Sacramento Post-Acute

Name: Sacramento Post-Acute
Address: 5255 HEMLOCK STREET, Sacramento, CA, 95841, US
Telephone: 9163314590

5255 Hemlock Street, Sacramento, CA 95841 · Sacramento County · 99 certified beds · avg 90 residents/day · certified since Dec 1, 1974

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.33

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Feb 20, 2026	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 20, 2026	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 20, 2026	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 20, 2026	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 20, 2026	E · Potential for harm, repeated	The facility did not dispose of garbage and refuse properly.
Feb 20, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 20, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Feb 20, 2026	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Feb 20, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Feb 20, 2026	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Feb 20, 2026	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Jan 30, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 18, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 18, 2024	E · Potential for harm, repeated	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Oct 18, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Oct 18, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 9, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jul 9, 2024	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 12, 2024	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint
Apr 18, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jan 16, 2024	D · Potential for harm, one-off	The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint
Aug 2, 2023	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Aug 2, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
May 19, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 19, 2023	E · Potential for harm, repeated	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
May 19, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 19, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 19, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
May 19, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 19, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (4 → 11).

Year	Citations	Worst severity that year
2023	9	E
2024	11	E
2026	12	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.33	4.31	3.95	bottom 5% in California; bottom 28% in the U.S.
Registered Nurse hours	0.33	0.61	0.69	bottom 17% in California; bottom 13% in the U.S.
Weekend total nurse staffing	3.09	3.90	3.50	bottom 7% in California; bottom 36% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.44	0.51	0.48	top 39% in California; top 41% in the U.S.
Total nursing staff turnover (%)	42.3	36.7	45.8	bottom 32% in California; top 42% in the U.S.
RN turnover (%)	38.5	38.1	42.9	bottom 48% in California; top 44% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.65, RN 0.47, weekend 4.31. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bay Bridge Capital Partners, LLC	Organization	5% or Greater Indirect Ownership Interest	100%	11/05/2021
Hudson River Opco LLC	Organization	5% or Greater Direct Ownership Interest	100%	11/05/2021
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Barbieri, Jeffery	Individual	W-2 Managing Employee	NOT APPLICABLE	05/01/2022
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Sandhu, Harkesh	Individual	Contracted Managing Employee	NOT APPLICABLE	01/29/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Can I see where garbage is stored and how often it's removed?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Manzanita Healthcare Center	0.5 mi	Carmichael, CA	★★★★★	3/5
College Oak Nursing and Rehabilitation Center	1.1 mi	Sacramento, CA	★★★☆☆	3/5
American River Center	1.9 mi	Carmichael, CA	★★★★☆	4/5
Eskaton Village Care Center	1.9 mi	Carmichael, CA	★★★★☆	4/5
Whitney Oaks Care Center	2.4 mi	Carmichael, CA	★★★☆☆	2/5
Mission Carmichael Healthcare Center	2.5 mi	Carmichael, CA	★★★☆☆	3/5
Citrus Heights Post Acute	3.3 mi	Citrus Heights, CA	★★★★☆	3/5
Mountain Manor Senior Residence	3.6 mi	Carmichael, CA	★☆☆☆☆	2/5
River Pointe Post-Acute	3.6 mi	Carmichael, CA	★☆☆☆☆	2/5	abuse
River City Post Acute	3.7 mi	Carmichael, CA	★☆☆☆☆	1/5	abuse
Fair Oaks Healthcare Center	4.3 mi	Fair Oaks, CA	★★★☆☆	2/5
Arden Park Post Acute	4.9 mi	Sacramento, CA	★★★☆☆	2/5	abuse

Compare this facility with the 3 closest →

All facilities in Sacramento →

Facility data as of CMS processing date 2026-08-01. CCN 056073.

The Care File

Visit checklist — Sacramento Post-Acute

5255 Hemlock Street, Sacramento, CA 95841 · 9163314590

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Can I see where garbage is stored and how often it's removed?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 056073 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)