The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited November 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
PIONEER HOUSE
SACRAMENTO, CA · Medicare-certified · 50 beds
Needs attention
Abuse citationFor-profitChain member
2 of 5 overall
PIONEER HOUSE (SACRAMENTO, CA) has an overall 2-star rating, with 2 stars for health inspections and stronger 4-star staffing and quality scores. It has no fines in the last 24 months, staffing is just above the federal benchmark (4.15 vs 4.1 hours per resident day), and there is a recent abuse citation along with recent inspection concerns about accidents, food service, and support staffing.
Facility ratings
Health inspections
Staffing
4.1452 hrs/resident/day
Quality measures
Last inspection: February 10, 2026Penalties, last 24 months: $0recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.1452.
Staffing detail
- Registered nurses
- 0.79
- Licensed practical nurses
- 0.79
- Nurse aides
- 2.57
- Weekend nursing
- 3.58
Hours per resident per day.
Total staff turnover: 44%
Registered nurse turnover: 42%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
15.9%Steady
Residents with a fall causing major injury
0%Steady
Residents with pressure ulcers (bedsores)
2.1%Improving
Residents with a urinary tract infection
0.8%Worsening
Residents who lost too much weight
7.1%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
8.5%Improving
Residents whose ability to walk got worse
18.3%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
10.2%Improving
Short-stay residents newly given an antipsychotic
2.6%Improving
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
13.7%Improving
Residents with depressive symptoms
2.3%Worsening
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
93.8%Steady
Short-stay residents given the pneumonia vaccine
95.5%Improving
What the inspectors found
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited October 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to provide enough support staff to safely and effectively run food and nutrition services. Cited October 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 802 — 42 CFR §483.60 — S/S: F
The home failed to properly dispose of garbage and other waste. Cited October 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 814 — 42 CFR §483.60 — S/S: F
The nursing home failed to provide services that met professional standards of quality. Cited December 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 met or exceeded the federal recommendation.
- 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 8 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of CYPRESS HEALTHCARE GROUP · 13 homes · 3.5 stars avg
- Occupancy
- 46.4 residents on an average day (93% of 50 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 33 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.