Sacramento Post-Acute

In the surveyor’s words

From the most serious findings on record at Sacramento Post-Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 20, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:Several kitchenware found not in sanitary manners and stored away in the clean and ready-to-use storage areas;The arrangement of the raw meat stored in the walk-in refrigerator were not in a food safety manner;The ice machine was not clean; andOne microwave designated for residents' food was not clean and not well maintained.These failures had the potential to result in food contamination which could cause illness for 71 medically [NAME] residents who received food prepared from the facility kitchen. The census was 89.Findings:1. During the kitchen observations on 2/17/26 at 9:03 a.m. […]

• No harm, potential for more than minimal, widespreadF880Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to follow infection control and prevention practices for a census of 89. when:Two certified nursing assistants (CNAs) did not follow the Enhanced Barrier Precautions (EBP-infection control measures that require staff to wear gowns and gloves during high-contact care, such as dressing, transferring, or changing linen) required during resident's care;Five packs of adult briefs and three elongated packs of vinyl plank flooring covered with whitish-to-brownish substances were inside the dusty floor of the linen storage room [ROOM NUMBER]; A resident's indwelling urinary catheter (IUC, flexible tube inserted through the urethra into the bladder to continually drain urine into an external collection bag) urine drainage bag… […]

• No harm, potential for more than minimal, patternF759Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5% for two of 23 sampled residents (Resident 76 and Resident 11) when:1. Licensed Nurse (LN) 5 applied a medication patch not in accordance with the Physician's Orders (POs) for Resident 76;2. A medication was not available for timely administration for Resident 76 by LN 5; and3.LN 5 administered the wrong dose of a medication to Resident 11. These failures resulted to three errors identified out of 29 opportunities for error during the observation of medication administration with the facility's medication error rate of 10.34%.Findings:1. […]

• No harm, potential for more than minimal, patternF761Feb 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure that prescription medications were labeled and that expired medications were not available for a census of 89, when:1. Multiple unlabeled prescription medications were found in the medication room and the treatment cart; and2. Expired wound dressings containing silver were found inside the treatment cart. These failures had the potential to compromise resident safety by increasing the risk of medication errors and the use of ineffective medications.Findings: 1. During an inspection on 2/17/26 at 8:55 a.m. in one out of two medication rooms with Licensed Nurse 7 (LN 7), the following meds were observed stored among other active medications without a resident specific pharmacy label:a. […]

• No harm, potential for more than minimal, patternF814Feb 20, 2026

  Based on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors for a census of 89, when one of one garbage dumpster, located outside the facility, was not closed securely with the dumpster lid.This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility.Findings:During an observation of the dumpster area outside the kitchen on 2/17/26 at 7:59 a.m., noted one of one garbage bin was not securely covered by the lid.During an interview with the Dietary Manager (DM) on 2/17/26 at 8:44 a.m., the DM confirmed and stated the garbage bin should be closed securely to prevent pest and rodent infestation. […]