Mission Carmichael Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mission Carmichael Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Mar 21, 2024

  Based 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. Findings: During the initial kitchen tour on 3/18/24 at 8:38 a.m., there was not a certificate or degree in the Food and Nutrition Services office. In a subsequent interview with the Dietary Manager (DM) at 8:45 a.m., she stated that she had worked as the Food and Nutrition Services manager for the past year. She further explained that she had not yet completed the process to become a Certified Dietary Manager, nor had she received the required six hours of Title 22 instruction. During an interview on 3/19/24 at 9:08 a.m. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based 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 111 residents who received facility prepared foods when: 1) The ice machine was not cleaned regularly, 2) The freezer gasket needed repair, frost build-up found on freezer door, freezer was overcrowded, and freezer burn found on frozen food, 3) Kitchen fan found with dirty blades, 4) Foods lacked labels and dates, and 5) Six cans of beef stew found stored on the storeroom floor. These failures had the potential to lead to food borne illness. Findings: 1) During the initial tour on 4/4/22 beginning at 8:57 a.m., the bin and ice shoot of the ice machine were wiped with a clean paper towel. […]

• No harm, potential for more than minimal, patternF684May 22, 2026

  Based 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.Findings:During a review of Resident 51's admission records, the records indicated Resident 51 was admitted in February 2026 with diagnoses that included displaced comminuted… […]

• No harm, potential for more than minimal, patternF690May 22, 2026

  Based 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.During a review of Resident 126's… […]