Health inspection·March 27, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care for one out of 29 sampled residents (Resident 49), when Resident 49 did not receive wound care treatments consistently as ordered. Residents Affected - Few This failure had the potential for Resident 49's wounds to worsen and for the resident to not achieve their highest practicable well-being. Findings: Resident 49 was admitted to the facility in April 2024 with multiple diagnosis which included morbid obesity, venous insufficiency (condition where the veins in the legs do not function properly, allowing blood to flow backward instead of upward to the heart), and immunodeficiency (failure of the immune system to protect the body adequately from infection). During a review of Resident 49's Treatment Administration Records (TAR, a legal document used to record treatments given to the residents) for February 2025 and March 2025, Resident 49 had the following orders: TX (treatment): Coccyx (tailbone) wound cleanse with wound cleanser, pat dry apply collagen, [brand], calcium alginate, Triad to the margin and cover with bordered foam with skin prep to adhesive exposed skin. every day shift - Start Date - 01/26/2025 0700 - D/C (discontinue) Date - 02/09/2025 .TX: Left foot posterior heel wound cleanse with wound cleanser, pat dry, collagen sheet packing. Calcium Alginate and cover with dry dressing. every day shift - Start Date - 01/16/2025 0700 - D/C Date - 02/07/2025 1434 .TX: Lt (left) medial food wound cleanse with wound cleanser, pat day, apply collagen, [brand], calcium alginate, triad to the margin and secure with foam dressing. every day shift - Start Date - 01/16/2025 0700 D/C Date - 02/09/2025 1425 .TX: Rt (right) ischium (hip) wound: Cleanse with wound cleanse, pat dry, apply Honey-based Gel, calcium alginate, Triad ton the margin and cover with bordered foam with skin prep to adhesive exposed skin. Change daily until healed and PRN (as needed) soiling/dislodge. every day shift Start Date - 12/28/2024 0700 - D/C Date - 02/09/2025 1423 .TX: for prophylactic (prevent disease) measure to Rt ischium scar tissue cleanse with wound cleanser, pat dry and cover with bordered gauze. every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for 30 Days - Start Date - 02/28/2025 0700 .Indwelling Catheter (a flexible tube, often made of plastic or rubber, inserted through the urethra into the bladder to drain urine and is left in place for a period ) Cre (care): Cleanse outside catherter [sp] and tissue surrounding meatus with normal saline. every shift - Start Date - 02/10/2025 2300 .TX: Prophylaxis to Coccyx scar cleanse with wound cleaner, pat dry, apply triad paste and cover with bordered gauze. every shift - Start Date - 03/18/2025 1400. During a concurrent interview and record review on 3/25/25, at 11:54 a.m., with the Assistant Director of Nursing (ADON), Resident 49's TAR for the months of February 2025 and March 2025 were reviewed. The ADON confirmed multiple treatments were not done as ordered for the following days and shifts: 2/2/25 Day shift, 3/17/25- Day shift, and 3/23/25- Day shift. The ADON further stated it was the Licensed Nurse's responsibility to perform the treatments as ordered and document. The ADON stated if treatments were not done as ordered, the resident could potentially have further skin breakdown, and the wound could potentially worsen or reopen. A review of Resident 49's care plans initiated on 2/8/25, indicated, Provide wound care per treatment order .Resident is high risk for re-occurrence of pressure injury due to non-compliant . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 2 of 26 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 03/27/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's document titled, Treatment Nurse, Job Description, dated 2023, indicated, Provide wound care on assigned residents, in accordance with physician orders . During a review of the facility's document titled, Licensed Vocational Nurse, Job Description, dated 2023, indicated, Performs wound treatments as per physicians' orders; observes for changes and documents accordingly. During a review of the facility's P&P titled, Provision of Quality of Care, dated 12/19/22, the P&P indicated, .the facility will ensure residents receive treatment and care by qualified persons in accordance with professional stands of practice, the comprehensive person-centered care plans .Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Nursing Services and Sufficient Staff, revised 3/11/25, the P&P indicated, .provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 3 of 26 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 03/27/2025 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 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 observation, interview, and record review, the facility failed to implement an ordered contracture device (a soft device that gently straighten fingers that have become stiff and painful) for one of 29 sampled residents, Resident 70. This failure had the potential to result in Resident 70 not reaching their highest practicable level of functioning. Findings: Resident 70 was admitted in 2023 with multiple diagnosis which included Contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) to the left and right hands. During an observation on 03/25/25 at 10:23 a.m. in Resident 70's room, Resident 70's was seen lying in bed without her contracture device applied to right hand. During a concurrent observation and interview on 03/25/25 at 11:08 a.m. in Resident 70's room, with CNA 4 (Certified Nursing Assistant 4) Resident 70's right hand was observed without a contracture device. CNA 4 confirmed the contracture device was not applied to Resident 70's right hand. CNA 4 stated she is supposed to have devices on both hands and feet to avoid any increased bending. During a concurrent interview and record review on 3/26/25 at 3:43 p.m., with the ADR (Assistant Director of Rehabilitation), of Occupational Therapy OT Evaluation & Plan of Treatment for [Resident 70], (undated) was reviewed. The Occupational Therapy OT Evaluation & Plan of Treatment indicated contracture device treatment for Resident 70's left and right hand. The ADR stated, the treatment plan indicated how many devices a Resident should have and where they should be worn. ADR further stated that (Resident 70) should have two contracture devices on 24 hours a day. During an interview on 3/26/25 3:55 a.m., with the DON (Director of Nursing), the DON stated she expected all staff to follow orders and care plans for contracture devices. The DON stated an adverse outcome of not having ordered contracture devices on, .can worsen the contracture. During an observation and interview on 3/26/25 at 4:13 p.m., with LN 10 (Licensed Nurse) in Resident 70's room, Resident 70's right hand did not have a contracture device applied. LN 10 confirmed Resident 70's contracture device was not applied to the right hand. During an interview on 3/26/25 at 4:34 p.m., with the DSD (Director of Staff Development), the DSD stated, I expect CNAs, RNAs (Restorative Nursing Assistants), RNs (Registered Nurses) and all staff to follow task order. The DSD stated if contracture device orders and care plans were not followed, Resident 70's conditions could worsen. The DSD stated, If it is care planned or ordered it will say what it is for and should be followed. During a concurrent observation and interview on 03/27/25 09:10 a.m. with RNA 1 in Resident 70's room, Resident 70's right hand was observed without the contracture device applied. RNA 1 stated, . if they don't have them [contracture devices] on it can get worst . if there were an order, I would expect them to be on. RNA 1 confirmed resident did not have contracture support device on right hand. RNA 1 Stated she [Resident 70] is supposed to have one [contracture device] on her right and left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 4 of 26 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 03/27/2025 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 hand. She just has one on her left hand. