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Nursing HomeMedicaid Investigative

Capital Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

6821 24th Street, Woodbine · Sacramento, CA 95822121 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 191 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Above-median deficiencies (22 vs median 13.0)

Below average in CA · Below recommended RN staffing · Worst in SPYGLASS HEALTHCARE chain · No penalties on record · Abuse citation

Source: Medicare data

What this means for your family

This facility offers excellent physical and occupational therapy, which is a major strength for those in rehabilitation. However, families must be extremely vigilant regarding medical instructions and hygiene, as multiple recent reviews report serious failures in following posted care protocols and responding to basic needs.

Google Reviews

Google Reviews

191 reviews on Google
Families often praise the facility for its compassionate physical and occupational therapy teams and the warm, welcoming demeanor of the nursing staff. However, there are serious, recurring allegations regarding medical errors, such as failure to follow specific care instructions for IV restrictions, and concerns about hygiene and responsiveness to patient needs.

Quality Themes

Tap a score for details
Food7.0Staff7.0Clean8.0Activities5.0Meds1.0MemoryN/AComms6.0ValueN/A

Strengths

  • Compassionate and professional therapy teams
  • Welcoming and friendly reception and nursing staff
  • Clean and well-maintained environment
  • Efficient check-in and visitor processes

Concerns

  • Failure to follow specific medical instructions (e.g., IV restrictions) (mentioned by 2 reviewers)
  • Neglect regarding basic hygiene and hydration needs (mentioned by 2 reviewers)
  • High noise levels impacting patient rest (mentioned by 2 reviewers)
  • Staffing shortages or being understaffed (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02023(17)5.02024(84)4.62025(64)4.02026(31)

Distribution · 196 analyzed

5
164
4
19
3
5
2
0
1
8
52 reviews posted between Mar 5, 2024Mar 9, 2024 · 52 were 5-star
16 reviews posted between Mar 10, 2024Mar 12, 2024 · 16 were 5-star
10 reviews posted between Dec 29, 2024Jan 4, 2025 · 8 were 5-star

How They Respond to Reviews

13%response rate
Generic

The owner uses highly templated, formulaic responses for negative reviews, focusing on expressing regret and directing users to a specific email address. Positive reviews receive very brief, one-sentence acknowledgments.

Questions for Your Tour

  • 1I noticed many people mention how friendly the reception and nursing staff are; how do you foster that welcoming culture among the team?
  • 2With the recent focus on improving health inspection scores, what specific steps is the facility taking to address medication management and following precise medical instructions?
  • 3How does the nursing team ensure that every resident's individual needs for hydration and personal hygiene are consistently met throughout their shift?
  • 4What measures are in place to manage noise levels in the hallways to ensure residents can get restful, uninterrupted sleep?
  • 5In the event of a medical emergency after hours, what is the protocol for communicating updates to the family?
  • 6What kind of daily activities or social programs are available to keep the residents engaged and connected with one another?

Personalized based on this facility's data


Key Review Excerpts

The nursing team was attentive and responsive, always keeping us informed and making sure his needs were met. The therapy staff worked hard to encourage and motivate him, and we truly appreciated the kindness shown to

Long-term resident's family · 2026★★★★★

My grandmother had multiple clearly posted medical signs in her room. One stated no IVs or blood draws in the right arm and another instructed staff to offer water every hour because she could be unable to get out of bed on her own. Despite these visible signs, medical personnel repeatedly entered the room and attempted procedures on the restricted arm before reading the posted instructions.

Long-term resident's family · 2026☆☆☆☆

The staff here have all been kind, courteous, caring, and attentive. Any concerns are addressed right away. The food served is great and if asked they will provide snacks in-between meals.

Family of both short and long-term residents · 2025★★★★★
Source: 191 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
69%
Registered nurses for medical care
Total Nursing
4.00hrs
98%
All nurses + aides combined
Staff Turnover
44%
Lower is better (< 30% = good)
RN Turnover
48%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

9

measures

Worse Than Avg

1

measures

Mixed Results

7

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility5.9%
Better than Avg
Here
5.9%
US
19.4%
CA
10.7%
Sacramento
9.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility3.0%
Better than Avg
Here
3.0%
US
15.3%
CA
10.5%
Sacramento
9.8%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility2.7%
Better than Avg
Here
2.7%
US
14.4%
CA
10.4%
Sacramento
6.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.7%
Better than Avg
Here
0.7%
US
12.1%
CA
7.0%
Sacramento
5.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility9.0%
Mixed vs Avgs
Here
9.0%
US
15.4%
CA
11.6%
Sacramento
8.7%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility14.1%
Mixed vs Avgs
Here
14.1%
US
19.5%
CA
13.7%
Sacramento
8.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.1%
Mixed vs Avgs
Here
96.1%
US
81.8%
CA
94.2%
Sacramento
98.2%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility90.7%
Mixed vs Avgs
Here
90.7%
US
79.7%
CA
93.2%
Sacramento
97.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.4%
Better than Avg
Here
0.4%
US
1.6%
CA
1.5%
Sacramento
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

16deficiencies
Above state avg (15.4)
44 complaint-triggered

Capital Post Acute has concerning patterns of repeated deficiencies, with families filing 36 complaints that triggered federal investigations. The facility struggles most with medication management, infection control, and protecting residents from abuse and neglect. While most issues show correction dates, problems persist across multiple surveys, including recent complaints about resident safety and one unresolved accident hazard citation, suggesting ongoing care quality challenges that warrant careful consideration.

Feb 24, 2026Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Feb 20, 2026Routine
22
0603Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0761Potential for harm · IsolatedCorrected

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.

0806Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0825Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0039Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0293Minimal · WidespreadCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0345Minimal · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Feb 20, 2026Complaint
1
0600Potential for harm · IsolatedCorrected

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.

Jan 28, 2026Complaint
1
0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Dec 12, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

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.

Dec 10, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

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.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Capital Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Spyglass Healthcare

Chain Size

8 facilities nationwide

Chain avg rating: 3.1/5 · Rank 7 of 7 (Worst)

Ownership & Management

Owners

Amm Trust

Owner · Organization

25%

Spyglass Healthcare LLC

Owner · Organization

50%

Gastwirth, Joshua

Owner

25%

Key personnel

Brandi, RobertOfficer / DirectorMccormack, RyanOfficer / DirectorOakwood Health LLCManagerSpyglass Healthcare LLCManagerBedrin, ChristaManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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