Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Miguel Covenant Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff was left unattended during incontinence care when one staff member left the room and the remaining student nursing assistant turned away to get gloves. The resident, whose bed was raised and bed rails were not in place, fell to the floor, sustaining a finger fracture and subsequent infection. Documentation and interviews confirmed that staff failed to provide adequate supervision and did not ensure the bed was in the lowest position, resulting in the resident's fall and injuries.
Failure to maintain ROM services for residents with contractures and limited mobility. Three residents with cerebral palsy, polyneuropathy, and rheumatoid arthritis had documented ROM deficits, contractures, and care plans that included PT or RNA, but services were stopped or not consistently provided. Staff interviews and record review showed repeated refusals, lack of documented reapproach, and no clear documentation supporting discontinuation of RNA for one resident on hospice.
Unsafe Food Handling Practices in Kitchen: Kitchen staff failed to follow food safety practices when hot dogs were kept past the discard date, bread pudding was left uncovered in the refrigerator, and a cook worked without a hair net despite having hair to the collar. During tray line service, the cook also touched cabinet handles and other surfaces with gloved hands and continued serving food without removing gloves or washing hands.
Feeding Assistance Provided While Standing Instead of at Eye Level: Two residents with severe cognitive deficits were observed being fed by CNAs who were standing rather than sitting at eye level. Staff and the DON stated that sitting during feeding promotes dignity, respect, comfort, and a better mealtime experience, and the facility did not provide a dignity policy and procedure.
A resident with rheumatoid arthritis, bilateral hand contractures, and hospice status was inaccurately coded on the MDS as having no upper extremity ROM impairment despite observations, staff interviews, and PT records showing limited ROM in both hands and the left shoulder. The MDS nurse stated she did not remember assessing the resident’s hands or asking for ROM demonstration, and prior MDSs had coded impairment on both sides. Staff also confirmed the resident had needed ROM support and ADL assistance, but the quarterly assessments were coded without documented ROM assessment during the review period.
A resident with a history of falls had multiple abrasions, bruises, and scabs noted on admission, including wounds on both arms and the right leg. Staff failed to ensure all wounds were placed on the TAR, several treatment orders were discontinued without explanation, and a loose dressing remained on the resident’s hand while the resident reported the skin conditions had not been assessed or treated. The ADON and DON confirmed the resident’s wounds should have been tracked and treated per physician orders.
Failure to assess fall risk and supervise residents with fall histories: A resident with unsteadiness and a prior fall was not reassessed with a new Morse Fall Scale after falling in the hallway. Another resident with dementia and weakness was found on the floor, but the post-fall Morse assessment still showed low risk and did not mark a new history of falling. A third resident with severe cognitive deficits and multiple recent falls was observed unsupervised in the dining room despite care plan directions for close monitoring and supervision.
Medication administration errors exceeded the allowed rate, with a 10.71% error rate identified during observation. An LPN administered eight pills or capsules to a resident but did not give all ordered medications, including eye drops, eye lubricant, and a nebulized medication. The resident had orders for medications scheduled multiple times daily, and the DON stated nurses were expected to administer all medications at the same time according to the physician’s order.
Unlabeled and Undated Food in Resident Refrigerator: A clear plastic bag with two cupcakes was found in a resident food refrigerator without a resident name or date. LN, the DSS, the RD, and the DON all stated food in the refrigerator was expected to be labeled and dated, and the facility policy required perishable foods to include the resident's name, room number, item, and use-by date, with a 3-day limit.
Used Meal Tray Left Accessible in Dining Room: A resident with dementia was observed in the dining room taking and eating a waffle from a used meal tray that had been left stored below the hydration cart. CNA staff stated used trays should be checked and removed from the dining area, and the ADON and DON stated the tray should not have been kept in the clean hydration cart area. The facility did not provide a dining infection control policy and procedure.
A resident with severe cognitive impairment was improperly restrained using a bed linen by an LN to prevent her from pulling her Foley catheter. The restraint was applied without a physician's order or family consent, violating the facility's policy on restraint use. Interviews with staff and a review of the resident's records confirmed the deficiency.
