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Complaint Investigation

Sacramento Post-acute

January 30, 2026 · Sacramento, CA · 5255 Hemlock Street
Citations 1
CMS Rating 4/5
Beds 99
Provider ID 056073
Healthcare Facility
Sacramento Post-acute
Sacramento, CA  ·  View full profile →
Inspection Summary

SACRAMENTO POST-ACUTE in SACRAMENTO, CA — inspection on January 30, 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.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During a review of Resident 1's Progress notes dated 1/5/26-1/27/26, indicated, no IDT meeting or investigation notes regarding Resident 1's fall on 1/9/26 were documented.

During an interview on 1/30/26, at 12:30 p.m., with Administrator (Admin), Admin stated, the facility protocol if someone alleges a fall, we investigate it.

During a review of Resident 1's Physician Progress Note dated 1/6/26, at 10:46 p.m., note indicated, she [Resident 1] expressed that she is very anxious about being in the facility because when they transferred her this morning she was dropped from the bed.

She states that she is scared of falling again.During a record request on 1/30/26, the facility was unable to provide documentation they investigated Resident 1's fall on 1/9/26.During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents-Investigating and Reporting dated, 2017, the P&P indicated, All accidents or incidents involving residents.occurring on our premises shall be investigated and reported to the administrator. 1.

The nurse supervisor/charge nurse and/or the department director shall promptly initiate an investigation of the accident or incident. 2.

The following data, if applicable, shall be included on the Report of Incident/Accident form: a.

The date and time the accident or incident took place.

Facility ID:

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 SACRAMENTO POST-ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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