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. (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 04/09/2025 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)