as ordered. 3. Resident 28's physician order for a plate guard (an adaptive device that prevents food from accidentally being pushed off the plate while eating) with all meals was not carried out as ordered. 4. […]
- No harm, potential for more than minimal, widespreadF842Aug 23, 2024
Based on observation, interview and record review, the facility failed to store and kept confidential multiple residents medical records. This failure had the potential to exposed multiple residents health information by persons not involved in the residents care, for a facility census of 51. Findings: On 8/20/24 at 1:54 p.m. a large open cardboard box was found underneath one of the desk in the Physical Therapy Department (PTD). The open box was observed to contain multiple residents confidential health information records of residents receiving Physical Therapy and Occupational Therapy (OT). The open and unsecured cardboard box was located near the doorway where other residents and visitors come and go outside to access the patio area. […]
- No harm, potential for more than minimal, widespreadF812Jun 29, 2023
Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food properly in accordance with professional standards for food service safety for a census of 47 when: 1. Dishes were stored upright instead of rim down, 2. Food was undated and unlabeled, 3. There was no thermometer in Freezer #2, 4. A radio was sitting on top of a stack of small clean plates, and 5. Particle board at the handwashing sink was warped and unable to be sanitized. These failures increased the potential for food borne illness. Findings: 1. […]
Read 21 findings in full →The most serious and the most recent: 21 of 184 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 17, 2026Standard13 findings
- Jun 9, 2026Complaint2 findings
- Jun 13, 2025Standard and complaint8 findings
- Nov 21, 2024Complaint1 finding
- Nov 15, 2024Complaint1 finding
- Oct 2, 2024Complaint1 finding
- Aug 23, 2024Standard16 findings
- Aug 7, 2024Complaint1 finding
Show the 53 earlier surveys
- Jun 13, 2024Complaint2 findings
- May 9, 2024Complaint1 finding
- Jan 10, 2024Complaint4 findings
- Nov 27, 2023Complaint1 finding
- Aug 21, 2023Complaint1 finding
- Jun 29, 2023Standard12 findings
- Jun 14, 2023Complaint1 finding
- May 2, 2023Complaint1 finding
- Mar 29, 2023Complaint1 finding
- Mar 2, 2023Complaint1 finding
- Jan 30, 2023Complaint2 findings
- Jan 24, 2023Complaint1 finding
- Nov 29, 2022Complaint1 finding
- Sep 9, 2022Complaint1 finding
- Jul 12, 2022Complaint1 finding
- Apr 28, 2022Complaint3 findings
- Feb 16, 2022Complaint1 finding
- Nov 17, 2021Complaint2 findings
- Oct 1, 2021Complaint2 findings
- Sep 23, 2021Complaint2 findings
- May 13, 2021Complaint2 findings
- Jan 21, 2021Complaint1 finding
- Dec 22, 2020Complaint1 finding
- Dec 4, 2020Infection control1 finding
- Nov 19, 2020Complaint1 finding
- Nov 5, 2020Complaint1 finding
- Jul 7, 2020Complaint1 finding
- Jan 21, 2020Complaint2 findings
- Nov 21, 2019Complaint1 finding
- Jun 5, 2019Complaint2 findings
- Jun 3, 2019Complaint2 findings
- Apr 18, 2019Standard8 findings
- Apr 11, 2019Complaint1 finding
- Apr 3, 2019Complaint1 finding
- Jul 17, 2018Complaint1 finding
- May 24, 2018Standard7 findings
- Apr 27, 2018Complaint1 finding
- Jul 18, 2017Complaint2 findings
- Jul 13, 2017Standard8 findings
- Jun 28, 2016Standard9 findings · 1 harm
- May 12, 2016Complaint1 finding
- May 3, 2016Complaint1 finding
- Aug 18, 2015Complaint1 finding
- Jul 9, 2015Standard4 findings
- Mar 12, 2015Complaint1 finding
- Feb 20, 2015Complaint1 finding
- Nov 25, 2014Complaint1 finding
- Sep 18, 2014Standard and complaint6 findings
- Aug 5, 2014Complaint3 findings
- Mar 10, 2014Complaint1 finding
- Sep 12, 2013—12 findings
- Oct 4, 2012—10 findings
- Sep 9, 2011—5 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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