Health inspection·September 5, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record the review the facility failed to revise the comprehensive care plan for one of 3 residents (Resident 1) reviewed for falls. This failure had the potential to result in Resident 1 ' s not attaining their highest practicable well-being. Findings: According to the admission Record, Resident 1 was admitted on [DATE] with diagnoses which included cerebral palsy (a disorder that affects body movement and muscle coordination) and generalized muscle weakness. During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 6/1/24, the MDS indicated, The ability to transfer to and from a bed to a chair (or wheelchair) .Partial/moderate assistanceHelper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort . A review of Resident 1 ' s Clinical Notes, dated 4/28/24 at 10:57 P.M. indicated, Resident 1 had .an Assisted/Witnessed fall on 4/14/24 at 14:30 (2:30) pm . The Clinical Note further indicated, Care plan was updated: Remind staff to follow care plan and care guide kiosk: Use of hoyer lift (a machine used to transfer patients from one place to another) when transferring patient to prevent further fall incidents if patient is weak/sleepy/tired. Use hoyer lift (transfers) or Easy stand (using the toilet) for transfer if patient is weak/sleepy/tired. Remind staff to check care guide kiosk for resident to know her transfer capacity . A review of Resident 1 ' s Clinical Notes, dated 8/22/24 at 7:21 P.M. indicated, (Resident 1) had an Assisted/Witnessed fall on 8/19/24 at 9:30 PM . The note further indicated, (Resident 1) has similar incident [sic] in the past where .both legs/knees buckles/give out during transfers . (Resident 1) had previous history of falls . The DON stated Resident 1's care plan should have been updated with new interventions. There was no documented evidence Resident 1 ' s care plan for falls was revised or updated. On 9/5/24 at 12:24 P.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated there was no new care plan intervention implemented after Resident 1 ' s fall on 8/19/24. The DON stated There ' s nothing new written as far as interventions . The DON stated care plans were important because .if something happens (to a resident), that is your guide Page 1 of 2 555134 555134 09/05/2024 Mount Miguel Covenant Village 325 Kempton St. Spring Valley, CA 91977

F 0657 moving forward to prevent the incident from happening again .for safety . Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change .The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident ' s condition; b. when the desired outcome is not met . Residents Affected - Few 555134 Page 2 of 2