A resident with cerebral palsy and muscle weakness experienced two falls, but the LTC facility failed to update the care plan after the second fall. Despite the facility's policy requiring care plan revisions after significant changes in condition, no new interventions were implemented, as confirmed by the DON.
The facility failed to ensure proper food safety and documentation practices, risking foodborne illness for 71 residents. Observations revealed an ice machine lid that did not close tightly, improper cooling and temperature documentation for leftover foods, and incomplete logs for refrigerator and freezer temperatures, thermometer calibration, and cleaning schedules. Additionally, not all food temperatures were documented before meal service, as required by facility policies.
The facility failed to maintain infection control standards when two residents' urinary catheter bags were found on the floor, contrary to policy, and a nurse did not perform hand hygiene between glove changes during a wound dressing for a resident with cellulitis. Staff acknowledged these lapses, which could lead to cross-contamination and infection.
The facility failed to assess and document skin conditions for two residents, leading to delays in treatment. One resident had leg discoloration that was not documented or assessed, while another had a neck dressing that was not checked or changed. The facility's policy on skin assessments was not followed, resulting in a lack of timely treatment.
A facility failed to implement non-pharmacological interventions (NPIs) for a resident with an unspecified mood disorder, leading to frequent administration of Ativan without documented attempts of NPIs. Staff interviews revealed a lack of individualized NPIs, despite facility policy emphasizing their importance to minimize medication use.
Resident Fall Due to Inadequate Supervision During Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-ambulatory status, and total dependence on staff for activities of daily living was left without adequate supervision during incontinence care. While two staff members were changing the resident, one left the room to get a nurse after being alerted by a roommate's wife about another resident's vomiting, leaving the resident alone with a student nursing assistant (SNA). The SNA turned her back to get gloves, during which time the resident fell from the bed, which was in a raised position and without bed rails in place. The fall was unwitnessed, and the resident was found on the floor with a bleeding laceration on the left finger and a head injury. The resident, who was on blood thinners, was transported to the hospital for evaluation and treatment of the laceration but did not receive an x-ray of the injured finger at that time. Several days later, the finger was observed to be red, swollen, and warm, and an x-ray revealed a comminuted fracture. The resident was subsequently admitted to the hospital with cellulitis and a finger fracture. Documentation and interviews confirmed that staff failed to ensure the resident's safety by leaving the resident unattended during care, not ensuring the bed was in the lowest position, and not maintaining appropriate support, directly leading to the fall and subsequent injuries.
Failure to Maintain ROM Services for Residents with Contractures and Limited Mobility
Penalty
Summary
The facility failed to provide ROM services to maintain or improve mobility for three residents who had limited ROM and significant functional impairment. The deficiency was identified through observation, interview, and record review for residents with cerebral palsy, polyneuropathy, and rheumatoid arthritis, all of whom had documented contractures, impaired mobility, and care plans that included ROM or restorative services. One resident with cerebral palsy was observed sitting up in bed eating breakfast with the left hand while the right hand was contracted. The resident stated that PT and restorative nursing assistance had stopped about a year earlier after insurance no longer covered the services, and that the right hand had worsened since the services stopped. The record showed no current PT or ROM services on the MDS, no additional PT or restorative orders after an older PT order, and the care plan did not show restorative services being provided. RNA notes showed the resident had refused several times in the prior year because of not feeling well or pain, but there was no documented evidence that the resident was reapproached to see if she felt better or wanted to resume RNA services. A second resident with polyneuropathy was observed in bed using a tablet with a severely contracted left hand and a brace on the right hand. The resident stated PT had stopped because of insurance and that RNA later stopped as well, and she wanted the services restarted because they helped. The record showed an order for ROM exercises was added after the observation, and the care plan included bilateral upper and lower extremity ROM exercises and hand splints. RNA notes showed repeated refusals related to pain in the right leg or knee, but there was no documented evidence that the resident was reapproached to see if she was feeling better or wanted to resume RNA services. Staff interviews confirmed the facility had an unwritten practice of dropping residents from RNA after three refusals and that documentation of reapproach, care conferences, and resident responses was expected, but not found in the record. A third resident with a history of rheumatoid arthritis and moderate cognitive deficits was observed being fed by a CNA because of hand contractures, and the breakfast tray remained untouched after the CNA left the room. The resident’s OT evaluation documented severe ROM deficits in both upper extremities, crepitus, severe pain, and that the resident benefited from the RNA program for BUE/BLE ROM to prevent further contractures. The DOR stated the resident had been removed from RNA after transitioning to hospice, but documentation could not be found showing that the RNA program was discussed with the family when it was discontinued. The active care plan still included PROM and AAROM interventions for the resident’s upper and lower extremities.
