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Complaint Investigation

Capital Post Acute

February 24, 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 24, 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

FF0880
Infection Control Deficiencies

perform hand hygiene during wound care between changing gloves.

This failure increased the

Resident 1 was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery. A review of Resident 1's MDS (Minimum data set- an assessment tool) dated 2/16/26, indicated Resident had moderate cognitive impairment.During a concurrent observation and interview on 2/26/26 at 10:37 a.m. in Resident 1's room with Licensed Nurse (LN 1), Resident 1 was observed lying supine in bed with steri-strips to the left thigh. LN 1 was observed placing wound care supplies directly on Resident 1's bed without separation of the clean and dirty area. LN 1 was observed not performing hand hygiene between changing gloves at 10:37 a.m., 10:39 a.m., and 10:41 a.m. LN 1 confirmed that she did not have a separate clean and dirty section which increased the potential for Resident 1 to get infections through cross contamination.

During an interview on 2/24/26 at 11:36 a.m. with Infection Preventionist (IP), the IP stated the expectation is to perform Hand hygiene before and after glove changes, sanitize non dedicated equipment after each use. IP stated expectation was to have a separate clean and dirty area during wound care to prevent cross contamination and spread of infections.

During an interview on 2/24/26 at 11:49 a.m. with Director of Nursing (DON), the DON stated the expectation is for staff to perform hand hygiene after each glove change and to sanitize equipment after use. DON stated there should be a separate clean and dirty area for items during wound care changes to prevent cross contamination and prevent spread of infections. DON stated the expectation was to maintain infection control practices during direct patient care.During a review of facility Policy and Procedure (P&P) titled, .Hand Hygiene. , Revised October 2023, indicated, .Hand hygiene is indicated . immediately before touching a resident . after touch a resident . immediately after glove removal.During a review of facility Policy and Procedure (P&P) titled, .

Wound Care Policy. dated 2/2026, indicated, .

Use disposable cloth (paper towel is adequate) to establish clean field .

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.


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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.