The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
Elk Grove Post Acute
Elk Grove, CA · Medicare-certified · 136 beds
Needs attention
Abuse citationFor-profitChain member
2 of 5 overall
Elk Grove Post Acute has a 2-star overall rating, with a very low 1-star health inspection rating but stronger staffing (4 stars) and quality measures (5 stars). It reports no fines in the last 24 months, but it has a recent abuse citation and reported nurse staffing of 3.72 hours per resident per day, below the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
3.7196 hrs/resident/day
Quality measures
Last inspection: March 30, 2026Penalties, last 24 months: $0recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.7196.
Staffing detail
- Registered nurses
- 0.82
- Licensed practical nurses
- 0.61
- Nurse aides
- 2.28
- Weekend nursing
- 3.56
Hours per resident per day.
Total staff turnover: 19%
Registered nurse turnover: 21%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
12.1%9.6%Improving
Residents with a fall causing major injury
3.1%3%No change
Residents with pressure ulcers (bedsores)
3.8%3.7%No change
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
2.4%2.2%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
2.7%9%Worsening
Residents whose ability to walk got worse
21.2%23.2%Worsening
Long-stay residents on antianxiety or sleep medication
9.3%8.7%Improving
Short-stay residents newly given an antipsychotic
0%1.9%Worsening
Residents with a long-term catheter
0%2.5%Worsening
Residents with new or worsening incontinence
4.7%8.4%Worsening
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—98.1%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—99%—
Short-stay residents given the pneumonia vaccine
99.6%97.9%Worsening
What the inspectors found
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: F
The home failed to make food and drinks appealing and served them at a safe, appetizing temperature. Cited February 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 804 — 42 CFR §483.60 — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited February 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The nursing home failed to provide services that met professional standards of quality. Cited February 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 658 — 42 CFR §483.21(b)(3) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $8,824 in total fines.
- $8,824
Federal fine
Feb 16, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of WINDSOR · 23 homes · 2.5 stars avg
- Occupancy
- 131.9 residents on an average day (97% of 136 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 59 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.