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 70's Care Plan Report, dated March 2025, the Care Plan Report indicated, RNA program for Placement of hand/palm protector 24 hours a day. Residents Affected - Few During a review of the facilities Policy and Procedure (P & P) titled, Restorative Nursing Programs, dated 2022, the P&P indicated, It is the policy of this facility to .maintain or improve a resident's abilities to the highest practicable level .services include splint or brace assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 5 of 26 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 03/27/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review, the facility failed to provide adequate services and assistance for prevention and/or early detection of possible urinary tract infection (UTI- an infection in the bladder/urinary tract) for one out of 29 sampled residents (Resident 84) when Resident 84's order for STAT (immediate) urinalysis (UA- a medical test that examines urine to check for various conditions, including urinary tract infections) was not done timely. This failure had the potential to result in delayed detection of a UTI subsequently causing delayed care and treatment which negatively affected Resident 84's health condition. Findings: A review of Resident 84's clinical record indicated Resident 84 was admitted November of 2022 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), UTI, sepsis (a life-threatening blood infection), extended-spectrum beta-lactamase (ESBL) resistance (and infection that is resistant to common antibiotics and may require complex treatments), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life, and the need for assistance with personal care. A review of Resident 84's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/13/25, indicated Resident 84 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of three out of 15 which indicated Resident 84 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 84's MDS Bladder and Bowel Conditions, dated 2/13/25, indicated Resident 84 was always incontinent (having no or insufficient voluntary control) on both urinary and bowel. A review of Resident 84's progress notes, dated 3/21/25 at 10:02 p.m., indicated, .Nursing observations, evaluation, and recommendations are: CNA [certified nurse assistant] notified LN [licensed nurse] of resident's .confusion. LN immediately went to assess resident. Upon observation, resident was A&O [alert and oriented], but not to her normal baseline .Resident was A&Ox2 [alert and oriented to person and place only] and having frequent urination episodes .Urine color is pale yellow. LN notified NP [nurse practitioneran advanced practice registered nurse that are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, prescribe medications and formulate treatment plans] and received order(s) for urine collection for stat urinalysis and may straight cath [straight catheter- a thin, flexible tube used to drain urine from the bladder when a person is unable to urinate naturally] if unable to void. Orders noted and carried out .Primary Care Provider responded with the following feedback: A. Recommendations: urine collection for stat urinalysis and may straight cath if unable to void . A review of Resident 84's physician's order, dated 3/21/25, indicated, May collect urine sample for urinalysis to r/o [rule out] possible UTI. May use straight cath if needed. one time only for possible uti for 1 Day. A review of Resident 84's progress notes, dated 3/22/25, indicated, .Resident is on monitoring for COC [change of condition with] frequent urination and confusion. Stat lab [laboratory] orders was faxed to Lab by Supervisor. Supervisor also called the Lab to notify them of Stat orders. Resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 6 of 26 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 03/27/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few still having episodes of some confusion. No slurred speech [sic]. This writer asked resident what his name is, and resident answered name correctly. NP notified of resident, NP advised to wait for UA and monitor resident for slurred speech [sic] and left sided weakness . A review of Resident 84's progress notes, dated 3/23/25, indicated, New UA specimen collected by writer at this time. Old urine specimen thrown away. Pt [patient] assisted to toilet by writer .Specimen collected 03/23/25 @2330 [11:30 p.m.]. A review of Resident 84's progress notes, dated 3/24/25 at 6:33 a.m., indicated, Nursing observations, evaluation, and recommendations are: pt first noted with altered behavior on the 21st. the condition has been getting gradually worse. UA was collected and picked up today d/t [due to] UA not being considered STAT according to lab. pt is repeating the same phrase over and over. pt is not responding to her first name. pt is very confused from baseline. symptoms have been getting increasing worse .Primary Care Provider responded with the following feedback: A. Recommendations: Per .NP .SEND TO [acute hospital] FOR FURTHER EVALUATION . During an interview on 3/24/25 at 9:10 a.m. with LN 2, LN 2 stated Resident 84 was noticed to have confusion last Friday (3/21/25) and was ordered with STAT UA. LN 2 also stated the lab said they would pick up the urine sample, but it was never picked up until this morning. LN 2 further stated Resident 84 was sent out to an acute hospital this morning, around 6 a.m., because of increased confusion. A review of Resident 84's laboratory requisition (also known as a lab order, is a formal document used by healthcare professionals to request specific laboratory tests or procedure), dated 3/21/25, indicated a STAT order for UA on 3/21/25 and the collection date was 3/22/25. During a concurrent interview and record review on 3/25/25 at 10:46 a.m. with the Infection Preventionist (IP), Resident 84's laboratory requisition was reviewed. The IP confirmed that Resident 84 had a STAT order for UA on 3/21/25 but the urine sample was just picked-up on 3/24/25. The IP stated, .depending on when the urine was collected, the nurse will call the lab, and they will come about 4-6 hours after. During