Nursing home

Pioneer House

415 P Street, Sacramento, CA 95814

★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures

Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.

Findings, latest cycle12
Findings with harm or immediate jeopardy, 3 cycles1
Fines, 3 years$0
Beds50

Inspection findings

Inspectors recorded 58 findings in the last three inspection cycles.

1 Actual harm to a resident57 No harm, but a risk of harm

Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.

Inspection dateAreaRequirement the home did not meet (official wording, in English)SeverityCorrected
Jun 3, 2026Quality of life and careProvide appropriate pressure ulcer care and prevent new ulcers from developing. (F0686)No harm, but a risk of harm
isolated · from a complaint
Corrected: Jun 4, 2026
Feb 10, 2026Quality of life and careEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689)No harm, but a risk of harm
isolated · from a complaint
Corrected: Feb 23, 2026
Dec 9, 2025Resident rightsEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. (F0627)No harm, but a risk of harm
isolated · from a complaint
Corrected: Jan 12, 2026
Earlier inspections (55)
Inspection dateAreaRequirement the home did not meet (official wording, in English)SeverityCorrected
Dec 4, 2025Building and environmentMake sure there is a pest control program to prevent/deal with mice, insects, or other pests. (F0925)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Infection controlProvide and implement an infection prevention and control program. (F0880)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Food and nutritionProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Pharmacy and medicationsEnsure 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. (F0761)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Pharmacy and medicationsProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755)No harm, but a risk of harm
isolated
Corrected: Dec 12, 2025
Dec 4, 2025Quality of life and careProvide enough food/fluids to maintain a resident's health. (F0692)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Quality of life and careProvide care and assistance to perform activities of daily living for any resident who is unable. (F0677)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Dec 4, 2025Resident assessment and care planningEnsure services provided by the nursing facility meet professional standards of quality. (F0658)No harm, but a risk of harm
pattern
Corrected: Dec 12, 2025
Nov 24, 2025Quality of life and careEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689)Actual harm to a resident
isolated · from a complaint
Corrected: Nov 25, 2025
Sep 5, 2025Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
isolated · from a complaint
Corrected: Sep 23, 2025
Feb 18, 2025Food and nutritionEnsure 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. (F0808)No harm, but a risk of harm
isolated · from a complaint
Corrected: Feb 25, 2025
Jan 24, 2025Resident rightsPrepare residents for a safe transfer or discharge from the nursing home. (F0624)No harm, but a risk of harm
isolated · from a complaint
Corrected: Feb 26, 2025
Dec 26, 2024Resident rightsHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (F0557)No harm, but a risk of harm
isolated · from a complaint
Corrected: Jan 8, 2025
Dec 19, 2024Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
pattern · from a complaint
Corrected: Jan 12, 2025
Nov 29, 2024Quality of life and careProvide care and assistance to perform activities of daily living for any resident who is unable. (F0677)No harm, but a risk of harm
isolated · from a complaint
Corrected: Dec 5, 2024
Nov 29, 2024Resident assessment and care planningEnsure services provided by the nursing facility meet professional standards of quality. (F0658)No harm, but a risk of harm
isolated · from a complaint
Corrected: Dec 5, 2024
Nov 15, 2024Infection controlProvide and implement an infection prevention and control program. (F0880)No harm, but a risk of harm
pattern
Corrected: Dec 15, 2024
Nov 15, 2024Food and nutritionProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812)No harm, but a risk of harm
pattern
Corrected: Dec 15, 2024
Nov 15, 2024Pharmacy and medicationsEnsure 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. (F0761)No harm, but a risk of harm
pattern
Corrected: Dec 15, 2024
Nov 15, 2024Quality of life and careHonor each resident's preferences, choices, values and beliefs. (F0675)No harm, but a risk of harm
isolated
Corrected: Dec 15, 2024
Nov 15, 2024Abuse, neglect and exploitationTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609)No harm, but a risk of harm
isolated
Corrected: Dec 15, 2024
Nov 15, 2024Resident rightsHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (F0557)No harm, but a risk of harm
isolated
Corrected: Dec 15, 2024
Jul 18, 2024Building and environmentPut firmly secured handrails on each side of hallways. (F0924)No harm, but a risk of harm
pattern · from a complaint
Corrected: Jul 26, 2024
Apr 2, 2024Building and environmentMake sure that a working call system is available in each resident's bathroom and bathing area. (F0919)No harm, but a risk of harm
isolated · from a complaint
Corrected: May 7, 2024
Feb 23, 2024Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
isolated · from a complaint
Corrected: Mar 11, 2024
Jan 17, 2024Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
isolated · from a complaint
Corrected: Feb 2, 2024
Nov 8, 2023Quality of life and careProvide medically-related social services to help each resident achieve the highest possible quality of life. (F0745)No harm, but a risk of harm
isolated · from a complaint
Corrected: Dec 11, 2023
Nov 8, 2023Abuse, neglect and exploitationTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609)No harm, but a risk of harm
isolated · from a complaint
Corrected: Dec 11, 2023
Nov 8, 2023Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
isolated · from a complaint
Corrected: Dec 11, 2023
Oct 12, 2023Building and environmentMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F0921)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Building and environmentMake sure that a working call system is available in each resident's bathroom and bathing area. (F0919)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Infection controlProvide and implement an infection prevention and control program. (F0880)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Food and nutritionDispose of garbage and refuse properly. (F0814)No harm, but a risk of harm
widespread
Corrected: Nov 7, 2023
Oct 12, 2023Food and nutritionProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812)No harm, but a risk of harm
widespread
Corrected: Nov 7, 2023
Oct 12, 2023Food and nutritionEnsure 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. (F0808)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Food and nutritionEnsure 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. (F0803)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Food and nutritionProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (F0802)No harm, but a risk of harm
widespread
Corrected: Nov 7, 2023
Oct 12, 2023Pharmacy and medicationsEnsure 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. (F0761)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Pharmacy and medicationsEnsure medication error rates are not 5 percent or greater. (F0759)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Pharmacy and medicationsImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F0758)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Pharmacy and medicationsEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F0756)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Pharmacy and medicationsProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Quality of life and careTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. (F0700)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Quality of life and careProvide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningEnsure services provided by the nursing facility meet professional standards of quality. (F0658)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F0657)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (F0655)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningAssess the resident when there is a significant change in condition (F0637)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident assessment and care planningAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F0636)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident rightsProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (F0623)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident rightsImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F0580)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident rightsReasonably accommodate the needs and preferences of each resident. (F0558)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023
Oct 12, 2023Resident rightsEnsure that residents are fully informed and understand their health status, care and treatments. (F0552)No harm, but a risk of harm
isolated
Corrected: Nov 7, 2023
Oct 12, 2023Resident rightsHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550)No harm, but a risk of harm
pattern
Corrected: Nov 7, 2023

Fines and payment denials

No federal fines or payment denials in the last three years.

Staffing

Nurse staff hours per resident per day4.26California median: 4.27
Registered nurse hours per resident per day0.65California median: 0.52
Nurse staff hours on weekends3.79California median: 3.85
Nursing staff who left within a year38.9%California median: 36.0%

About this home

Beds50
Residents per day, average44.7
OwnershipFor-profit, limited liability company
Legal business nameAlister LLC
ChainCypress Healthcare Group (13 homes)
In Medicare/Medicaid sinceApr 1, 1993

Questions to ask when you call

Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov

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