Health inspection·August 30, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a cane. Residents Affected - Few This failure resulted in Resident 1 sustaining injury and pain to the right lower leg . Findings: A review of Resident 1's admission Record indicated Resident 1 was most recently admitted to the facility in October 2023 with multiple diagnoses including paraplegia (paralysis of the legs), Stage 4 pressure ulcer (full thickness skin loss extending into deep tissues due to prolonged pressure to area) of the sacral region (bottom of the spine), diabetes (too much sugar in the blood), and dementia (loss of memory and thinking abilities). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 5/29/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's Change in Condition Evaluation, dated 8/25/24, indicated .skin discoloration d/t [due to] alleged physical aggression with other resident . A review of Resident 1's Progress Notes, dated 8/25/24 at 5:30 a.m., indicated .Licensed nurse received a report at 5:30am from CNA [Certified Nursing Assistant] that resident [Resident 1] was been hit by resident [Resident 2] with the cane and both resident was separated immediately. Body assessment done and Noted skin discoloration at right lower leg . A review of Resident 1's Progress Notes, dated 8/25/24 at 6:39 p.m., indicated .Resident has bruising and raised bumps to his right leg from a reported altercation from his roommate . A review of Resident 1's Progress Notes, dated 8/26/24 at 10:55 a.m., indicated .IDT [Interdisciplinary Team] met to discussed [sic] regarding incident of altercation with his roommate .[Resident 2] hit resident with his cane .DON [Director of Nursing] asked what happened, and he stated I don't know. He just came to me and started hitting me with his cane. I think he is bored of being here and has some mental issues . A review of Resident 1's Progress Notes, dated 8/26/24 at 5:25 p.m., indicated .when asked about the incident, resident stated his roommate all of a sudden started waving his cane at the ceiling and then came over to him and hit him on the leg with his cane. He stated he hit him one time with his (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 08/30/2024 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)