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Nursing HomeMedicaid Investigative

River City Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2540 Carmichael Way, Carmichael, CA 95608178 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.5/5

based on 141 Google reviews

5
4
3
2
1
River City Post Acute Nursing Home in Carmichael, CA — Street View
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8/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (32 vs median 13.0)
  • High staff turnover (54%)
  • High RN turnover (79%)

Bottom 25% in CA · Below recommended RN staffing · Worst in WINDSOR chain · No penalties on record · Abuse citation

Source: Medicare data

What this means for your family

This facility's rehabilitation and therapy teams are exceptional and often lead to significant physical improvements for residents. However, families should be extremely vigilant about communication, as multiple reviewers have reported significant difficulty reaching the facility by phone and delays in response to call lights. If you choose this facility, we recommend frequent in-person visits to monitor cleanliness and care standards.

Google Reviews

Google Reviews

141 reviews on Google
River City Post Acute is highly regarded for its exceptional physical and occupational therapy teams, which many families credit with significant recovery progress. While the facility is noted for having an older building, the primary praise centers on the compassion and professionalism of the rehab and nursing staff. However, potential residents should be aware of serious recurring concerns regarding communication failures, difficulty reaching the facility by phone, and inconsistent cleanliness in some patient rooms.

Quality Themes

Tap a score for details
Food8.0Staff8.0Clean4.0Activities9.0MedsN/AMemoryN/AComms3.0ValueN/A

Strengths

  • Exceptional rehabilitation and therapy teams
  • Compassionate and attentive nursing staff
  • Effective communication from social workers and management
  • Welcoming and supportive environment for recovery

Concerns

  • Difficulty reaching the facility by phone or getting call lights answered (mentioned by 7 reviewers)
  • Issues with facility cleanliness and unpleasant odors (mentioned by 3 reviewers)
  • Inconsistent responsiveness of CNA and nursing staff during certain shifts (mentioned by 3 reviewers)
  • Aging building infrastructure and room maintenance (mentioned by 4 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'18(8)'20(12)'22(28)'24(17)'26(12)

Distribution · 258 analyzed

5
141
4
19
3
4
2
7
1
87
18 reviews posted between Nov 12, 2025Nov 14, 2025 · 18 were 5-star
12 reviews posted between Jul 7, 2023Jul 8, 2023 · 12 were 5-star
10 reviews posted between Sep 12, 2019Sep 14, 2019 · 8 were 5-star

How They Respond to Reviews

0%response rate
Generic

The owner relies heavily on templated, repetitive responses that use standardized phrasing to acknowledge feedback. While they attempt to provide contact information for specific issues, the core of the responses is highly formulaic.

Questions for Your Tour

  • 1We've heard wonderful things about your rehabilitation and therapy teams; could you tell us more about how they work with residents to support their recovery?
  • 2How does the nursing team ensure that call lights are answered promptly, especially during the night shifts?
  • 3What specific steps are being taken to maintain the cleanliness of the rooms and manage the overall upkeep of the building?
  • 4How do the social workers and management team stay in touch with families to ensure we are always updated on our loved one's care?
  • 5What is the protocol for handling a medical emergency after hours, and how quickly can a physician be reached?
  • 6What kind of daily activities or social events are available to help residents stay engaged and connected with others?

Personalized based on this facility's data


Key Review Excerpts

The rehab department really works here. They take the time to understand your needs and will work their magic.

Rehab patient's family · 2026★★★★★

The facility is an older location but my mom was there this last year recovering from hip surgery and the staff were all very friendly and accommodating.

Rehab patient's family · 2026★★★★

I was in here for over a year and was admitted into there Hospice Wing. 12 months later I walked out using a cane only after having a life ending stroke. Everyone is top of their game.

Long-term resident · 2024★★★★★
Source: 141 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
69%
Registered nurses for medical care
Total Nursing
3.64hrs
89%
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
86%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

8

measures

Worse Than Avg

4

measures

Mixed Results

5

measures

Long-Stay Residents
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility82.5%
Worse than Avg
Here
82.5%
US
95.5%
CA
98.2%
Sacramento
98.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.4%
Better than Avg
Here
0.4%
US
12.1%
CA
7.0%
Sacramento
5.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.1%
Mixed vs Avgs
Here
9.1%
US
19.5%
CA
13.7%
Sacramento
8.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility9.1%
Better than Avg
Here
9.1%
US
19.4%
CA
10.7%
Sacramento
9.3%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility4.7%
Better than Avg
Here
4.7%
US
14.4%
CA
10.4%
Sacramento
6.3%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.0%
Better than Avg
Here
7.0%
US
15.3%
CA
10.5%
Sacramento
9.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility67.9%
Worse than Avg
Here
67.9%
US
79.7%
CA
93.2%
Sacramento
97.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility86.5%
Mixed vs Avgs
Here
86.5%
US
81.8%
CA
94.2%
Sacramento
98.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.7%
Worse than Avg
Here
1.7%
US
1.6%
CA
1.5%
Sacramento
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

42deficiencies
Well above state avg (15.4)
58 complaint-triggered

River City Post Acute shows concerning patterns with over half of its 116 deficiencies triggered by family complaints, indicating ongoing quality issues. The facility repeatedly struggles with infection control, nutrition and food safety, and protecting residents from abuse and neglect. While all violations show correction plans, the high volume of complaint-driven investigations and recurring problems in critical care areas suggest systemic challenges that families should carefully investigate before considering placement.

Mar 6, 2026Routine
33
0023Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0605Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0687Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0692Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0561Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0640Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0351Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0741Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0004Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0013Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

0029Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop a communication plan.

0036Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0916Minimal · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Feb 24, 2026Complaint
2
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Feb 11, 2026Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Feb 9, 2026Complaint
2
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Dec 2, 2025Complaint
1
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Nov 20, 2025Complaint
2
0551Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Ownership & Operations

Who Operates This Facility

Owner / Operator

River City Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Windsor

Chain Size

23 facilities nationwide

Chain avg rating: 2.3/5 · Rank 16 of 19 (Worst)

Ownership & Management

Owners

Antelope Realty Holdings I, LLC

Owner · Organization

Windsor Norcal 13 Holdings LLC

Owner · Organization

Antelope Holdings I, LLC

Owner (parent company) · Organization

Tress, Avrohom

Owner (parent company)

Key personnel

Robin, AaronOfficer / DirectorTress, AvrohomOfficer / DirectorNewgen Administrative Services, LLCManagerGardner, RamseyManagerShaw, PamelaManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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