a phone interview on 3/25/25 at 2:11 p.m. with the U.S. Diagnostics Manager (USDM), the USDM stated their laboratory is typically available seven days a week and is operational even on weekends. The USDM further stated that for standard lab orders, it would be done the day of or the following day of the order, and for STAT orders, the typical response time would be 4 hours. During a concurrent phone interview and record review on 3/25/25 at 3:10 p.m. with the USDM, Resident 84's laboratory order was reviewed. The USDM stated the lab received the STAT order for UA on 3/22/25 and was collected only on 3/24/25. The USDM stated she was not sure what happened why the urine specimen was only collected on 3/24/25. A review of Resident 84's UA laboratory result, dated 3/25/25, indicated Resident 84's urine showed presence of blood, protein, Leukocyte esterase (released by white blood cells), and bacteria which were all flagged as abnormal compared to the normal reference range. During an interview on 3/27/25 at 10:26 a.m. with the Director of Nursing (DON), the DON stated, From our contract with the [laboratory] company, STAT orders have to be done as soon as possible. The DON also stated she would expect that laboratory orders would be done timely. The DON further stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 7 of 26 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 03/27/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the risk if the laboratory order was not done timely would be delay of care which could negatively affect the health status of the resident. A review of the facility's agreement with U.S. Diagnostic Management Inc. (USDM Inc.), titled, California Professional Diagnostic Services Agreement, dated and signed on 10/18/24, indicated, For all STAT orders provided by the physician, USDM [Inc.] will prioritize and expedite the services and return results to the facility as promptly as possible . A review of the facility's policies and procedures titled, Laboratory Services and Reporting, dated 12/19/22, indicated, The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 8 of 26 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 03/27/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 29 sampled residents (Resident 4) when Resident 4's physician's order for oxygen therapy was not followed. Residents Affected - Few This failure had the potential to result in unsafe delivery of oxygen to Resident 4 and for Resident 4 to not achieve her highest practicable well-being. Findings: A review of Resident 4's clinical record indicated Resident 4 was admitted March of 2025 and had diagnoses that included respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), and need for assistance with personal care. A review of Resident 4's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 3/7/25, indicated Resident 4 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 4 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 4's MDS Health Conditions, dated 3/7/25, indicated Resident 4 experienced shortness of breath or trouble breathing when lying flat. A review of Resident 4's active physician's order, dated 3/20/25, indicated, Oxygen at 2-3L/min [liters per minute or LPM- unit of measurement for oxygen administration flow rate] .every shift. During a concurrent observation and interview on 3/24/25 at 8:43 a.m. in Resident 4's room, Resident 4 was seen lying on bed, awake, and was on oxygen delivered via nasal cannula with the oxygen concentrator (machine) set at 5 LPM. Resident 4 stated she uses oxygen daily and the nurses would set it up for her. During a concurrent observation and interview on 3/24/25 at 1:14 p.m. in Resident 4's room with Certified Nurse Assistant (CNA) 1, CNA 1 confirmed that Resident 4's oxygen was set at 5 LPM. During another observation on 3/25/25 at 8:55 a.m. in Resident 4's room, Resident 4 was seen lying on bed, awake, and was on oxygen delivered via nasal cannula with the oxygen concentrator still set at 5 LPM. During a concurrent observation and interview on 3/25/25 at 11:03 a.m. in Resident 4's room with Licensed Nurse (LN) 6, LN 6 confirmed that Resident 4's oxygen was set at 5 LPM. LN 6 stated if the oxygen being delivered is higher than what was ordered, the resident would be at risk for oxygen toxicity (a lung damage that happens from breathing in too much extra [supplemental] oxygen). A review of Resident 4's care plan intervention, initiated 3/25/25, indicated, Administer oxygen as prescribed or per standing order. During an interview on 3/27/25 at 10:26 a.m. with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 9 of 26 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 03/27/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete oxygen administration should always be within the doctor's order because it could have a bad effect on the resident ' s condition if the resident receives higher oxygen that what is prescribed. The DON further stated she would expect staff to follow what is ordered for the resident. A review of the facility's policies and procedures titled, Oxygen Administration, revised 6/5/23, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident ' s goals and preferences .1. Oxygen is administered under orders of a physician . Event ID: Facility ID: 056304 If continuation sheet Page 10 of 26 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 03/27/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that discontinued non-controlled medications (pharmaceutical preparations that can only be obtained through a medical practitioner's prescription and dispensed by a pharmacist but are not considered controlled substances under the Controlled Substance Act) and those which remained in the facility after discharge of the patient were destroyed in the presence of two licensed nurses. This failure had the potential risk for diversion (deflection of prescription drugs from medical sources into the illegal market) and/or misuse of non-controlled medications. Findings: During a concurrent interview and record review on [DATE] at 4:22 p.m. with the Infection Preventionist (IP), the non-controlled medication disposition logbook was reviewed. The IP confirmed that the destruction of non-controlled medications was not being signed consistently by two licensed nurses on multiple dates and with multiple medications. Some of the documents reviewed had only one licensed nurse signature, and some did not have any signature at all. The IP stated that non-controlled medications should be destroyed and signed by two (2) licensed nurses. During a phone interview on [DATE] at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated that for non-controlled drug destruction, there should always be two license nurses signing the sheets when the medications are being destroyed. The PC further stated that there would be a potential for drug diversion if the non-controlled drug destructions were not done and signed by two licensed nurses. During an interview on [DATE] at 10:26 a.m. with the Director of Nursing (DON), the DON stated that the non-controlled medications should be destroyed and signed consistently by two licensed nurses. The DON further stated that there would be possible misuse of the medications if the destructions were not done and signed by two licensed nurses. A review of the facility's policy and procedure titled, Destruction of Unused Drugs, revised [DATE], indicated, All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .4. The actual destruction oof drugs conducted by our staff must be witnessed by: .Non-controlled Medication: i. Consultant pharmacist; or ii. Licensed nurse. 