B+
81/100Pioneer House Inspection Report, Violations & Safety Grade (Sacramento, California)
415 P Street, Sacramento, California 95814
Phone: 9164424906
CMS Overall:4/5
Overview & Bed Count
Certified Beds
50
Avg Residents/Day
44.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Sacramento
Sprinkler Systems
Yes
Special Focus
None
Abuse Citation
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing4/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | California Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.65 | 0.68 | -0.03 |
| Total Nurse Hours per Resident per Day | 4.26 | 4.54 | -0.28 |
| CMS Staffing Rating | 4/5 | 3.3/5 | - |
| Nursing Staff Turnover | 38.9% | 36.6% | - |
Health Citation History
58 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-03 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-02-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-12-09 | Resident Rights Deficiencies | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | D – Moderate Harm Potential |
| 2025-12-04 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2025-12-04 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2025-12-04 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | E – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-12-04 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-12-04 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-04 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | E – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-11-24 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-09-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-02-18 | Nutrition and Dietary Deficiencies | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D – Moderate Harm Potential |
| 2025-01-24 | Resident Rights Deficiencies | Prepare residents for a safe transfer or discharge from the nursing home. | D – Moderate Harm Potential |
| 2024-12-26 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2024-12-19 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | E – Moderate Harm Potential |
| 2024-11-29 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2024-11-29 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-11-15 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-11-15 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-11-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-11-15 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2024-11-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-11-15 | Quality of Life and Care Deficiencies | Honor each resident's preferences, choices, values and beliefs. | D – Moderate Harm Potential |
| 2024-07-18 | Environmental Deficiencies | Put firmly secured handrails on each side of hallways. | E – Moderate Harm Potential |
| 2024-04-02 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2024-02-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-01-17 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2023-11-08 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2023-11-08 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2023-11-08 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
| 2023-10-12 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F – Moderate Harm Potential |
| 2023-10-12 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2023-10-12 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2023-10-12 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2023-10-12 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2023-10-12 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2023-10-12 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2023-10-12 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2023-10-12 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2023-10-12 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-10-12 | Nutrition and Dietary Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-10-12 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-10-12 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2023-10-12 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2023-10-12 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2023-10-12 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D – Moderate Harm Potential |
| 2023-10-12 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2023-10-12 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
Showing 50 of 58 citations.
Fire Safety Citation History
34 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-04 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-12-04 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2025-12-04 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-12-04 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-12-04 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2025-12-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2025-12-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2025-12-04 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | C – Minimal Harm Potential |
| 2025-12-04 | Smoke Deficiencies | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | C – Minimal Harm Potential |
| 2025-12-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | C – Minimal Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | F – Moderate Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Have an alternate power supply for its alarm system. | F – Moderate Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Properly install and monitor supervisory attachments on automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-11-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-11-15 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2024-11-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2024-11-15 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | C – Minimal Harm Potential |
| 2024-11-15 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | C – Minimal Harm Potential |
| 2024-11-15 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | C – Minimal Harm Potential |
| 2023-10-12 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2023-10-12 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | F – Moderate Harm Potential |
| 2023-10-12 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-10-12 | Smoke Deficiencies | Properly provide smoke detection systems in areas open to corridors. | F – Moderate Harm Potential |
| 2023-10-12 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-10-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-10-12 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2023-10-12 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-10-12 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2023-10-12 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2023-10-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2023-10-12 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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Verified Helpline
Care & Coverage Review
Researching facilities in Sacramento, California? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.
📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Free, confidential consultation. We may receive referral compensation.