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 (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 09/05/2024 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)