Health inspection·April 9, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure 2 of 5 sampled residents (Resident 1 and Resident 2) were properly positioned during feeding assistance as per care plan and facility's meal assistance policy and procedure. Residents Affected - Few This failure placed Resident 1 and Resident 2 at risk for aspiration and possible discomfort when eating. Findings: 1a. A review of Resident 1's admission record indicated Resident 1 was admitted in March 2025 with multiple diagnoses including COPD (a lung disease that makes it difficult to breathe) and GERD (Gastroesophageal reflux disease- a condition where stomach acid and food can flow backward from the stomach into the throat). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 3/28/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Functional Abilities and Goals, indicated Resident 1 required maximum assistance for rolling left to right and eating. A review of Resident 1's care plan titled, The resident has GERD dated 3/24/2025, indicated .Avoid lying down for at least 1 hour after meals. Keep HOB elevated. Encourage to stand/sit upright after meals . A review of Resident 1's care plan titled, The resident has nutritional problem . , dated 3/25/2025, indicated, .Maintain the HOB [Head of Bed] at 30-45 degrees during feeding . During an observation on 4/9/25 at 12:25 p.m. with CNA 1 at Resident 1's bedside, Resident 1 was observed in a left side lying position. No assistive devices for positioning were observed. CNA 1 was observed as she fed a spoon of yellow jello to Resident 1 without repositioning the resident. During an interview on 4/9/25 at 12:35 p.m. with CNA 1 outside of Resident 1's room, CNA 1 stated Residents should be sitting upright when eating meals. CNA 1 confirmed yellow jello was fed to Resident 1 while lying on his left side. During a follow up observation on 4/9/25 at 12:37 p.m. outside of Resident 1's room, Resident 1 was observed lying with head of bed lower than 30 degrees and lying on his left side. Page 1 of 2 056304 056304 04/09/2025 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1b. A review of Resident 2's admission record indicated, Resident 2 was admitted in March 2025 with multiple diagnoses including Need for assistance with personal care and dysphagia (difficulty swallowing). During a review of Resident 2's MDS, Cognitive Patterns, dated 4/2/25, indicated Resident 2 had a BIMS score of 99 out of 15 that indicated Resident 1 could not complete the interview. A review of Resident 2's MDS, Functional Abilities and Goals, indicated Resident 2 was dependent on staff for rolling left to right and eating. A review of Resident 2's care plan, titled the Resident has nutritional problem . , dated 4/4/25, indicated, .Maintain the HOB at 30-45 degrees . During an observation on 4/9/25 at 12:41 p.m., in Resident 2's room with CNA 2 present, Resident 2 was observed in supine position with head of bed lower than 30 degrees. CNA 2 was observed offering resident a spoon of yellow pudding while resident was in supine lying position. During a concurrent observation and interview on 4/9/25 at 12:41 p.m. with CNA 2 at Resident 2's bedside, CNA 2 confirmed that she attempted to give Resident 2 a spoon of yellow pudding while Resident 2 was in a lying position. CNA 2 stated staff should always put the head of bed up when feeding residents. During review of facility policy and procedure (P&P) titled Activities of Daily Living (ADLs) , dated 12/19/2022, the P&P indicated . a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition . During a review of facility P&P titled, Meal Supervision and Assistance , dated 12/19/2022, the P&P indicated .the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped. 056304 Page 2 of 2