5. A destruction record must be maintained for all drugs destroyed. The actual destruction of drugs conducted by our facility must be witnessed by facility staff as per state requirements .The following information shall be included on this record: .g. The signature of the consultant pharmacist or licensed nurse destroying the non-controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 11 of 26 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 03/27/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure irregularities reported by the pharmacist to the facility were acted upon for one out of 29 sampled residents (Resident 2). Residents Affected - Few This failure put Resident 2 at an increased risk for developing adverse (unwanted, uncomfortable or dangerous) drug reactions related to medication therapy and had the potential for Resident 2 to not achieve their highest practicable physical, mental, and psychosocial well-being. Findings: Resident 2 was admitted to the facility in February 2025 with multiple diagnosis which included heart failure, depression, anxiety disorder, and myalgia (pain in a muscle or group of muscles). A review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 2/11/25, indicated, Resident 2 had intact cognition. During a review of Resident 2's Order Summary Report, dated 3/26/25, Resident 2 had an order for, Esomeprazole Magnesium [blocks acid from being made in the stomach] Oral Capsule Delayed Release 40mg [milligrams, measure of unit] Give 1 capsule by mouth one time a day for chronic N/V [nausea and vomiting] - Start Date 02/06/2025 0800. During a review of Resident 2's Consultant Pharmacist's Medication Regimen Review (MRR), dated 2/28/25, the following was recommended for the anti-acid medication, Please administer on an empty stomach, at least 60 minutes before meal. There was no documented revision applied to the anti-acid medication. During a review of Resident 2's Order Summary Report, dated 3/26/25, Resident 2 had an order for, Ventolin HFA Inhalation Aerosol Solution [used to treat or prevent breathing problems]108 (90 Base) MCG [micrograms, measure of unit]/ACT (Albuterol Sulfate) 1 inhalation inhale orally every 4 hours as needed for SOB [shortness of breath]/wheezing. During a review of Resident 2's MRR, dated 2/28/25, the following was recommended for the breathing medication, Please add 'Shake well before each spray' to the order. There was no documented revision applied to the breathing medication. During a review of Resident 2's Order Summary Report, dated 3/26/25, Resident 2 had two orders for PRN (as needed) pain medications, [brand] Oral Tablet 50 MG [brand] Give 1 tablet by mouth every 4 hours as needed for pain, and [brand] Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain. During a review of Resident 2's MRR, dated 2/28/25, the following was recommended for the pain medications, Resident is on PRN pain medication(s). If pain is present, please treat initially with Non-Pharmacological intervention. Please add this to PCC [electronic medical record]. There was no documented revision applied to the pain medications. During a concurrent interview and record review on 3/26/25, at 3:26 p.m., with the Assistant Director of Nursing (ADON), Resident 2's MRR, dated 2/28/25, and Resident 2's current Order Summary Report were reviewed. The ADON confirmed the pharmacist recommendations for the anti-acid medication, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 12 of 26 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 03/27/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete breathing medication, and pain medications were not carried out and should have been completed by now. The ADON further stated not carrying out the pharmacy recommendations could potentially interrupt care for Resident 2 and increase their risk of side effects. During a review of the facility's P&P titled, Medication Regimen Review, revised 12/19/22, the P&P indicated, Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication .The requirements associated with the MRR apply to all residents .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Event ID: Facility ID: 056304 If continuation sheet Page 13 of 26 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 03/27/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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 practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 125. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in two out of eight residents (Resident 96 and Resident 132) observed for medication administration. Residents Affected - Some These failures had the potential for unsafe and ineffective medication use of Resident 96 and Resident 132 and had the potential to affect the residents' medical conditions. Findings: 1. During a concurrent medication administration observation and interview which started on 3/24/25 at 11:48 a.m. with Licensed Nurse (LN) 3, LN 3 stated she already checked Resident 96's blood sugar level, and it was 217. LN 3 then administered a total of seven units of Insulin Lispro (a fast- acting medication used to manage blood sugar levels) to Resident 96 on her right upper outer arm. There was no observed meal tray in Resident 96's room. LN 3 stated lunch was scheduled at 11:30 a.m. but it was running late on that day. A review of Resident 96's active physician's order, dated 2/10/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML (unit per milliliters- unit of measurement) .Inject 5 unit subcutaneously (under the skin) two times a day related to TYPE 1 DIABETES MELLITUS (a chronic condition where the body doesn't produce insulin, causing too much sugar in the blood) . A review of Resident 96's active physician's order, dated 2/10/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML .Inject as per sliding scale: .201-250= 2 units .subcutaneously before meals related to TYPE 1 DIABETES MELLITUS . During an observation on 3/24/25 at 12:23 p.m. in Resident 96's room, there was still no observed meal tray in Resident 96's room. During a concurrent observation and interview on 3/24/25 at 12:37 p.m. with Certified Nurse Assistant (CNA) 8 in Resident 96's room, CNA 8 confirmed that Resident 96 did not receive her lunch meal tray yet. CNA 8 stated the kitchen has just started bringing out food carts. During an observation on 3/24/25 at 12:41 p.m. in Resident 96's room, Resident 96 was observed eating her lunch meal. A review of Resident 96's, Weights and Vitals Summary, indicated Resident 96 had blood sugar levels as follows: 3/24/25 at 4:41 p.m.- 86 mg/dl (milligrams per deciliter- unit of measurement) 3/24/25 at 23:01 p.m.