F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on interview, and record review, the facility failed to provide appropriate treatment and services to
maintain or improve mobility and prevent decline in range of motion (ROM) for one out of five sampled
residents (Resident 5) when Resident 5's frequency for Physical Therapy Rehabilitation (therapy given to
restore an individual back to their highest possible level of physical, mental, and psychosocial well-being)
were not followed.
This failure had the potential for Resident 5 to experience decline in range of motion or impairment in
mobility.
Findings:
A review of Resident 5's clinical record indicated Resident 5 was admitted May of 2024 and had diagnoses
that included polyosteoarthritis (a chronic condition that causes the cartilage and bone in joints to break
down in at least five joints at the same time), fusion of spine (permanently joined two or more backbone),
and chronic pain syndrome (a condition that occurs when chronic pain causes other symptoms that
interfere with daily life).
A review of Resident 5's Minimum Data Set (MDS- a federally mandated assessment tool) Cognitive
Patterns, dated 11/19/24, indicated Resident 5 had an intact cognition (mental process of acquiring
knowledge and understanding). A review of Resident 5's MDS Functional Abilities, dated 11/19/24,
indicated Resident 5 needed Partial/moderate assistance with lower body dressing and putting on/taking off
footwear, and supervision or touching assistance with toilet transfer, shower transfer, and walking 10 to 50
feet.
During an interview on 1/23/25 at 12:11 p.m. with Resident 5, in Resident 5's room, Resident 5 stated she
was on Physical Therapy (PT) before, but she only had a few days of the therapy sessions. Resident 5
stated she needed more Physical Therapy exercises so she could improve her leg functions.
During a concurrent interview and record review on 1/23/25 at 2:09 p.m. with Physical Therapist Assistant
(PTA) 1, Resident 5's therapy records were reviewed. PTA 1 confirmed that Resident 5's PT certification
period of 6/16/24- 7/15/24 indicated Resident 5 should have five times a week therapy for four weeks. PTA
1 then confirmed that Resident 5 only had therapy on 6/17, 6/18, 6/20, 6/21, 6/24, 6/25, 7/2, 7/4, 7/10 and
had documented missed visits on 6/19, 7/3, and 7/9. PTA 1 also confirmed that Resident 5's PT certification
period of 7/11/24- 8/9/24 indicated Resident 5 should have five times a week therapy for four weeks. PTA 1
then confirmed that Resident 5 only had therapy on 7/11, 7/16, 7/18, 7/23, 7/24, 7/25, 7/29, 7/30, 7/31, 8/5,
8/8, 8/9 and had documented missed visits on 7/17, and 8/1. PTA 1 further confirmed that the PT frequency
on the 6/16/24- 7/15/24 and 7/11/24- 8/9/24
(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
01/24/2025
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
certification period were both not followed. PTA 1 stated the frequency should have been followed because
there would be a risk for the resident to not improve her condition.
During an interview on 1/23/25 at 4:11 p.m. with the Director of Nursing (DON), the DON stated the
assessed frequency of therapy visits by the Physical Therapist should be followed.
Residents Affected - Few
During an interview on 1/24/25 at 2:56 p.m. with the DON, the DON stated the facility should always follow
the indicated frequency of therapy visits and if the resident refuse, it should be documented.
A review of the facility's policy and procedure (P&P) titled, INPATIENT REHABILITATION SERVICES,
revised 3/23/16, indicated, It is the objective of the rehabilitation department to provide comprehensive and
integrated therapy services to restore patients to their highest level of function. Therapist will develop an
individualized plan of care upon evaluation and continuous assessment during treatment plan.
A review of the facility's P&P titled, Physician Orders for Rehab Services, revised 12/19/22, indicated, The
evaluating therapist must establish the therapy plan of care after completion of initial assessment. The plan
of care shall include at a minimum .frequency and duration of treatment .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056304
If continuation sheet
Page 2 of 2
