Health inspection·February 21, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to train Certified Nursing Assistant (CNA) 1 to operate a specialty electric wheelchair (powered wheelchair) per the facility's policy for one resident (Resident 1), when CNA 1 did not check the power prior to moving the wheelchair, and the wheelchair moved forward hitting the resident's left foot. As a result, Resident 1 was sent to the hospital due to complaints of pain and was diagnosed with a comminuted calcaneus (heel) fracture of left foot. This deficient practice had the potential risk of causing harm or injury to other residents, which could affect the safety and well-being of the residents. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses that included congenital malformation of spine and quadriplegia (a form of paralysis that affects all four limbs and torso), per the resident ' s Face Sheet. During an interview on 1/12/24 at 1:40 P.M., the Director of Nursing (DON) stated that Resident 1 was a quadriplegic and had been at the facility since 2022. The resident has a customized electric wheelchair that he brought from home which he maneuvers using a mouth joystick controller. The mouth joystick was on a wire halo that can be moved up or down to place in front of the resident to use. The DON stated, When he first came, we gave training [to the CNAs] about his electric wheelchair. According to the DON, on 1/6/24 CNA 1 was getting the resident ready for bed. When CNA 1 left the room, she had turned the wheelchair off. The resident later called to be put back to bed. CNA 1 went to move the halo down in front of the resident and bumped the mouth joystick, which caused the wheelchair to move forward and into the wall, hitting the resident ' s left foot. Resident 1 was complaining of pain when the charge nurse went in to do an assessment. At that time, Resident 1 was already on the phone talking to 911. The resident was sent to the hospital where x-rays showed a comminuted calcaneus (heel) fracture of the left foot. According to the DON, surgery was not required, and a splint was placed on the resident ' s left lower leg. The resident returned back to the facility on 1/7/24. The DON stated that the resident has been doing well since returning and the resident ' left foot should heal on its own. The resident will follow up with the orthopedic physician for splint removal. A joint interview and record review was conducted with the DON on 1/12/24 at 2 P.M. An in-service sign-in sheet, dated 7/26/22, indicated the Therapy Department conducted staff training on Resident 1 (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 2 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 02/21/2024 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)