Unsafe Food Handling Practices in Kitchen
Penalty
Summary
Safe food handling practices were not followed in the kitchen when hot dogs were found in freezer #4 in a sealed plastic bag with a discard date of 7/24/25, and the Registered Dietitian stated they should have been thrown away on or before that date. In refrigerator #2, a large shallow tray of bread pudding that was being served for lunch was observed uncovered and exposed in the refrigerator, and the RD stated it should have been covered with plastic wrap to protect it. The facility policy stated that foods are to be labeled, dated, and securely covered. During a follow-up kitchen observation, CK 3 was seen working at the food warmer and tray line without a hair net, despite having dark black hair down to the collar and sideburns; CK 3 stated he should have put on a hair net when entering the kitchen. During lunch tray line service, CK 3 was also observed touching cabinet handles, drawers, and other surfaces with gloved hands and then continuing to serve food without removing gloves or washing hands. The RD stated kitchen staff were expected to remove gloves and wash hands after touching anything other than food, and the DON stated she expected the kitchen to always be clean and sanitary to prevent food borne illness.
Feeding Assistance Provided While Standing Instead of at Eye Level
Penalty
Summary
The facility failed to provide dignified and person-centered feeding assistance when CNAs were observed feeding two residents while standing instead of sitting at eye level. Resident 60 was re-admitted with a history of dementia and had an MDS BIMS score of 3 out of 15, indicating severe cognitive deficits. On 8/5/2025, CNA 26 was observed standing over Resident 60 while assisting with breakfast in the resident's room. The ADON stated that standing was inappropriate, could be intimidating, and did not promote a good mealtime experience, while sitting at eye level promotes dignity and respect. The DON later stated it was her expectation that CNA 26 be at eye level while feeding Resident 60 to promote a comfortable, dignified, and respectful mealtime experience. Resident 64 was admitted with a history of a disease characterized by progressive decline in mental abilities and had an MDS dated 5/20/25 showing she was rarely or never understood with severe cognitive deficits. On 8/4/2025, CNA 23 was observed feeding Resident 64 while standing in the Valley View Dining room. CNA 23 stated she should have been sitting down while assisting Resident 64 and that sitting at eye level would make the resident feel more comfortable and show dignity and respect. CNA 21 stated nursing staff should feed residents while sitting because it promotes respect and dignity, and the DON stated staff were expected to assist residents in a dignified manner by sitting at eye level to promote an interactive and quality eating experience. The facility did not provide a policy and procedure for dignity.
Inaccurate MDS Coding of Upper Extremity ROM
Penalty
Summary
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). Resident 78 was admitted with a history of rheumatoid arthritis and had moderate cognitive deficits on the MDS. During observation, the resident was seen needing help with feeding because of hand contractures, and the resident stated she had pain in both hands and the left shoulder, required assistance with all ADLs, and was unable to fully stretch both arms and hands without staff assistance. Interviews with CNA staff, RNA staff, PT, and the DOR confirmed that Resident 78 had bilateral hand contractures and limited ROM in the left shoulder and both hands. PT documentation from the resident’s rehab evaluation described severe ROM deficits in the upper extremities, including impaired ROM in the right shoulder, elbow/forearm, wrist, and impaired wrist/hand/forearm ROM on the left. The resident had previously been on an RNA program for ROM, but staff stated the program had stopped after the resident transitioned to hospice services. The DOR stated the resident would benefit from RNA participation, but documentation could not be found showing that the RNA program was discussed with the family or that refusal was documented. The MDS nurse stated she did not remember assessing the resident’s hands or asking the resident to demonstrate ROM during the MDS time frame, and acknowledged that the MDS was coded inaccurately on two quarterly assessments as having no upper extremity impairment. Prior MDS coding had shown impairment to both sides, but later assessments were coded as no impairment. The chart contained care plan interventions for ADL assistance and passive/active ROM, but there was no documentation showing that ROM was assessed during the MDS time frame on the dates reviewed. The DON and ADON stated the MDS nurse was responsible for the assessments and that inaccurate coding could result in needed services being omitted from the resident’s plan of care.
