Mount Miguel Covenant Village

Inspectors wroteBased on interview and record review, the facility failed to prevent 1 of 3 sampled residents (Resident 1) from falling, when Resident 1 was not provided with adequate supervision and appropriate support to prevent an accident. As a result, Resident 1 fell out of bed, sustaining a left finger fracture and subsequent infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice safe food handling practices in the kitchen when:1. Hot dogs were not discarded by the discard date,2. Bread pudding was not covered before placing in the refrigerator, and3. A hair net was not worn by the cook, and4. Hand washing and glove changes were not made after touching contaminated surfaces during tray line. These failures had the potential for residents to be exposed to food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignified and person-centered feeding assistance with certified nursing assistants (CNA) observed feeding residents while standing instead of sitting at eye level for two of eight reviewed residents (Resident 60 and 64) who required assistance. This deficient practice placed two residents (Resident 60 and 64) at risk for loss of dignity, reduced quality of mealtime experience, and potential difficulty or discomfort during mealtimes.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code a hospice resident's limitation in range of motion (ROM) for the upper extremities on the Minimum Data Set (MDS- a federally mandated resident assessment tool) for one of four residents reviewed with hand contractures. As a result, inaccurate information was sent to the federal database and placed Resident 78 at risk for inaccurate care planning and avoidable decline in functional mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and treat multiple skin abrasions and scabs for one of one residents reviewed for skin conditions (Resident 35). This failure had the potential to result in delayed provision of care and treatment for Resident 36's skin condition.

Inspectors wrote1. Based on observation, interview and record review, the facility failed to assess, monitor and provide adequate supervision to prevent accidents for three of four residents (Resident 15, 21 and 60) reviewed for falls when:1. Resident 15 was not reassessed for fall risk following a fall, 2. Resident 21 was not accurately reassessed for fall risk following a fall, and,3. Resident 60 was left unsupervised in the facility dining room. This deficient practice placed residents with fall risks for potential accidents with recurrent falls, injuries and further health decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 10.71%. Three medication errors were observed, a total of 28 opportunities during the medication administration process for one of three randomly observed residents (Residents 22, 75 and 76)As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods in a residents' personal food refrigerator (located in the resident dining room) were labeled and dated with the discard date, per facility policy. This failure had the potential for residents to experience food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of eight residents (Resident 58) reviewed by not promptly removing a used meal tray that was left within reach of other residents in the dining room. This deficient practice placed all residents using the dining room at risk for exposure to germs that could cause illness, choking hazards, and potential allergic reactions from consuming food that was not theirs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1 was free from physical restraint when Licensed Nurse (LN) 1, placed a bed linen (flat sheet) from the Resident ' s shoulders to her waistline. In addition, both sides of the bed linen were tucked under the mattress. This bed linen was used to prevent Resident 1 from pulling her foley catheter (a flexible tube that drains urine from the bladder). This deficient practice had the potential for Resident 1 to not move freely and possible choking, serious injury or death.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food production and storage were implemented in a manner that lessened the risk for foodborne illness when: 1. The ice machine lid did not close tightly, 2. Leftover food temperatures were not documented on a cool-down log, 3. Refrigerator and freezer temperature logs, thermometer calibration logs, and sanitation logs were incomplete, and 4. Temperatures were not taken for all foods on the trayline prior to meal service. These failures had the potential to cause foodborne illness to a population of 71 residents who received food from the kitchen.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure safe infection control practices when: 1. A urinary catheter (a tube inserted into the bladder to aide in urine flow) bag was lying on the floor for two of two residents reviewed for urinary catheter care (Resident 41 and Resident 43), and, 2. The Licensed Nurse (LN) 11 did not perform hand hygiene in between glove changed during wound treatment for a sampled resident (Resident 22). These failures had the potential for cross contamination (spread of germs and bacteria) and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents skin was assessed on admission and reevaluated for two of two residents reviewed for skin conditions when: 1. Resident 15 had leg discoloration and, 2. Resident 71 had a right neck dressing. These failures resulted in a delay of assessment and or treatment for Residents 15 and 71.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure non-pharmacological interventions (NPI, an approach to healthcare that did not involve medications, such as relaxation or repositioning) were implemented for one of three residents reviewed for behaviors (Resident 19). This failure had the potential to place Resident 19 at risk for overuse of medication.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to protect the privacy of one resident (1). As a result, a Certified Nursing Assistant (CNA 1) shared an unauthorized picture of Resident 1 via text message group chat.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on reporting communicable diseases and/or infections, when multiple residents tested positive for COVID-19. This failure had the potential to result in the spread of COVID-19 infection to other residents, visitors, and staff.

Inspectors wroteBased on the interview and record review, the facility failed to administer an anti-depressant medication (a medication that improve mood and emotion) as ordered by physician for two days for one of three residents (1). As a result, there was potential for Resident 1's treatment for depression to become less effective.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain the infection prevention and control program (IPCP) when the infection preventionists (IP1 and IP2) did not collect and record all required data for infection monitoring and antibiotic use as indicated by facility policy. This failure had the potential for inadequate infection controls and interventions for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not assure care for one out of eighteen residents, Resident 41 reviewed for comunication in her primary language. This created the potential for Resident 41 to become upset and not understand the actions of the staff.

Inspectors wroteBased on interview and record review, the facility failed to provide a preferred activity to one of two sampled residents (Resident 61). In addition, the facility failed to fully complete the activities assessment for Resident 61. This failure placed Resident 61 at increased risk for isolation and decreased physical activity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when: 1. Discontinued medications and discharged residents' medications in the medication carts were stored along with other active medications for resident use. This had the potential for residents to receive wrong, ineffective medications; 2. There was a medication of foreign origin stored along with other active medications for resident use in the medication cart; 3. There was a physician order with missing frequency of administration for one resident's medication (Resident 35). This had the potential to be given to the resident more frequently then intended by the prescriber and recommended by the manufacturer; and 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were free from unnecessary medications when Resident 167, antipsychotic medication (medication to treat psychotic symptoms such as delusions and hallucinations) was used without monitoring for targeted behaviors for effectiveness and for potential adverse consequences. This had the potential for ineffective antipsychotic medication use and/or increased risk for adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' medications were properly labeled as required in accordance with the facility's policy and procedure. This has the potential for residents receiving wrong, contaminated, expired, or ineffective medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to employ a full time Infection Preventionist (IP, the person(s) designated by the facility to be responsible for the infection prevention and control program) with primary professional training, education and experience in nursing, medical technology, microbiology, epidemiology, or other qualified field. This failure had the potential to compromise the facility's ability to maintain a safe and effective infection prevention and control program (IPCP) for all residents residing in the facility.