- 119 mg/dl A further review of Resident 96's, Weights and Vitals Summary, indicated Resident 96's previous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 14 of 26 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 03/27/2025 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 0759 blood sugar levels usually ranges from 217 - 398 mg/dl. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 3/26/25 at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated Insulin lispro should be administered before meals, if not, it could cause hypoglycemia (low blood sugar). The PC further stated nurses should follow the doctor's order when administering Insulin Lispro. Residents Affected - Some A review of an online publication, Drugs.com, titled, When does insulin lispro peak / how long does it last?, dated 6/17/24, indicated, Insulin Lispro .Starts working within 0 to 15 minutes after administration .Peaks in 30 to 90 minutes .Keeps working for less than five hours (usually two to four hours . (https://www.drugs.com/medical-answers/insulin-lispro-peak-long-3544836/) 2. During a medication administration observation which started on 3/25/25 at 9:20 a.m. with LN 5, LN 5 administered a total of 10 medications to Resident 132 which included 1 tablet of Pantoprazole (a medication that reduces the amount of acid the stomach) 40 mg (milligrams- unit of measurement). A review of Resident 132's active physician's order, dated 3/18/25, indicated, Pantoprazole Sodium Oral tablet Delayed Release 40 MG .Give 1 tablet by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE (a condition where stomach contents flow back up into the food pipe, causing inflammation and discomfort) . A review of Resident 132's Medication Administration Record (MAR- a legal document used to record medications given to the residents), for the month of March 2025, indicated Resident 132's pantoprazole was scheduled to be administered every 7:30 a.m. During a phone interview on 3/26/25 at 3:21 p.m. with the PC, the PC stated that Resident 132's pantoprazole should be administered 1 hour before or 1 hour after the scheduled time. The PC further stated that the medications efficacy (ability to produce a desired or intended result) would be affected if the pantoprazole was not administered within the scheduled time of administration. During an interview on 3/27/25 at 10:26 a.m. with the Director of Nursing (DON), the DON stated that she would expect staff to follow the physician's order when administering prescribed administering medications. A review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 12/19/22, indicated, Medications are administered .as ordered by the physician and in accordance with professional standards of practice .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 15 of 26 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 03/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and stored in accordance with manufacturer's guidelines, the facility's policies and procedures, and accepted professional standards for a census of 125 residents when: 1. An unlabeled, opened glucose gel tube (a medication administered for low blood sugars) was found in medication cart North 3; 2. A discharged resident's medications were found loose in a bag in the medication room; and 3. The refrigerator in the North Medication Room was not within the correct temperature range. These failures had the potential to result in unsafe medication administration and drug diversion. Findings: 1. During a concurrent observation and interview on [DATE] at 10:03 a.m. with Licensed Nurse (LN) 2, a glucose gel tube was found in the top drawer of medication cart North-3. LN 2 confirmed the gel had been opened and there was no label which indicated the date it had been opened, or when it expired. During a concurrent interview and record review on [DATE] at 9:40 a.m. with LN 8, LN 8 reviewed the manufacturer's instructions for use and confirmed the gel was a single use medication. During an interview on [DATE] at 11:50 am with LN 2, LN 2 confirmed the gel was a single use medication and there was a risk it could have been already administered to another resident. 2. During a concurrent observation and interview on [DATE] at 3:30 p.m. with the Infection Preventionist (IP), a plastic bag with resident belongings was on the counter of the North medication room. The IP confirmed the bag contained a resident's medications and there was an opened pill bottle with loose pills in the bag. The IP stated when a resident was discharged , they kept their medications in the medication room, if they don't return within 7 days, they disposed of them. The IP stated an open medication bottle was a risk for drug diversion and would not be appropriate to return to the resident should they return to the facility. 3. During a concurrent observation and interview on [DATE] at 4:01 p.m. with the IP, the IP confirmed the temperature of the North medication room refrigerator was 51 degrees Fahrenheit (F° a unit of measurement.) The refrigerator contained insulin vials, emergency medication kits, and vials for vaccination. During a concurrent observation and interview on [DATE] at 4:14 p.m. with the IP, the temperature of the medication refrigerator was rechecked and the IP confirmed it was still at 51 F°. The IP stated if the refrigerator temperature was out of range, it could compromise the efficacy of the medication and make them unsafe for resident use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 16 of 26 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 03/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE] at 4:07 p.m. with Pharmacy Consultant (PC), the PC concurred the glucose gel was for individual use. The PC stated an unlabeled, opened tube should not have been in the medication cart, should have been disposed of immediately after resident administration, was a risk of cross-contamination and had the potential for it to be administered to another resident. The PC said all medications at the facility need to be monitored, recorded and accounted for. The PC confirmed medications stored in a refrigerator at the incorrect temperatures could compromise their efficacy and make them unsafe for use. During an interview on [DATE] 10:26 a.m. with the Director of Nursing (DON), the DON confirmed that nurses needed to label, dispose of and store all medications appropriately. During a review of a facility policy titled, Labeling of Medications and Biologicals, revised [DATE], the policy indicated, All medications and biologicals will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. During a review of the product insert for the glucose gel it indicated, Do not use if tube has been previously opened or punctured and, Use before the expiry date printed on the carton. During a review of the facility policy titled, Storage of Medication Requiring Refrigeration, revised [DATE], the policy indicated, Refrigerators used for storage of biologicals .Temperature should be maintained between 36-46 F°. During a review of the facility policy titled, Destruction of Unused Drugs, revised [DATE], the policy indicated, Unused, unwanted