Failure to Assess and Treat Multiple Skin Wounds
Penalty
Summary
The facility failed to assess and treat multiple skin abrasions and scabs for one resident with a history of falling. On observation, the resident was in bed with both arms exposed and had a large reddened area on the left forearm, a large scab on the right hand between the thumb and index finger, several additional abrasions and bruises on both arms, and dry, flaky skin. A loose dressing dated 8/1 was hanging from the scab on the right hand, and the resident stated he had fallen at home and had more abrasions on his legs. The resident also showed two intact dressings on the right lower leg, both dated 8/1, and stated the nurses had not assessed or treated his skin conditions and that he had noticed the leg dressings that morning. The admission nursing evaluation documented 11 areas of bruising, scabs, or wounds and instructed that a wound evaluation be opened for each wound. Review of the TAR showed that six skin areas had treatment discontinued without explanation, while three wounds remained on treatment orders and were signed off as completed on 8/1 and 8/3. The ADON stated all 11 wounds should have been on the TAR and could not explain why treatment orders had been discontinued. The DON stated nurses were responsible for following physician orders and should not sign off treatments as completed if dressings had not been changed.
Failure to assess fall risk and supervise residents with fall histories
Penalty
Summary
The facility failed to assess, monitor, and provide adequate supervision to prevent accidents for three residents reviewed for falls. One resident with diagnoses including unsteadiness on feet and a history of falling was admitted with a low-risk Morse Fall Scale score on admission, then fell in the hallway while returning to his room. The record review did not identify a new Morse Fall Scale assessment after that fall. The DON stated a new Morse assessment should have been completed after the fall, and that if the assessment was wrong or missing, the facility would miss the opportunity to render the care necessary to prevent another fall. A second resident with dementia and weakness had a Morse Fall Scale score of 40, documented as low risk, both on 5/16/25 and again after being found on the floor inside her room on 6/3/25. On the post-fall assessment, the nurse marked “No” to the item asking whether the resident had a history of falling within the present admission, despite the directions stating that if a patient falls for the first time, the score immediately increases by 25. Staff interviews reflected that the resident was confused, tried to get out of bed, and was likely at risk for falls, while the LN stated the risk level could be too low and might prevent the right interventions from being implemented. A third resident with severe cognitive deficits and a history of multiple falls, including a recent fall with a right intertrochanteric femur fracture, was observed unsupervised in the Valley View dining room sitting in a wheelchair and wheeling herself while leaning forward with a blanket over her legs. Her care plan directed that she be placed in an observable area for close monitoring, redirected when attempting to get up unassisted, and supervised during ambulation. Staff interviews stated she needed supervision and assistance with transfers due to unsteadiness, and that there was no staff specifically assigned to supervise residents in the dining room after mealtimes. The DON stated residents should not be left unattended in the dining room and that this resident should not be left unsupervised because she was a high fall risk.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, with a calculated medication error rate of 10.71%. During observation of medication administration for one of three randomly observed residents, three medication errors were identified across 28 opportunities. On 8/6/25 at 8:03 A.M., LN 1 prepared and administered eight pills or capsules to Resident 76, but did not administer all of the resident’s ordered medications during the medication pass. Record review showed Resident 76 had physician orders for Artificial Tears 1%/0.2%-0.2% eye drops three times daily, Artificial Eye Lubricant 83%-15% ointment to both eyes daily, and budesonide 0.5 mg/2 mL suspension for nebulization twice daily. A facility document titled Medication Time indicated medications ordered three times daily were to be given at 9 A.M., 1 P.M., and 5 P.M., daily medications at 9 A.M., and twice-daily medications at 9 A.M. and 5 A.M. On 8/7/25, LN 1 stated she did not administer the eye drops, eye lubricant, or inhaler during the medication administration. The DON stated the expectation was for nurses to administer all medications at the same time so they were given according to the physician’s order.
