Double Tree Post Acute Care Center
7400 24th Street · Sacramento, CA · 95822 · 9164224825
122 certified beds For profit - Limited Liability company Chain: Bvhc, LLC
Why this verdict
- Carries CMS’s abuse warning icon.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 4 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.11 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.81 | 0.55–0.75 |
| Weekend hours / resident-day | 3.74 | ≈ weekday level |
| Nursing turnover / year | 30% | median 45% |
| Fines (3-yr window) | 1 · $10,842 |
Inspection citations (47 in the current record)
-
Potential for harm · D January 23, 2026
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected February 16, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D January 23, 2026
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 16, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D January 23, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 16, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D January 23, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 16, 2026 · Quality of Life and Care
-
Potential for harm · D January 23, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 16, 2026 · Quality of Life and Care
-
Potential for harm · D January 23, 2026
Provide enough food/fluids to maintain a resident's health.
Corrected February 16, 2026 · Quality of Life and Care
-
Potential for harm · D January 23, 2026
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.
Corrected February 16, 2026 · Quality of Life and Care
-
Potential for harm · D January 23, 2026
Ensure that residents are free from significant medication errors.
Corrected February 16, 2026 · Pharmacy Service
-
Potential for harm · D January 23, 2026
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.
Corrected February 16, 2026 · Pharmacy Service
-
Potential for harm · D January 23, 2026
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.
Corrected February 16, 2026 · Nutrition and Dietary
-
Potential for harm · E January 23, 2026
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected February 16, 2026 · Nutrition and Dietary
-
Potential for harm · F January 23, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 16, 2026 · Nutrition and Dietary
-
Potential for harm · D December 22, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 16, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D July 9, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D July 9, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D October 24, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected November 25, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J October 3, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 18, 2024 · Quality of Life and Care
-
Potential for harm · E October 3, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 18, 2024 · Pharmacy Service
-
Potential for harm · E October 3, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected October 18, 2024 · Pharmacy Service
-
Potential for harm · E October 3, 2024
Ensure that residents are free from significant medication errors.
Corrected October 18, 2024 · Pharmacy Service
-
Potential for harm · E October 3, 2024
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.
Corrected October 18, 2024 · Pharmacy Service
-
Potential for harm · D October 3, 2024
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.
Corrected October 18, 2024 · Nutrition and Dietary
-
Potential for harm · E October 3, 2024
Keep all essential equipment working safely.
Corrected October 18, 2024 · Environmental
-
Potential for harm · E April 17, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 15, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D December 28, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 28, 2023 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 3, 2024 | Fine | $10,842 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056177 · certified since August 1, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.