Deficiency Records for Mission Carmichael Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Mission Carmichael Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-27 | 2023-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-20 | 2023-07-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2022-12-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-13 | 2022-05-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-04-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-07 | 2022-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-07 | 2022-04-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-07 | 2022-04-29 | N |
| 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. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-07 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-04-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-07 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-04-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-09 | 2021-12-09 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-02-06 | 2020-04-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-06 | 2020-04-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-06 | 2020-04-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-04-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-06 | 2020-04-06 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-02-06 | 2020-04-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-06 | 2020-04-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-06 | 2020-04-06 | N |
| 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. | Health | 2020-02-06 | 2020-04-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-18 | 2020-03-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-03-06 | 2019-04-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-31 | 2019-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-02-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-31 | 2019-02-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-31 | 2019-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-31 | 2019-02-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-31 | 2019-02-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-31 | 2019-02-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-31 | 2019-02-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-31 | 2019-02-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-31 | 2019-02-25 | N |
