Other·February 2, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00448211. Representing the Department of Public Health: HFEN, 17069 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(c)

F314 02/01/2017 Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This REQUIREMENT is not met as evidenced by: Based on staff interview, record review and policy and procedure review, the facility failed to ensure 1 of 3 sampled residents (Resident A) did not develop an avoidable pressure ulcer when: 1. A care plan was not developed to prevent skin breakdown. 2. Policies and procedures related to wound and skin management were not implemented. These failures lead to the development of a Stage II pressure ulcer on Resident A's left lateral (outer) ankle which progressed to a Stage 4 (Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.). Findings: Resident A was admitted to the facility on 3/4/15 and diagnosis included cardiovascular disease (refers to a group of conditions that affect the supply of blood to the brain, causing limited or no blood flow to the affected areas), hypertension (high blood pressure), chronic kidney disease (gradual loss of kidney function over time) and congestive heart failure (the heart is unable to pump to sufficiently to meet the body's needs). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident A's Admission MDS (Minimum Data Set-an assessment tool), dated 3/17/15, described him as having clear speech, able to make himself understood and able to understand others. His BIMS (a brief screening that aids in detecting cognitive impairment) score was "12" indicating moderate impairment. The MDS described Resident A as having no signs or symptoms of delirium or behavioral symptoms. The MDS also described Resident A as needing extensive assistance with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. The MDS further described Resident A as having impairment on one side of his upper and lower extremity. Review of the CAA (Care Area Assessment) Worksheet (part of the MDS), dated 3/17/15, indicated under section "2. Cognitive Loss/Dementia" that "Res (resident) requires max to total assist w/ADLs (Activities of Daily Living), non-ambulatory and requires staff assist for locomotion." It also indicated, "Res is at risk for pressure ulcer development d/t (due to) above risk factors and also d/t impaired mobility/balance, left hemiplegia (complete paralysis on one side of body), incontinence and meds (medications) (particularly antianxiety, antidepressants, and narcotics)." Review of the CAA Worksheet, dated 3/17/15, under section "16. Pressure Ulcer" indicated, "Proceed to care plan to minimize complications r/t (related to) risk factors." Review of Resident A's clinical record revealed no documentation of a care plan regarding the prevention of skin breakdown nor a care plan regarding Resident A's left sided hemiplegia. Review of the facility's policy titled, "Skin Management," with a date of 2012, indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "A care plan is developed upon admission, identifying the contributing risk for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to: hydration, nutrition, preventive devices, physical activity, pain, positioning requirements and proper body alignment." Review of the facility's policy titled, "Skin Management," with a date of 2012, indicated, "Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents identified as risk (score of 18 or less on the Braden Scale-For Predicting Pressure Sore Risk), and the interventions documented on the care plan." Review of Resident A's "Braden Scale for Predicting Pressure Sore Risk," dated 3/8/15, documented his Braden Score Scale Score as " 17" with the risk scale category "at risk." During an interview with the MDS Coordinator, on 8/12/15 at 11:50 a.m., she stated, "I might of missed it" regarding creating a care plan for preventive skin care. During an interview with the Director of Nursing (DON), on 8/12/15 at 12:10 p.m., she confirmed there was no care plan regarding the prevention of skin breakdown. She also confirmed there was no care plan regarding Resident A's left sided hemiplegia. During an interview with the DON, on 11/13/15 at 10:10 a.m. she stated "ideally" a care plan would have been developed and the interventions then would have been put on the Kardex (a card-filing system that allows quick reference to the particular needs of each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE patient for certain aspects of nursing care). Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Following admission, the Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks (for a total of 4 weeks including admission), quarterly, annually, and with a significant change in status for their risk for development of pressure ulcers." During an interview with the DON, on 8/27/15 at 11:10 a.m., she confirmed the Braden ScaleFor Predicting Pressure Sore Risk was not completed weekly for 3 additional weeks for Resident A, per the facility's policy. Resident A's "Skin-Weekly Pressure Ulcer Record," dated 5/14/15, indicated he had developed a "new" "acquired at facility" "Stage II" (Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) open area on his left outer (lateral) ankle measuring length 1.5 cm x width 1.5 cm x depth 0.1 cm. "Skin-Weekly Pressure Ulcer Record," dated 5/18/15 documented the wound size as 3 cm x 3 cm x UTD (unable to determine) and indicated a "Wound culture done to check for infection. Noted some pus." On 5/18/15 Resident A was seen by the wound care specialist. Review of "Wound Care Specialist Initial Evaluation," described Resident A's left lateral ankle as "unstageable DTI (deep tissue injury)" and measured length 3 x depth 3 x width Not Measurable cm." The facility's, "Skin Management" policy, with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE date of August 2012, read "Unstageable" described as "when eschar (slough or dead body tissue that may be tan, brown, black in color) is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided." The facility's, "Skin Management" policy, with a date of August 2012, "Suspected Deep Tissue Injury" described as "purple or maroon localized area of discolored intact skin or bloodfilled blister due to damage to underlying soft tissue from pressure and/or shear. This area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. May open and deteriorate rapidly even with optimal treatment." Wound culture results, dated 5/22/15, indicated Resident A had MRSA (Methicillin Resistant Staphylococcus Aureus- bacterial infection that is resistant to numerous antibiotics) in his left outer ankle wound and was prescribed an antibiotic. On 5/25/15, the "Wound Care Specialist Evaluation," described Resident A's left outer ankle wound as "unstageable necrosis (dead body tissue) " and measured "3.3 x 2.2 x 0.1 cm." Documentation indicated the "wound was debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue." Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 5/26/15 documented the left outer ankle measured 3.3 cm x 2.2 cm x UTD and described the "wound bed appears with slough and necrotic tissue. [Physician] debrided at bedside ...Pt [Resident A] has MRSA (on that wound and is currently on ATB (antibiotic)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 6/1/15, the "Wound Care Specialist Evaluation," indicated Resident A's left lateral ankle was a "Stage 4" (Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.) and measured "3.5 x 2 x 0.1 cm." Documentation indicated the wound again was "debrided via surgical excision and muscle removed along with necrotic tissue." Resident A's "Skin-Weekly Pressure Ulcer Record," dated 6/4/15, documented Resident A's left outer ankle wound measured 3.5 cm x 2 cm x 1.2 cm and described the "wound bed with slough and necrotic tissue." On 6/8/15, the "Wound Care Specialist Evaluation," Resident A's left outer ankle wound was described as "Stage 4," measured "2.7 x 1.7 x 0.3 cm" and for a 3rd time the "wound was debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue." Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 6/9/15, documented the measurements of the left outer ankle wound as 2.7 cm x 1.7 cm x 0.3 cm and the wound was described as having "slough and necrotic tissue noted to wound bed." Resident A's "Skin-Weekly Pressure Ulcer Record," dated, 6/15/15, documented the measurements of Resident A's left outer ankle as 3 cm x 2.5 cm x 0.3 cm and described "wound bed appears with necrotic tissue and slough noted." On 6/15/15 the "Wound Care Specialist Evaluation" described Resident A's left lateral ankle as a "Stage 4" and measured "3 x 2.5 x 0.2 cm" and as having "no change." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Documentation indicated again the wound was debrided, a fourth time, via (by) surgical excision and muscle removed along with necrotic tissue. On 6/22/15 the "Wound Care Specialist Evaluation" described Resident A's left lateral ankle was a "Stage 4" and measuring as "2.3 x 2 x 0.1 cm." Documentation indicated the wound was debrided, a fifth time, via surgical excision and muscle removed along with necrotic tissue. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "A Registered Dietician will assess all residents identified with skin impairment for nutritional status in a timely manner." Review of Resident A's clinical record revealed he was seen by a Registered Dietician (RD) on 6/3/15, 20 days after the development of the pressure ulcer on his left outer ankle. During an interview with the DON, on 8/27/15 at 11:10 a.m., she stated the RD comes into the facility "three times a week." During an interview with the DON, on 11/13/15 at 10:10 a.m., she confirmed Resident A should have been seen by the RD "ideally when the wound gets worse." The DON confirmed Resident A should have been seen by the RD the week of 5/18/15. During an interview with Treatment Nurse 1, on 11/3/15 at 10:20 a.m., she stated she verbally notified the RD, by phone, of Resident A's ankle wound as documented on Resident A's "Skin-Weekly Pressure Ulcer Record" dated 5/18, 5/26 and 6/6/15. Treatment Nurse 1 was asked