Health inspection·November 8, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe medication administration to one resident (Resident 1) of two sampled residents when medications were left unattended at bedside. Residents Affected - Few This decreased the facility's potential to ensure medications were safely ingested by the intended resident. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in 2024 with diagnoses which included anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress) and chronic pain syndrome (a condition that involves chronic pain that interferes with daily life and is accompanied by other symptoms). A review of Resident 1's care plan initiated on 7/31/24 indicated a focus on, Resident accusing NOC [nocturnal shift] nurse of not giving her medications that were scheduled . Licensed nurses were supposed to, increase communication between [Resident 1] .about care and living environment .Explain all procedures and .medications . A review of Resident 1's care plan initiated on 8/27/24 indicated a focus on, [Resident 1] yelling at NOC CNA [Certified Nurse Assistant] and this nurse and accusing NOC CNA and this nurse of not providing care to resident .Resident also throwing her medication at this nurse. Licensed nurses were supposed to, increase communication between [Resident 1] .about care and living environment .Explain all procedures and .medications . A review of Resident 1's self-administration of medication dated 10/13/24 at 1:40 a.m. indicated no members of the interdisciplinary team (IDT, a group of health professionals from different disciplines who work together to treat a patient) was documented. In an observation on 11/8/24 at 2:05 p.m. in Resident 1's room, an open medication cup labeled with Resident 1's room number and bed sat on a food tray next to various food items. The medication cup had no lid and approximately 9 pills of different colors and sizes. The surveyor took a photo of the medication cup. In an interview and concurrent record review on 11/8/24 at 3:30 p.m., the Director of Nursing (DON) was shown the photo of the medication cup with Resident 1's room number and bed. The DON stated leaving medications at bedside was a safety concern because the licensed nurse could not ensure what Resident 1 would do with the medications. The DON also confirmed Resident 1's self-administration of (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 11/08/2024 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)