and non-returnable medications should be removed from their storage area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 17 of 26 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 03/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store and ensure food safety in accordance with professional standards for food service safety to prevent an outbreak of foodborne illness for the census of 125 residents when: 1. Food items found in the freezer were unlabeled with the open and the use by dates. a. opened bag of garlic bread; b. opened box of pork sausage links with net weight of 10 lb.; and c. opened box of fish fillet with net weight of 15 lb. 2. Food items found in the walk-in refrigerator unlabeled with the open and use by dates. a. mustard (condiments) with net weight of 48 oz; and b. honey mustard (dressing) with net weight of 1 gal. 3. Food items found in the dry storage room were unlabeled and had lapsed use by dates. a. corn meal with use by date of 2/17/25; b. cake mix with use by date of 2/30/25; c. soy sauce with net weight of 1 gal, unlabeled with the open and the use by date; and d. white powder with unreadable name label, the open date and the use by date. 4. four (4) dented cans were found in the dry storage room: a. artichoke in can with net weight of 5 lb.; b. beef ravioli in can with net weight of 6 lb. 12oz; c. pinto beans in can with net weight of 6lb 15oz; d. tomato soup in can with net weight of 50 oz; and e. tomato soup in can with net weight of 7.52 oz. These failures had the potential to cause foodborne illness to highly susceptible residents. Findings: During a concurrent observation and interview in the kitchen with the Dietary Manager (DM), on 3/24/25 at 8:40 a.m., the DM confirmed and agreed on all findings listed above. The DM stated, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 18 of 26 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 03/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some perishable food should be legibly labeled with the name of the product, date it was opened, use by date and monitored to ensure the food is safe to eat by the residents. The DM emphasized that food items with lapsed use by dates should have been thrown out as well as food items with unreadable labels as it's not safe and may cause possible foodborne illness. The DM confirmed there were 4 dented cans stored with the non-dented cans. The DM stated that dented cans should have been removed from the non-dented can shelves as it's not safe to use and may cause botulism (rare but serious bacterial infection) to the residents as a potential outcome. During an interview in the kitchen with [NAME] 1 on 3/24/25 at 9:30 a.m., [NAME] 1 stated they are not supposed to use dented cans as it may be compromise and not safe to cook. During a concurrent observation and interview in the kitchen with [NAME] 2 on 3/24/25 at 10:10 a.m., 1 (one) dented can of tomato soup was placed on the countertop prep table beside the microwave and [NAME] 3 stated that he was going to use the dented can and make tomato soup. [NAME] 3 acknowledged he's not supposed to use dented cans as they may cause botulism. During an interview with the Registered Dietician (RD) on 3/27/25 at 10:19 a.m., the RD stated opened food items should be labeled with the name of the product, open date and use by date to avoid possible foodborne illness. A review of the facility's policy and procedure, titled, Date Marking for Food Safety, date implemented 12/19/22, indicated, The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall include the date of opening, and the date the item must be consumed or discarded . 6. The Head Cook, or designee, shall be responsible for checking the refrigerators daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Supervisor (Manager), or designee, shall spot check the refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed . A review of the facility's policy and procedure, titled, Dented or Damaged Cans, dated 10/19, indicated, Upon delivery, all canned food products should be inspected for safe transport and quality upon receipt . A review of the Food and Drug Administration (FDA) Document titled, Food Code 2022, dated 1/18/23, indicated, 3-201.11 Compliance with Food Law. Refer to the public health reason for § 3-401.11. Source A primary line of defense in ensuring that food meets the requirements of § 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting and processing, they do not fall victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 19 of 26 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 03/27/2025 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure safe and sanitary practices were instituted for food brought in to residents by family or visitors from outside the facility when food saved for resident consumption was unlabeled and undated for 25 sampled residents. Residents Affected - Few This failure had the potential to result in consumption of food that is unsafe and cause foodborne illness in residents who received food from outside sources. Findings: During an interview with the Dietary Manager (DM) on 3/26/25 at 12:20 p.m., the DM stated, nurses should label the food brought from home with the date received and the use by date to assure that the resident's food is safe to eat. A review of the facility's signage posted on the refrigerator's front door, undated, indicated, Please label the resident's food with the following details before putting it in the fried: [sic] Name and Rm# .Date Received .Used-by date (3 days from received). Any and all food items must have a date. Any food items that are not dated will be discarded. During a concurrent observation and interview inside the Medication Room, North Station with Licensed Nurse 11 (LN 11), on 3/26/25 at 12:40 p.m., LN 11 confirmed there was a square, black plastic container that held cooked noodles, a container of wild berry jam, and a juice drink inside the resident's refrigerator that were unlabeled with a resident's name, use by date, and a received by date. LN 11 stated, it's important to label the food items brought from home to ensure the food is safe to eat and consumed by the rightful owner. LN 11 further stated, the signage posted on the refrigerator's front door should be followed by the staff to prevent confusion and food must be thrown away after 3 days from the received date to avoid potential harm to residents. LN 11 emphasized unlabeled food items should be discarded to prevent possible cross contamination. During an interview with the Director of Nursing (DON) on 3/27/25 at 11:25 a.m., the DON stated, the resident's food brought from home should be labeled with resident's name, received date, and open date to ensure the food is safe to eat. The DON emphasized there was signage posted on the refrigerator's front door to remind the staff to label the stored food items. A review of the facility's policy and procedure titled, Use and Storage of Food Brought in by Family or Visitors, date implemented 12/19/22, indicated, 1. All food items that are already prepared by the family or visitor brought in must be approved per Nursing to ensure