Inspection·March 5, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for one of three sampled residents, (Resident 1). Residents Affected - Few This failure had potential to result in under- and over-medicating a resident for pain. Findings: During an interview on 3/5/24 at 2:30 p.m. with Resident 1, Resident 1 stated on Friday night 3/1/24, she had pain seven-eight (7-8)/10 (pain scale with 10 being the most pain) in right knee, and pressed the call light at 3 a.m. In between 3:30 a.m. and 4 a.m., a nurse came in with two Tylenol® (a medication commonly used for pain relief) pills, did not turn on the light, did not offer Resident 1 water, and turned off the call light. Resident 1 further stated she did not know the name of the nurse and described them as an African American nurse. A review of Resident 1's Medication Administration Record (MAR), dated March 2024, indicated on 3/1/24, for 3 a.m. to 4 a.m. administration time, the licensed nurse did not sign the administering Tylenol® to Resident 1 for pain. A review of Resident 1's Case Management Progress Notes, dated March 2024, indicated, On 3/2/24 at 9:05 a.m., DON [Director of Nursing] came to address the resident's concerns regarding the call light not being answered timely from last night .She said she pressed her call light 3 times and when someone (not sure if a nurse or CNA) came to give her the pain meds, the person touched the wall for the reset button . During a concurrent interview and record review on 3/5/24 at 3:35 p.m. with the DON, Resident 1's MAR, dated March 2024, was reviewed. The MAR indicated, on 3/1/24 for 3 a.m. to 4 a.m. administration time, there was no Licensed Nurse initials in the box for Resident 1's Tylenol® pills, to demonstrate the medication was administered. The DON stated the MARs were missing documentation of administering Tylenol® pills to Resident 1 in between 3 a.m. to 4 a.m. The DON stated that a nurse told her she gave Tylenol for pain around that time. During a concurrent interview and record review on 3/5/24 at 3:45 p.m. with DON, the facility's Nursing Daily Assignment and Sign-in Sheet, dated March 2024 was reviewed. The Nursing Daily Assignment and Sign-in Sheet indicated, on 3/1/24 for the night shift, a nurse matched the description given by Resident 1. DON confirmed that she was Resident 1's night shift Licensed Nurse. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, (continued on next page) 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 3 Event ID: 056304 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 056304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Carmichael Healthcare Center 3630 Mission Avenue 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)