Inspection·August 22, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview, and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of five sampled residents (Resident 1) when Resident 1 alleged that a female staff grabbed him firmly on the right arm. This failure resulted in a delayed investigation of Resident 1's abuse complaint and had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted January of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), care provider dependency, weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 6/26/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 1 had an intact cognition. A review of Resident 1's MDS Mood status, dated 6/26/24, indicated Resident 1 had experienced feeling down, depressed, or hopeless half or more of the days in two weeks. A review of Resident 1's MDS Functional Abilities, dated 6/26/24, indicated Resident 1 needed partial/moderate assistance with toileting hygiene, showering/bathing, and upper body dressing. During an observation on 8/22/24 at 11:20 a.m. at Resident 1's room, Resident 1 was observed to be wearing a gray hand splint on the right hand. During an interview on 8/22/24 at 11:44 a.m. with Resident 1's daughter/ Responsible Party (RP) 1, RP 1 stated when she visited Resident 1 on the morning of 8/14/24, Resident 1 told her about his complaint on his right arm. RP 1 further stated, .Yes, I told them [nursing staff] about his [Resident 1] complaint of his arm, I told [name of Licensed Nurse (LN) 1]. I did tell [name of LN 1] about dad saying that a female went and grabbed him in the arm firmly. That time, he [Resident 1] was so adamant that I listen to him [Resident 1], and he wrote the number 5. He [Resident 1] was basically saying it happened around 5 a.m . I notified the nurse around 11 a.m. of that day .When I talked to her [LN 2], the nurse already had noticed about his [Resident 1] arm .He [Resident 1] was in a lot of pain. They [nursing staff] knew but were not sure why he [Resident 1] was hurting. (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 2 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 08/22/2024 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)