Complaint Investigation

North Pointe Care Center

September 26, 2025 · Sacramento, CA · 500 Jessie Avenue

Citations 1

CMS Rating 2/5

Beds 161

Provider ID 555400

Healthcare Facility

North Pointe Care Center

Sacramento, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

North Pointe Care Center in Sacramento, CA — inspection on September 26, 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

FF0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Actual Harm

During an interview with Physical Therapy Staff (PTS) on 9/26/25, at 1:17 p.m., PTS stated he worked with Resident 2 frequently and in order for the resident to participate in therapy the resident had to be in good mood.

The PTS added, I have not seen anything physical, but he is verbally aggressive to other residents; I've seen on multiple occasions.

The PTS stated that he was working with another resident in the morning on 9/10/25 when he met Resident 2 near nursing station 2.

The PTS added, He seemed on the verge of being very angry, was loudly talking to himself. I heard him saying something like hurting my roommate.

During an interview with CNA 1 on 9/26/25, at 1:45 p.m., CNA 1 stated that when she went to check on Resident 1 on 9/10/25 the resident was in bed. CNA 1 stated when she entered the resident's room, Resident 1 pointed to his face and said, look at my face. CNA 1 added that Resident 1's face was bloody, the face and nose were red and right side of the face was swollen.He pointed to his roommate's bed, closer to the door but did not say what happened. A review of the facility's 'Abuse Prevention Program,' with revision date of 8/2006 indicated, Our residents have the rights to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to .other residents.A concurrent interview and review of Resident 2's clinical record was conducted with Administrator (ADM) on 9/30/25, at 3:05 p.m.

Upon reviewing nursing progress notes dated 8/3/25, 8/4/25, 8/11/25, 8/20/25, and 9/6/25 the ADM stated he was aware of Resident 2's multiple verbal aggressive behaviors toward Resident 1.

The ADM added, [Resident 2's name] had history of threatening his roommate, but never done anything physical.

The ADM agreed that Resident 2's verbal aggression and threatening placed Resident 1's safety at risk.

The ADM confirmed that on 9/10/25 Resident 1 was found in his room with swollen bloody face and multiple facial lacerations.

The ADM added, The incident happened, but we can't say for sure that it was [Resident 2] that hit [Resident 1], he might have injured himself.

The ADM acknowledged that the facility was responsible for keeping all residents safe.

When asked about interventions to keep Resident 1 safe, the ADM stated the staff were to provide snacks, redirect, and engage Resident 2 in activities.

When asked if the interventions were effective, the ADM did not respond.A review of the facility's policy titled, Safety and Supervision of Residents, revised 7/2017, indicated, Resident safety and supervision.are facility-wide priorities.Safety risks.are identified on an ongoing basis.Resident supervision is a core component of the system approach to safety.The type and frequency of resident supervision may vary.Resident supervision may need to be increased when.there is a change in the resident's condition.

Facility ID:

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 Sacramento, 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 North Pointe Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.