Health inspection·December 27, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the dignity of one resident (1). As a result, a Certified Nursing Assistant (CNA 1) took an unauthorized picture of Resident 1 sleeping, and shared it via text message group chat. Findings: On 12/12/23, the facility reported to the Department, former CNA had shared a picture of (Resident 1) as he was sleeping in their group chat . On 12/19/23 an unannounced visit of the facility was conducted. On 12/19/23 at 10:40 A.M., the Director of Nursing was interviewed. The DON stated CNA 1 sent a picture of Resident 1 sleeping to friends via a text message group chat. The DON stated in the picture Resident 1 ' s dentures were partially out of his mouth. The DON stated the facility did not allow staff to take pictures of residents. The DON stated Resident 1 was cognitively impaired and not aware of the picture being taken. The DON stated the family was notified and concerned about Resident 1 ' s dignity. CNA 1 was not available for interview. The DON stated the picture was taken July 2023, and CNA 1 resigned from the facility November of 2023. On 12/19/23, at 11:15 A.M., the Director of Social Services (DSS) was interviewed. The DSS stated no picture taking was allowed in the facility. The DSS stated Resident 1 was not alert/aware of the situation and support was offered to the family. On 12/19/23 at 11:25 A.M., the Director of Staff Development (DSD) was interviewed. The DSD stated part of abuse training included focus on privacy and dignity. On 12/20/23, the clinical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s Disease (a progressive disorder of the nervous system) and Neurocognitive Disorder (dementia), according to the facility Face Sheet. The Brief Interview for Mental Status (BIMS) was 3 out of 15, which indicated severe cognitive impairment. The picture provided by the DON was of Resident 1 on his right side in bed. His eyes were closed, and mouth was open with dentures partially out of his mouth. The heading of the picture indicated, Bestie Chat and had comments about the picture from two different phone numbers. (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 3 Event ID: 555134 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 555134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Miguel Covenant Village 325 Kempton St. Spring Valley, CA 91977 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)