F 0675
Honor each resident's preferences, choices, values and beliefs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure assistance with the use of
dentures was provided for one of three sampled residents (Resident 1).This failure increased the potential
for Resident 1 to refuse meals and lose weight.A review of the admission Record indicated Resident 1 was
admitted early December 2025 with diagnosis including generalized muscle weakness. Resident 1's
Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/10/25 indicated
Resident 1 was cognitively intact, had impairment on both upper extremities and required substantial or
maximal assistance (helper does more than half the effort) for oral hygiene which included ability to insert
and remove dentures into and from the mouth. Further review of Resident 1's clinical records indicated the
following:-Care plan, initiated 12/4/25 indicated, Resident 1 had Activities of Daily Living (ADL) self care
performance deficit and at risk for ADL decline related to generalized weakness, carpal tunnel syndrome (a
pinched nerve of the wrist causing numbness, pain and weakness in the hand) and macular degeneration
(age related eye disease affecting central vision); and, -Nutritional assessment dated 12/8 25 indicated
Resident 1 had dentures. During a concurrent observation and interview on 12/19/25 at 10:46 a.m.,
Resident 1 was lying in bed, with eyeglasses on, edentulous. Resident 1 stated nobody assisted her with
her dentures this morning. Resident 1's denture cup was observed on top of the dresser. During an
interview on 12/19/25 starting at 10:52 a.m. with Certified Nursing Assistant 1 (CNA 1) inside Resident 1's
room. The CNA 1 stated she assisted Resident 1 with her breakfast tray. The CNA 1 further stated she did
not notice Resident 1 had no teeth and she did not know Resident 1 had dentures. Resident 1 stated she
asked a staff to help her with her dentures at around 8:30 a.m. and staff did not come back. During an
interview on 12/19/25 starting at 2 p.m. with the Director of Nursing (DON), the DON stated it is important
for staff to offer Resident 1's dentures. The DON further stated Resident 1 will not be able to chew her food,
and the potential for Resident 1 to eat less and lose weight without the dentures. A review of the facility's
policy and procedure revised March 2018 and titled, Activities of Daily Living (ADLs), Supporting indicated,
.Appropriate care and services will be provided for residents who are unable to carry out ADLs
independently, with the consent of the resident and in accordance with the plan of care, including
appropriate support and assistance with.Dining (meals and snacks).
Residents Affected - Few
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
Page 1 of 2
Event ID:
056101
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056101
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Pointe Post-Acute
6041 Fair Oaks Blvd
Carmichael, CA 95608
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Based on observation, interview, and record review, the facility failed to ensure medication was stored in a
safe manner for one of three sampled residents (Resident 1).This failure had the potential for diversion or
unauthorized use of medication not being securely stored. A review of the admission Record indicated
Resident 1 was admitted early December 2025 with diagnosis including generalized muscle weakness.
Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and
identify memory, orientation, and judgment status of the resident) dated 12/10/25 indicated Resident 1 was
cognitively intact with a score of 15. During a concurrent observation and interview on 12/19/25 at 11:16
a.m., three unlabeled medication cups with white cream were observed inside a white plastic rectangular
container on top of Resident 1's dresser. Resident 1 stated the little cups were lidocaine cream (topical
cream used to relieve pain) brought in by the nurse, and the cream was applied to her hands twice a day.
During a concurrent observation and interview on 12/19/25 at 12:31 p.m., with Certified Nursing Assistant 1
(CNA 1), the CNA 1 confirmed the container where the three unlabeled medication cups were found
belonged to Resident 1. During a concurrent observation and interview on 12/19/25 at 12:34 p.m., the CNA
2 stated the white cream should not be there. The CNA 2 further stated the medication cups were not
labeled, and a confused resident might grab and eat the cream. The CNA 2 added it was not safe to leave
the cream at bedside. During a concurrent observation and interview on 12/19/25 at 12;44 p.m., with the
Treatment Nurse (TN) inside Resident 1's room. The TN stated the medication cups were not labeled and
the white cream inside the cups looked like barrier cream (topical solution that forms a physical shield
between the skin and irritants). During an interview on 12/19/25 at 2 p.m., with the Director of Nursing
(DON), the nurse surveyor showed the picture of the white cream in Resident 1's room. The DON stated
this was not acceptable and licensed staff cannot leave creams or unknown substances or medication at
bedside. A review of the facility's policy and procedure revised November 2020 and titled, Storage of
Medications indicated, .Drugs and biologicals used in the facility are stored in locked compartments.
Event ID:
Facility ID:
056101
If continuation sheet
Page 2 of 2