Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
10’23
24’24
26’25
34’26
94 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 25, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 25, 2026 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Aug 25, 2026 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jul 21, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jun 23, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 10, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 29, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 30, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 29, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 22, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Mar 6, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Mar 6, 2026 | D · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Mar 6, 2026 | E · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Mar 6, 2026 | D · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Mar 6, 2026 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Mar 6, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Mar 6, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Mar 6, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Mar 6, 2026 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Mar 6, 2026 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Mar 6, 2026 | E · potential | Provide appropriate foot care. | Routine |
| Mar 6, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Mar 6, 2026 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Mar 6, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Mar 6, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Mar 6, 2026 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Mar 6, 2026 | E · potential | 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. | Routine |
| Mar 6, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 6, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 24, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 24, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 11, 2026 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 9, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 9, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Dec 2, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Nov 20, 2025 | D · potential | Give the resident's representative the ability to exercise the resident's rights. | Complaint |
| Nov 20, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Aug 7, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 7, 2025 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Aug 1, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 29, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Jul 29, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 29, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Jul 24, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 24, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 1, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 25, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 11, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 11, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 6, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 3, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| May 6, 2025 | D · potential | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Complaint |
| Apr 25, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 16, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 15, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 15, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 3, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 2, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 2, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Feb 20, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Nov 21, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Nov 21, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Nov 21, 2024 | D · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Nov 21, 2024 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 21, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 21, 2024 | D · potential | Keep all essential equipment working safely. | Routine |
| Nov 21, 2024 | D · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Oct 7, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 24, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Sep 24, 2024 | F · potential | Dispose of garbage and refuse properly. | Complaint |
| Aug 20, 2024 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Aug 20, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Aug 20, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jul 19, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 18, 2024 | E · potential | Assist a resident in gaining access to vision and hearing services. | Complaint |
| Jul 2, 2024 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Jun 14, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Jun 5, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 9, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| May 9, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Apr 29, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 15, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 15, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 11, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Dec 14, 2023 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Dec 14, 2023 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Dec 14, 2023 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Dec 14, 2023 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Dec 14, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Dec 14, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 14, 2023 | E · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Nov 7, 2023 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Oct 20, 2023 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Oct 4, 2023 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
River City Post Acute
2540 Carmichael Way, Carmichael, CA 95608 · (916) 482-0465
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055402
- Certified beds
- 178
- Legal owner
- Windsor El Camino Care Center, LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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