River Pointe Post-acute
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interview and record review, the facility failed to report an allegation of abuse when an incident involving two of five sampled residents (Resident 1 and Resident 3) was not reported to the Department .This failure had the potential to place residents at risk for continued or escalating abuse.Findings:Resident 1 was admitted to the facility in July of 2025 with diagnoses that included violent behavior, restlessness, and agitation.Resident 3 was admitted to the facility in August of 2021 with diagnoses that included dementia. A review of Licensed Nurse 1 (LN 1)'s Nurses Notes (NN), dated 7/29/25, indicated, [Resident 1] was observed striking roommates [Resident 3] in the room and being verbally abusive.During an interview
on 8/12/25 at 10:57 a.m. with LN 1, LN 1 stated, [Resident 1] started taking all of [Resident 3]'s things from [Resident 3]'s closet. [Resident 3] saw her [Resident 1] and tried to take her things back and [Resident 1] started to hit her. I don't think it was reported to the state.I turned the corner and saw them tugging back and forth. [Resident 1] was kicking and slapping.I reported to the direct supervisor for the day which was [Nurse Supervisor]. He didn't tell me to fill out an SOC341 [Report of Suspected Dependent Adult/Elder Abuse form, required by law under California's Elder Abuse and Dependent Adult Civil Protection Act].During an interview on 8/12/25 at 11:49 a.m. with the Administrator (ADM), the ADM stated, If there is
a case of abuse between residents with dementia and no injury, we still report everything. We report to 3 agencies, which include Law Enforcement, ombudsman and CDPH [California Department of Public Health] as soon as possible within 2 hours.We are mandated reporters. Our role is safety of patients and to communicate to the respective agencies with that information.During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, the P&P indicated, Investigate and report any allegations within timeframes required by federal requirements.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
RIVER POINTE POST-ACUTE in CARMICHAEL, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CARMICHAEL, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from RIVER POINTE POST-ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.