is in accordance with the Diet Order and labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by the facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 20 of 26 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 03/27/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Upon the Team's entrance on 3/24/25 at 8 a.m., the DON instructed all surveyors to wear masks as they have current residents with an active respiratory infection in the facility. The DON emphasized that all employees are required to wear masks to promote infection control and decrease transmission of respiratory infection. Residents Affected - Some During a concurrent observation and interview at the North Station hallway with the NP on 3/25/25 at 11:25 a.m., the NP was not wearing a mask, stood across from the North Nurses Station while reading documents. The NP acknowledged she should wear a mask as required by the facility to promote infection control. In a review of the facility's P&P titled, Management of Respiratory Syncytial Virus (RSV, respiratory virus that infects the lungs and respiratory tract), date implemented 12/19/22, indicated, .3. Infection control principles will be followed to decrease the risk of transmission based on federal, state or local guidance. These principles include .d. Appropriate personal protective equipment (PPE, [equipment used to prevent or minimize exposure to hazards].) Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 125 when: 1. Residents' non-pharmaceutical (not medicinal drug related) personal belongings were found stored in four out of four sampled medication carts with pharmaceutical products; 2. Two facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 70 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); and, 3. A facility staff, Nurse Practitioner (NP) was not wearing a facemask as required by the facility. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 3/25/25 at 9:47 a.m. with Licensed Nurse (LN) 7 of medication cart 1, three rings and a white phone charger labelled with residents' name and room numbers were found stored next to the controlled medications (medications with high potential for abuse or addiction). LN 7 confirmed the observation. LN 7 stated the phone charger was owned by a discharged patient. LN 7 further stated they would store resident's personal items in medication carts to keep it safe. During a concurrent observation and interview on 3/25/25 at 10:03 a.m. with LN 2 of medication cart north-3, a hearing aid stored in a black container with its packaging box, a cellular phone [NAME] kit with its packaging card, two compact discs both stored in white paper sleeves, a black phone charger tied up with a rubber band, and a black key all labelled with residents' name and room numbers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 21 of 26 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 03/27/2025 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 0880 were all found stored next to the controlled medications. LN 2 confirmed the observation. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/25/25 at 10:25 a.m. with LN 8 of medication cart south-3, a hearing aid stored in a black container was found stored next to the controlled medications. LN 8 confirmed the observation. Residents Affected - Some During a concurrent observation and interview on 3/25/25 at 10:37 a.m. with LN 6 of medication cart south-5, a hearing aid with its packaging box, and a pair of eyeglasses labelled with residents' name and room number were found stored next to the controlled medications. LN 6 confirmed the observation. During an interview on 3/25/25 at 10:42 a.m. with the IP, the IP stated she did not feel that there was an issue with residents' personal items being stored in medication carts next to the controlled medications. The IP also stated that residents' personal items were stored in medication carts so the items would not be lost, and the nurses could keep on eye on the personal items. During a phone interview on 3/26/25 at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated that medications carts should only contain pharmacological products and equipment's necessary for medication administration, and it should not contain personal items. The PC also stated that the facility should have a different area to keep resident's personal items safe. The PC further stated that it would be a risk for cross contamination (movement or transfer of harmful bacteria from one person, object or place to another) if personal items are stored next to controlled medications because the items would still be in the same drawer. During an interview on 3/27/25 at 10:26 a.m., with the Director of Nursing (DON), the DON stated she would not expect to have resident's personal items stored in medication carts. The DON further stated having personal items in the medication cart could result in contamination or spread of germs which could cause infection to other residents. A review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 12/19/22, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation . 2. Resident 70 was admitted in Summer of 2023 with multiple diagnosis which included Resistance to multiple antibiotics (bacterial that do not respond to several types of antibiotics) and stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a concurrent interview and observation on 3/26/25 at 4:06 p.m., Certified Nursing Assistant (CNA) providing bed bath to Resident 70 without a ppe gown on. CNA 5 stated We should wear PPE for precaution. During a concurrent interview and observation on 3/26/25 at 4:07 p.m., CNA 6 providing bed bath to Resident 70 without PPE gown on. CNA 6 stated We should wear enhanced barrier precautions because she has a tube and wound. If we don't wear it we are at risk of fluids going on us. During an interview on 3/26/25 at 4:13 p.m. with LN (Licensed Nurse) 10, LN 10, stated For (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 22 of 26 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 03/27/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [Resident 70] bed bath I would wear gown, and gloves. I will look at the EHB (Enhanced Barrier Precaution, safety steps used to help stop the spread of germs) sign or care plan to guide me . all patients with g-tubes are on enhanced barrier precautions An adverse outcome could be risk for infection. During an interview on 3/26/25 at 4:15 p.m. with DON (Director of Nursing), the DON confirmed it was the expectation for all staff to wear gowns, masks, and gloves, when providing direct patient care for residents on EBP. The DON stated wearing proper PPE while providing care to residents on EBP due to risk of infection. During an interview on 3/27/25, at 9:34 a.m., with the IP (Infection Preventionist), the IP confirmed it was the expectation for all staff to wear gowns, masks, and gloves, when providing direct patient care for residents on EBP. The IP stated wearing proper PPE while providing care to residents on EBP was needed to prevent the spread of infection to staff and residents. During a review of Resident 70's Care Plan Report, dated 