Double Tree Post Acute Care Center
DOUBLE TREE POST ACUTE CARE CENTER in SACRAMENTO, CA — inspection on December 22, 2025.
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
During a review of Resident 2's clinical record, Resident 2 was admitted [DATE] with diagnosis that included chronic pain syndrome (pain that lasts longer than three months), psychoactive substance abuse (a pattern of compulsive substance use).During a review of Resident 2's MDS dated [DATE], Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 had intact cognition.During a review of Resident 1's Change of Condition (COC) note, dated 12/13/25, the COC indicated Resident 1 was hit in the head by Resident 2 and Resident 1 complained of pain in the area he was struck and dizziness.
The COC indicated Resident 1 was sent to the hospital for evaluation.During an interview on 12/22/25 at 10:35 a.m. with Resident 1, Resident 1 stated another resident hit him behind his ear. Resident 1 stated he has continued pain behind his right ear.During a review of Resident 2's Situation, Background, Appearance, Review and Notify (SBAR) communication form, dated 12/12/25.
The SBAR indicated Resident 2 got upset and hit Resident 1 with a closed fist and Resident 1 returned an open-handed hit to Resident 2's chest three times.
During an interview on 12/22/25 at 10:47 a.m. with Resident 2, Resident 2 stated Resident 1 hit him in his chest while he was in bed and Resident 2 got up and hit Resident 1 in the head. Resident 2 stated there was no one in the room during the altercation.
During an interview on 12/22/25 at 2:25 p.m. with the Director of Nursing (DON), the DON confirmed residents have the right to be free from abuse.During a review of the facility's Policy and Procedure (P&P) titled, Residents Rights revised December 2016, the P&P indicated, . residents' right to be free from abuse.
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.
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