Inspection citations
17’23
16’24
19’25
1’26
53 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Mar 10, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 26, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 16, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 16, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Jul 16, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 24, 2025 | D · potential | 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. | Routine |
| Apr 24, 2025 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Routine |
| Apr 24, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 24, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Apr 24, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Apr 24, 2025 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Apr 24, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 24, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 24, 2025 | E · potential | 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. | Routine |
| Apr 24, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Apr 24, 2025 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Apr 24, 2025 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 24, 2025 | D · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Apr 24, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 24, 2025 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Oct 30, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Aug 6, 2024 | D · potential | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Complaint |
| Jun 6, 2024 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Jun 6, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 6, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 6, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jun 6, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 6, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Jun 6, 2024 | C · minimal | Post nurse staffing information every day. | Routine |
| Jun 6, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 6, 2024 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Jun 6, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 6, 2024 | E · potential | 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. | Routine |
| Jun 6, 2024 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Jun 6, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 6, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 11, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| May 11, 2023 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| May 11, 2023 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| May 11, 2023 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| May 11, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| May 11, 2023 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| May 11, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 11, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| May 11, 2023 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| May 11, 2023 | F · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| May 11, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| May 11, 2023 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| May 11, 2023 | E · potential | 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. | Routine |
| May 11, 2023 | E · potential | 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. | Routine |
| May 11, 2023 | D · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| May 11, 2023 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 11, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Mountain Manor Senior Residence
6101 Fair Oaks Boulevard, Carmichael, CA 95608 · (916) 488-7211
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555889
- Certified beds
- 47
- Legal owner
- Grandcare INC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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