6/24/2024, indicated, Resident is placed on Enhanced Barrier Precautions related to unhealed wounds. During a review of the facilities Policy and Procedure (P & P) titled Enhanced Barrier Precautions, dated 3/10/25, PPE for enhanced barrier precautions is only necessary when performing high-contact care activities High-contact resident care activities include bathing/showering .device care . feeding tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 23 of 26 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 03/27/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure call light system was accessible for five out of 29 sampled residents (Resident 122, Resident 75, Resident 55, Resident 27, and Resident 112) when: Residents Affected - Some 1. Resident 122 and Resident 75's call light button was not within reach; 2. Resident 55's call light was broken; and, 3. Bathroom call system was not available for Resident 27 and Resident 112. These failures had the potential to result in residents' needs not being met and prevent communication for assistance when needed. Findings: 1a. A review of Resident 122's clinical record indicated Resident 122 was admitted August of 2024 and had diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 122's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/14/25, indicated Resident 122 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 3 out of 15 which indicated Resident 122 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 122's MDS Functional Abilities, dated 2/14/25, indicated Resident 122 was dependent with eating, shower/bathing self, lower body dressing, and putting on/taking off footwear, and needed substantial/maximal assistance with oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. A further review of Resident 122's MDS Functional Abilities indicated Resident 122 needed substantial/maximal assistance with rolling left and right, sit to lying, lying to sitting on the side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. A review of Resident 122's care plan intervention, dated 8/28/24, indicated, Place the resident's call light is [sic] within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 3/24/25 at 8:40 a.m. in Resident 122's room, Resident 122 was observed lying on bed, awake, and her call light button was on the floor, below her bed, and was tangled with the bed frame. During a concurrent observation and interview on 3/24/25 at 1:14 p.m. with Certified Nurse Assistant (CNA) 1, in Resident 122's room, CNA 1 confirmed that Resident 122's call light button was on the floor, below her bed, and was tangled with the bed frame. CNA 1 stated the call light button should be within Resident 122's reach so whenever Resident 122 needs anything, she could call for help. 1b. A review of Resident 75's clinical record indicated Resident 75 was admitted August of 2021 and had diagnoses that included dementia, respiratory failure (is a serious condition that develops (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 24 of 26 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 03/27/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), and major depressive disorder. A review of Resident 75's MDS Cognitive Patterns, dated 1/31/25, indicated Resident 75 had BIMS score of 3 out of 15 which indicated Resident 75 had a severely impaired cognition. A review of Resident 75's MDS Functional Abilities, dated 1/31/25, indicated Resident 75 needed substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bathing self, lower body dressing, and personal hygiene. A further review of Resident 75's MDS Functional Abilities indicated Resident 75 needed substantial/maximal assistance with rolling left and right, sit to lying, lying to sitting on the side of bed, chair/bed-to-chair transfer, and tub/shower transfer. A review of Resident 75's care plan intervention, dated 8/17/21, indicated, Place the resident's call light is [sic] within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 3/24/25 at 9:34 a.m. in Resident 75's room, Resident 75 was observed lying on bed, awake, and his call light button was on the floor, at the bottom of his bed. Resident 75 stated he did know where his call light button was at. During a concurrent observation and interview on 3/24/25 at 10:44 a.m. with CNA 2, in Resident 75's room, CNA 2 confirmed that Resident 75's call light button was on the floor, at the bottom of his bed. CNA 2 stated the call light button should be placed within Resident 75's reach. During an interview on 3/27/25 at 10:26 a.m. with the Director of Nursing (DON), the DON stated the call light buttons should be within reach of the resident. A review of the facility's policies and procedures (P&P) titled, Call Lights: Accessibility and Timely Response, dated 12/19/22, indicated, 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident ' s room. 2. A review of Resident 55's clinical record indicated Resident 55 was admitted January of 2024 and had diagnoses that included dementia, cerebral infarction (damage to a part in the brain due to a disrupted blood flow), 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 55's MDS Cognitive Patterns, dated 12/26/24, indicated Resident 55 had BIMS score of 3 out of 15 which indicated Resident 55 had a severely impaired cognition. A review of Resident 55's MDS Functional Abilities, dated 12/26/24, indicated Resident 55 was dependent with eating, oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A further review of Resident 55's MDS Functional Abilities indicated Resident 55 was dependent with rolling left and right, chair/bed-to-chair transfer, and tub/shower transfer. A review of Resident 55's care plan intervention, dated 3/15/24, indicated, Place the resident's call light is [sic] within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 25 of 26 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 03/27/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 3/24/25 at 9:45 a.m. in Resident 55's room, Resident 55 was observed lying on bed, awake, and her call light system wire was observed on the floor with missing call light button. During a concurrent observation and interview on 3/24/25 at 10:50 a.m. with CNA 4, in Resident 55's room, CNA 4 confirmed that Resident 55's call light system was broken. CNA 4 stated, I don't know if it's [broken call light button] on purpose, but it's [Resident 55 ' s call light] broken. CNA 4 further stated Resident 55 knows how to a call light button so she would expect Resident 55 to be provided with working call light system. During an interview on 3/27/25 at 10:26 a.m. with the DON, the DON stated she would expect the residents' call light system to be functional and not broken. A review of the facility's P&P titled, Accommodation of Needs, dated 12/19/22, indicated, 3. Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. A review of the facility's P&P titled, Call Lights: Accessibility and Timely Response, dated 12/19/22, indicated, The purpose of this policy is to assure the facility is adequately equipped with a call light. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056304 If continuation sheet Page 26 of 26