Nursing home report card · Sacramento, CA
Double Tree Post Acute Care Center
7400 24th Street, Sacramento, CA 95822
Call this home: (916) 422-4825
View this home on Medicare.gov ↗
Quick summary
Medicare shows an abuse warning
Medicare’s Care Compare site shows an abuse icon here. That is one of the strongest public warnings CMS publishes — dig into the inspection history and talk with an attorney if a loved one was hurt.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Jan 23, 2026
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Below-average Medicare rating
Based on problems found during health inspections.
Below-average Medicare rating
Based on staffing levels and related measures.
Above average
Based on reported health and care results.
Below-average Medicare rating
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 056177
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Immediate danger to residents · isolated case
Oct 3, 2024 · Inspection rule 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Could have caused harm · isolated case
Jan 23, 2026 · Inspection rule 0609
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Could have caused harm · isolated case
Jan 23, 2026 · Inspection rule 0692
Provide enough food/fluids to maintain a resident's health.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 46 minutes per resident per day
about 4 hr 6 min per resident per day
about 38 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 2 stars
- Health inspection rating: 2 stars
- Staffing rating: 4 stars
- Registered nurse time per resident: 0.77 hours/day
- Total nurse time per resident: 4.11 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; California averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Medicare shows an abuse warning icon for this home
- Overall star rating is 2 or lower
- Health inspection rating is 2 stars or lower
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
- CMS has fined this home in the recent reporting period
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Immediate danger to residents1 citation
- Could have caused harm44 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 45
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Limited Liability company.
- We do not have individual owner names for this home.
Other homes in this group: All Bvhc, Llc nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
January 23, 202612 findings
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0605 · code D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0658 · code D
Ensure services provided by the nursing facility meet professional standards of quality.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0689 · code D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0692 · code D
Provide enough food/fluids to maintain a resident's health.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0693 · code D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0801 · code D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
December 22, 20251 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
July 9, 20252 findings
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
October 24, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
October 3, 20247 findings
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Quality of Life and Care problemsImmediate danger to residents · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code E
Ensure medication error rates are not 5 percent or greater.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code E
Ensure that residents are free from significant medication errors.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0908 · code E
Keep all essential equipment working safely.
- Nutrition and Dietary problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0803 · code D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
April 17, 20241 finding
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0600 · code E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
December 28, 20231 finding
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
August 17, 202320 findings
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0584 · code E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- Resident Assessment and Care Planning problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0656 · code E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code E
Ensure medication error rates are not 5 percent or greater.
- Pharmacy Service problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0804 · code E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0809 · code E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0813 · code E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Infection Control problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code E
Provide and implement an infection prevention and control program.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0908 · code E
Keep all essential equipment working safely.
- Environmental problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0921 · code E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0578 · code D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0550 · code D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0758 · code D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is…
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0756 · code D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- Environmental problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0925 · code F
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- Fine · Oct 3, 2024$10,842
Other homes in this chain
Bvhc, Llc · other locations in California
- Riverside Village Healthcare Center · Riverside2 of 5 · 60 problems
- Casa Coloma Health Care Center · Rancho Cordova2 of 5 · 47 problems
- Katherine Healthcare · Salinas2 of 5 · 50 problems
- Heartwood Avenue Healthcare · Vallejo3 of 5 · 35 problems
- River Bend Nursing Center · West Sacramento3 of 5 · 47 problems
- Socal Post-Acute Care · Whittier3 of 5 · 43 problems
- Forest Hill Manor Health Center · Pacific Grove4 of 5 · 28 problems
- Haven Post Acute · San Bernardino4 of 5 · 22 problems
Related topics
Questions about Double Tree Post Acute Care Center
What is Double Tree Post Acute Care Center's Medicare star rating?
Has Double Tree Post Acute Care Center been fined?
Does Double Tree Post Acute Care Center have a Medicare abuse warning?
How does Double Tree Post Acute Care Center compare with other nursing homes in California?
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