Report
TheVardellReport
Double Tree Post Acute Care Center
Skilled nursing facility and nursing facility
7400 24th Street
Sacramento, CA 95822
Report
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The Vardell Report.Double Tree Post Acute Care Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Sacramento, CA
- Record Period
- 2023–2026
- Source Documents
- 10
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 8 inspections from August 2023 to January 2026, state surveyors documented 45 findings at Double Tree Post Acute Care Center; 45 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 8
- 2023–2026, standard and complaint
- Findings
- 45
- Deficiencies cited by state inspectors
- Corrected
- 45
- Of 45 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 21 | 0 |
| 2024 | 3 | 9 | 1 |
| 2025 | 2 | 3 | 0 |
| 2026 | 1 | 12 | 0 |
What the Record Shows
- 45 of 45 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $10,842, its payment not published.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, January 23, 2026, recorded 12 findings (most serious: Level F).
What to Ask About
- Protection From Abuse and Neglect, Cited in Four Inspections
- Medication Labeling and Storage, Cited in Three Inspections
- Reporting Suspected Abuse, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Pharmacy Services, Cited in Two Inspections
- Medication Error Rate, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Food Quality and Temperature, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
- Keep all essential equipment working safely, Cited in Two Inspections
Report at a Glance
- Facility
- Double Tree Post Acute Care Center
- Address
- 7400 24th Street, Sacramento, CA 95822
- CMS Certification Number
- 056177
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 122
- Ownership
- For profit - Limited Liability company
- Record Window
- August 17, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
12 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 16, 2026
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Feb 16, 2026
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level DNo actual harm, potential for moreCorrected Feb 16, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jan 16, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jul 25, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jul 25, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Nov 25, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
7 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Oct 18, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
- F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
- F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Oct 18, 2024
- F803Ensure 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.Level DNo actual harm, potential for moreCorrected Oct 18, 2024
Enforcement Action
Civil money penalty, $10,842 imposed October 3, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 3, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level ENo actual harm, potential for moreCorrected May 15, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
20 findings
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Sep 8, 2023
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F809Ensure 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.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Sep 8, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
- F758Implement 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 limited.Level DNo actual harm, potential for moreCorrected Sep 8, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Protection From Abuse and Neglect, Cited in Four Inspections
Inspectors cited F600 in April 2024, October 2024, July 2025 and December 2025. This citation covers whether residents are protected from abuse and neglect by anyone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F600 across all 8 inspections, oldest to newest - 2
Medication Labeling and Storage, Cited in Three Inspections
Inspectors cited F761 in August 2023, October 2024 and January 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F761 across all 8 inspections, oldest to newest - 3
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in July 2025 and January 2026. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F609 across all 8 inspections, oldest to newest - 4
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in October 2024 and January 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F684 across all 8 inspections, oldest to newest - 5
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in August 2023 and October 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F755 across all 8 inspections, oldest to newest - 6
Medication Error Rate, Cited in Two Inspections
Inspectors cited F759 in August 2023 and October 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F759 across all 8 inspections, oldest to newest - 7
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in October 2024 and January 2026. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F760 across all 8 inspections, oldest to newest - 8
Food Quality and Temperature, Cited in Two Inspections
Inspectors cited F804 in August 2023 and January 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F804 across all 8 inspections, oldest to newest - 9
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in August 2023 and January 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F812 across all 8 inspections, oldest to newest - 10
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2023 and December 2023. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F880 across all 8 inspections, oldest to newest - 11
Keep all essential equipment working safely, Cited in Two Inspections
Inspectors cited F908 in August 2023 and October 2024. The agency describes it this way: Keep all essential equipment working safely. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2323242424252526F908 across all 8 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in four inspections, most seriously at level E.
- 02
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
- 03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level D.
- 04
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level J.
- 05
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
- 06
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
- 07
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level E.
- 08
May we try a meal, and how do you check food temperature by the time it reaches residents?
Food Quality and Temperature: cited in two inspections, most seriously at level E.
- 09
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
- 10
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
- 11
What changed after F908 was cited, and how do you check it now?
Keep all essential equipment working safely: cited in two inspections, most seriously at level E.
- 12
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 13
What led to the 2024 fine, and has it been paid?
A $10,842 civil money penalty was imposed October 3, 2024. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 17, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Dec 28, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Apr 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jul 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Dec 22, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jan 23, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 056177
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 17, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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