why Resident A was not seen earlier by the RD but Treatment Nurse 1 did not know FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE why. During a telephone interview with the RD, on 11/3/15 at 11:58 a.m., she stated that the treatment nurses never verbally talk to her. The RD stated, "They don't personally call me or email me." The RD also stated the treatment nurses write that they notify her "all the time" but they don't. The RD stated, "They don't call me." The RD could not remember why she did not see Resident A sooner. The RD stated sometimes she'd get a skin sheet with residents' names on who needs to be seen but this skin sheet is "not given all the time." The RD stated she may get it once a week if the Licensed Nurses remember to give it to her. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR)." Review of Resident A's May and June 2015 TARs revealed no documentation that Licensed Nurses (LN) conducted daily monitoring of Resident A's pressure ulcer on his left outer ankle. During an interview with the DON, on 8/27/15 at 11:10 a.m., she confirmed there was no documentation on Resident A's May and June 2015 TAR that the LNs conducted daily monitoring of Resident A's pressure ulcer on his left outer ankle, per the facility's policy. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "A physician's order will be written to monitor each ulcer and documentation on the TAR will reflect the status of the dressing, surrounding skin color and skin and pain associated with the wound. The Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nurse will record: Plus sign (+) if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound. Minus sign (-) if abnormalities or changes to the dressing, skin or pain associated with the wound are present/observed. If any abnormalities are observed, document a descriptive note of findings and the Licensed Nurses responses in the Nurses notes section of the resident's medical record. The Licensed Nurse will record his/her initials on the TAR to reflect the monitoring of each wound regardless of findings." Review of Resident A's clinical record revealed no physician's order to monitor Resident A's left outer ankle pressure ulcer. Review of Resident A's May and June 2015 TARs revealed no documentation to reflect the status of the dressing, surrounding skin color and skin and pain associated with Resident A's left outer ankle pressure ulcer. During an interview with the DON, on 8/27/15 at 11:10 a.m., she confirmed there was no physician's order written for Resident A's left outer ankle pressure ulcer to be monitored, per the facility's policy. She also confirmed there was no documentation to reflect the status of the dressing, surrounding skin color and skin and pain associated with Resident A's left outer ankle pressure ulcer on the May and June 2015 TARs. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Skin assessment findings will be documented weekly on the Head to Toe Skin Check form." Review of Resident A's clinical record revealed there was no documentation that a "Skin-Head FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to Toe Skin Check" form was completed weekly, per the facility's policy. During an interview with the DON, on 8/27/15 at 11:10 p.m., she confirmed a "Skin-Head to Toe Skin Check" form was not completed for Resident A on the following weeks: 3/153/21/15, 3/22-3/28/15, 3/29-4/4/15, 4/5-4/11/15, 4/19-4/25/15, 5/10-5/16/15 and 5/17-5/23/15. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Weekly Skin Check" will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted." Review of Resident A's May and June 2015 TARs revealed no documentation Resident A's "Weekly Skin Check" was transcribed onto the Treatment Record including the day and shift on which the check was conducted. During an interview with the DON, on 8/27/15 at 11:10 a.m., she confirmed there was no documentation Resident A's "Weekly Skin Check" was transcribed onto the Treatment Record including the day and shift on which the check was conducted, per the facility's policy. Review of the facility's policy titled, "Skin Management," with a date of August 2012, indicated, "Completion of the weekly skin assessment will be noted on the Treatment Administration Record (TAR) with the Licensed Nurse's initials." Review of Resident A's May and June 2015 TARs revealed no documentation that the completion of Resident A's weekly skin assessment was noted on the TARs with the LN initials, per the facility's policy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056304 (X3) DATE SURVEY COMPLETED 01/27/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARMICHAEL HEALTHCARE CENTER 3630 Mission Avenue Carmichael, CA 95608 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the DON, on 8/27/15 at 11:10 a.m., she confirmed there was no documentation that the completion of Resident A's weekly skin assessment was noted on the TARs with the LN initials, per the facility's policy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 194911 Facility ID: CA030000028 If continuation sheet 12 of 12