River Pointe Post-acute
RIVER POINTE POST-ACUTE in CARMICHAEL, CA — inspection on August 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
Facility ID: