Mission Carmichael Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of 27 sampled residents (Resident 126 and Resident 51) when:1. Follow-up appointments were cancelled and delayed for Resident 51; and,2. There was no monitoring and care plan for Resident 126's use of offloading boot (a specialized medical device designed to reduce pressure, friction, and weight on specific areas of the foot or heel). These failures resulted in delays in care for Resident 51 and increased Resident 126's risk to develop skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the care and services necessary to ensure appropriate treatment and services to prevent urinary tract infections were provided for two of 27 sampled residents (Resident 126 and Resident 144) when:There was no physician order for suprapubic catheter (a tube inserted directly into the bladder to drain urine) and there was no output monitoring for Resident 126; andThere was no output monitoring for Resident 144 while the resident had suprapubic catheter in place. These failures decreased the facility's potential to monitor Resident 126's use of catheter and had the potential to place Resident 126 and Resident 144 at risk for complications, including urinary tract infections. [...]

Inspectors wroteBased on interview and record review, three residents reviewed for weight loss (Resident 1, Resident 3 and Resident 56) did not maintain weight and no root cause analysis was done to determine best approach for reversing weight loss. This failure had the potential of leading to malnutrition and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide substitutions when the given meal was refused for three residents (Resident 1, Resident 26 and Resident 82) for a census of 129. This had the potential to result in hunger, weight loss, and malnutrition.

Inspectors wroteBased on interview and posted mealtimes, the facility failed to keep the amount of time between dinner and breakfast to 14 hours or less for census of 129. This had the potential to result in residents' hunger and unstable blood sugar levels.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the standards for food service safety for a census of 129 when:The water curtain/splash shield of the ice machine revealed calcium buildup,The floor in front of the ice machine had two large breaks of approximately 3 by 10,Food labeling in the dry storage was inconsistent with the storage guidelines, A box of beef patties was not securely covered in the freezer, andThe middle dining room was being used for haircuts as residents were set up for the lunch meal. These failures had the potential of leading to cross-contamination and food borne illness.1. During the initial kitchen tour on 5/19/26 at 8:40 a.m. with the Director of Maintenance (DOM), the Manitowoc ice machine was opened to view the internal components. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control prevention practices for 6 of 27 sampled residents (Resident 15, Resident 115, Resident 16, Resident 93, Resident 44, and Resident 128) when: 1. Staff did not use required personal protective equipment (PPE- clothing and equipment worn or used to provide protection against hazardous substances and/or environment) while providing care to Resident 15 on enhanced barrier precaution (EBP- an infection control method); 2. Staff did not perform hand hygiene in between glove use during wound care for Resident 115;3. Resident 16's Oxygen tubing was not stored properly;4. A glucometer for Resident 93 not cleaned per manufacture recommendations; 5. Resident 44's nebulizer machine (device that turns liquid medicine into mist that can be inhaled) was on the floor; and 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards for two of twenty-seven sampled Residents (Residents 78 and 93) when:1. Physician inhaler order for Resident 78 was not followed and 2. Resident 93's blood glucose was not obtained prior to mealtime insulin administration. These failures had the potential to result in provision of inappropriate treatment for both residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper foot care for 2 of 27 sampled residents (Resident 15, Resident 63) when: Resident 15 had thick and long toenails; and,Resident 63 had long, thickened toenails and the toenail on first toe of left foot was curving into second toe. These failures had the potential to cause foot infection, pain, and to decrease mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standard of practice for two of 27 sampled residents (Resident 115 and Resident 128) when: Resident 115 had no oxygen signage and oxygen order in place; and, Resident 128 was not fitted with the correct BiPAP (Bilevel Positive Airway Pressure-noninvasive ventilation machine that helps with breathing) mask. These failures had the potential for Resident 115 and Resident 128 to experience respiratory distress and increased risk for fire hazard for Resident 115.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving dialysis (treatment to remove extra fluid and waste when kidneys fail) received care and services consistent with professional standards of practice for one of 27 sampled residents (Resident 5) when Resident 5's fluid restrictions (limits in the total daily intake of liquids) were not followed per physician's order. This failure placed Resident 5 at high risk for fluid overload (too much fluid in the body that could cause swelling, high blood pressure, breathing problems, and heart issues). During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in March 2026 with diagnoses that included end stage renal disease (permanent kidney failure) and dependence on renal dialysis. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) had an annual performance review for three of three sampled CNA staff (CNA 3, CNA 4, and CNA 7). This failure had the potential for CNA 3, CNA 4, and CNA 7 to provide inadequate care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services was provided for one of 27 sampled residents (Resident 113) when Resident 113's lower denture was missing. This failure increased the potential for Resident 113 to experience difficulty in chewing and weight loss. A review of the admission Record indicated Resident 113 was admitted [DATE] with diagnoses including hypothyroidism (the thyroid gland [small, butterfly -shaped gland in the neck] does not produce enough thyroid hormones leading to extreme fatigue, unintentional weight gain, and feeling cold all the time) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was accessible for 1 of 27 sampled residents (Resident 142) when Resident 142 was not able to reach his call light device to call for assistance. This failure placed Resident 142 at risk for his care needs to be unmet and at increased risk for falls. [...]

Inspectors wroteBased 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. This failure placed Resident 1 and Resident 2 at risk for aspiration and possible discomfort when eating.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wrote3. 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. 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. [...]

Inspectors wroteBased 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: 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was initiated within 48 hours of a resident's admission for one of 29 sampled residents (Resident 482), who was admitted to the facility with a peripherally inserted central catheter (PICC) line (a thin flexible tube inserted into a vein in the upper arm and threaded into a larger vein near the heart to deliver medications) for antibiotic (a class of medications used to treat bacterial infections) administration. This failure had the potential to compromise the residents' care and could have resulted in serious health complications.

Inspectors wroteBased 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. This failure had the potential for Resident 49's wounds to worsen and for the resident to not achieve their highest practicable well-being.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for one out of five sampled residents (Resident 5) when Resident 5's frequency for Physical Therapy Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) were not followed. This failure had the potential for Resident 5 to experience decline in range of motion or impairment in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration to one resident (Resident 1) of two sampled residents when medications were left unattended at bedside. This decreased the facility's potential to ensure medications were safely ingested by the intended resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a cane. This failure resulted in Resident 1 sustaining injury and pain to the right lower leg .

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one of five sampled residents (Resident 1) when Resident 1 alleged that a female staff grabbed him firmly on the right arm. This failure resulted in a delayed investigation of Resident 1's abuse complaint and had placed Resident 1 and other residents in the facility at risk for further abuse, and possible serious physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to hire a Director of Food and Nutrition Services who had the qualifications required. This had the potential of leading to food borne illness for the 124 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 124 residents who received facility prepared foods when: 1. Proper food labeling was not followed, 2. Expired foods were not discarded, 3. Perishable salads were not kept in safe food temperature range, 4. Foods were not kept covered while in storage, 5. Freezer had an ice drip from the fan onto the food box, 6. Cutting boards were found with debris on the cutting surface, and 7. Can opener tip was found rusted and missing metal. These failures had the potential to lead to food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of 43 sampled residents (Resident 91, Resident 4, and Resident 46) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when; 1. Resident 91 had long fingernails with blackish substance underneath the fingernails; 2. Resident 4 had long fingernails with brownish substance underneath the fingernails; and, 3. Resident 46 had jagged fingernails with sharp edges with blackish substance underneath the fingernails. These failures had the potential for Resident 91, Resident 4, and Resident 46 to sustain injury and/or for the residents to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pharmacy services were maintained when controlled drug (medication that may be abused or cause addiction) record forms were inaccurately signed for a census of 126. The failure had the potential to result in diversion of the residents' medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled correctly, when: 1. Loose pills and were found in the South wing medication cart one. 2. Opened vials and one bottle of perishable medications were not dated with open or expiration dates in the North wing medication room. 3. Packets of medicated powder did not have an expiration date in the North wing treatment cart three. 4. Opened inhaler and glucose strips were not dated with open or expiration dates in the North wing medication cart three. 5. Expired and discontinued medications were in the North wing medication cart three. 6. A bag containing medications for a resident was found in the nursing office closet. 7. Prescription eye ointment was found in a resident's room at the bedside and was not labeled with an open date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods that conserved nutritive value, flavor, and appearance; and served food at unappetizing temperatures. This had the potential of leading to poor intake, malnutrition and weight loss for the 124 residents eating facility prepared meals when: 1. Vegetables were heated for over 2 hours, 2. Pureed meals were prepared without measuring ingredients, and 3. Pureed food was prepared in a dirty food processor bowl.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate food allergies and food preferences for six of 43 sampled residents (Resident 100, Resident 26, Resident 34, Resident 57, Resident 97, and Resident 89). This had the potential of leading to allergic reactions (including death), as well as lead to poor intake and weight loss in the 124 residents receiving facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program was followed and maintained for a census of 126 when: 1. A clean-linen delivery cart and two clean linen storage shelves were found with a thick layer of dusts in the laundry room; 2. A nasal cannula (oxygen tubing) had no labeled date for Resident 27; 3. An empty intravenous (IV) medication bag with no administration date and licensed nurse (LN) initial hanged in Resident 682's room; 4. An IV tubing was not labeled for Resident 131; 5. A urinary bag was found on the floor in Resident 19's room. These failures had the potential to result in the transmission of infection and cross-contamination in a vulnerable population.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure essential kitchen equipment (ice machine and oven) were in safe operating conditions. This had the potential of leading to food borne illness for the 124 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right for privacy and dignity was promoted to maintain the resident's self-worth for one of 43 sampled residents (Resident 33), when the privacy curtains were not pulled, or the door not closed during resident care. This failure resulted in not attaining or maintaining the resident's highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs for two of 43 sampled residents (Resident 588, Resident 28) when: 1. Resident 588's call light button was not within reach; and 2. Resident 28 was not assessed and provided with the appropriate call light type to call staff when needed. These failures resulted in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with the regulatory time frame for one of 43 sampled residents (Resident 681), when the admission MDS (Minimum Data Set, an assessment tool) was not completed. This failure had the potential to result in the resident not attaining the highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan (BCP, document that outlines initial care needs) for two of 43 sampled residents (Resident 681 and Resident 6) when the BCP was not completed within 48 hours after the resident's admission. This failure had the potential to place the residents at risk for unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for two out of 43 sampled residents (Resident 107 and Resident 44) when Resident 107 and Resident 44's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed. This failure had the potential for Resident 107 and Resident 44 to experience decline in range of motion or impairment in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free from accident hazards, for one of 43 sampled residents (Resident 57), when there was an uneven pathway leading to, from and inside the designated smoking area. This failure resulted in Resident 57 feeling unsafe navigating the pathway to the smoking area and had the potential to result in accidents and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper delivery of respiratory care was consistent with the facility's policy and procedures (P&P) and the professional standards of practice for one out of 43 sampled residents (Resident 18) when Resident 18's physician's order for oxygen therapy was not followed. This failure had the potential to result in unsafe delivery of oxygen to Resident 18 that could lead to respiratory problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical records were complete and accurate for one of three sampled residents, (Resident 1). This failure had potential to result in under- and over-medicating a resident for pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident call system was functioning for three residents out of 65 sampled residents (Resident 1, Resident 2, and Resident 3). This failure decreased the potential for the residents to get assistance from staff in a timely manner.