Complaint Investigation

Capital Post Acute

February 20, 2026 · Sacramento, CA · 6821 24th Street

Citations 1

CMS Rating 2/5

Beds 121

Provider ID 555442

Healthcare Facility

Capital Post Acute

Sacramento, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

Capital Post Acute in Sacramento, CA — inspection on February 20, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

punishment, and neglect by anybody.

interview and record review, the facility failed to protect the resident's right to be free from physical

right hand.This failure resulted in Resident 89 not being free from abuse by Resident 61, and Resident 89's right to be free from abuse not protected.Findings:During a review of Resident 89's admission Record (AR), indicated, Resident 89 was initially admitted [DATE] with diagnosis including Orthopedics (a medical and surgical specialty focused on the prevention, diagnosis, and treatment of muscles, joints, and bones disorders) Aftercare following Surgical amputation (amputation-a surgical removal of all or part of a limb or extremity to treat severe infection, disease such as diabetes [Diabetes Mellitus -a disorder characterized by difficulty in blood sugar control and poor wound healing]).During a review of Resident 89's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/24/25, indicated, Resident 89 had intact memory.During a review of Resident 89's Progress notes dated 2/8/26 at 8:18 p.m., indicated, .CNA [certified nursing assistant] 7, who was present at the time along with CNA 6.

Per CNA 6's report, Resident 89 extended his hand outward in front of him as Resident 61 was walking down the hallway toward Resident 89. Resident 61 allegedly made contact with and hit Resident 89's right hand.During a review of Resident 61's AR, indicated, Resident 61 was admitted [DATE] with diagnosis including Cerebral Infarction (a type of stroke where a part of the brain dies due to lack of oxygen caused by a blocked vessel) and Vascular Dementia ( a decline in thinking skills caused by restricted blood flow to the brain often following a stroke) with other Behavioral Disturbance.During a review of Resident 61's MDS dated [DATE] indicated, Resident 61 has severe memory problems.During a review of Resident 35's AR, indicated, Resident 35 was initially admitted [DATE] with diagnosis including Central Cord Syndrome (a type of incomplete spinal cord injury, usually in the neck, characterized by disproportionate weakness in the arms compared to the legs.) at C4 level of Cervical Spinal Cord.During a review of Resident 35's MDS dated [DATE] indicated Resident 35 has intact memory.During a review of a signed note by CNA 6 dated 2/8/26, indicated.Resident 61 was coming in the direction of Resident 89. Resident 89 stretched his hands and told Resident 61 to go back. Resident 61 got angry and started cursing and hit Resident 89.

During an interview on 2/19/26 at 3:20 p.m. at Resident 89's room, Resident 89 stated he was at Resident 35's doorway talking with Resident 35 when Resident 61 walked straight at him and slapped his right hand. Resident 89 further stated, Resident 61 was angry and was saying he would kick his butt and hurt him.

During an interview on 2/19/26 at 3:35 p.m. at Resident 35's room, Resident 35 stated he witnessed Resident 61's right hand raised up and slapped Resident 89's right hand. Resident 35 further stated, Resident 61 was angry and was yelling at Resident 89 saying, .I'm gonna hurt you.I'll kick your butt.

During an interview on 2/19/26 at 4:20 p.m. with the Administrator (ADM), the ADM confirmed that residents in their facility have the right to be free from any form of abuse by any individual.During a review of the facility's policy and procedure (P&P) titled, Resident Right's, dated 12/5/25, indicated, .resident rights. be free from abuse, neglect, misappropriation, exploitation, corporal punishment, involuntary seclusion, and retaliation.' Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Sacramento, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Capital Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.