Unlabeled and Undated Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure foods in a resident personal food refrigerator located in the resident dining room were labeled and dated with a discard date, as required by facility policy. During observation, a large clear plastic zip-lock baggie containing two cupcakes, one green with white frosting and one yellow with white frosting, was found in the refrigerator with no label identifying which resident the cupcakes belonged to and no date showing when they were placed there. Licensed Nurse 1 stated the food should be labeled and dated because no one would know who it belonged to or how long it had been in the refrigerator, and stated the cupcakes might be old and someone could get sick if the food was not discarded within three days. The Dietary Staff Supervisor stated licensed nurses were responsible for checking the resident food refrigerator daily to ensure all foods were labeled and dated, and expected all food to include the resident's name and the date it was placed in the refrigerator. The supervisor stated all food placed in the refrigerator needed to be discarded after 72 hours and that staff should remove any food that was not dated or labeled. The Registered Dietitian and the Director of Nursing both stated they expected all food inside the resident refrigerator to be labeled and dated, and the DON stated licensed nurses were expected to inspect the refrigerator every day and remove food not labeled and dated. The facility policy titled Foods Brought by Family/Visitors stated perishable foods must be stored in re-sealable containers in a refrigerator and containers must be labeled with the resident's name, room number, the item, and the use by date, with no more than 3 days for perishable foods.
Used Meal Tray Left Accessible in Dining Room
Penalty
Summary
The facility failed to follow infection control practices when a used meal tray was left within reach of residents in the Valley View dining room and was not promptly removed. During an observation on 8/4/2025 at 12:02 P.M., Resident 58 was seen sitting in a wheelchair and wheeling self toward the hydration cart, where the resident grabbed a waffle from a used meal tray stored below the cart and ate it. During an interview later that day, CNA 1 stated nursing staff should be checking the dining room and putting away used meal trays that are outside of the dining room. CNA 1 also stated that residents in the Valley View nursing station, including Resident 58, have memory problems and could be at risk if they consume foods that do not belong to them. The ADON stated Resident 58 had dementia and that the used meal tray should not have been stored in the hydration cart because the cart was considered clean and used by other residents. The DON stated used trays were expected to be removed promptly and placed in dirty tray carts, and that the tray left in the dining room was an infection control issue. The facility did not provide a policy and procedure for infection control with dining.
Improper Use of Physical Restraint on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a licensed nurse (LN 1) who used a bed linen as a restraint. The resident, who had severe cognitive impairment and was unable to make her own decisions, was found with a flat sheet placed from her shoulders to her waistline, with both sides tucked under the mattress. This was done to prevent the resident from pulling her Foley catheter, as she had been confused and aggressive, and had previously pulled out the catheter. The incident was reported to the Department, and an unannounced visit to the facility was conducted. Interviews with staff, including a certified nursing assistant (CNA 1) and LN 1, confirmed that the sheet was used as a restraint without a physician's order or consent from the resident's family. The facility's records did not indicate any authorization for the use of restraints, and there was no documented evidence that the physician was notified before the sheet was applied. Further interviews with other staff members, including another licensed nurse (LN 2) and the Director of Nursing (DON), revealed that the restraint was not permitted in the facility without proper authorization. The DON confirmed that a restraint was applied to the resident and emphasized the importance of not using restraints without a physician's order and family consent. The facility's policy on abuse prevention, which includes the misuse of restraints, was also reviewed, highlighting the requirement for proper authorization and adherence to the resident's care plan.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who was reviewed for falls. The resident, who was admitted with diagnoses including cerebral palsy and generalized muscle weakness, experienced an assisted/witnessed fall on two occasions. The first fall occurred on April 14, 2024, and the care plan was updated to remind staff to use a Hoyer lift or Easy Stand for transfers if the resident was weak, sleepy, or tired. However, after a second fall on August 19, 2024, there was no documented evidence that the care plan was revised or updated with new interventions. During a joint interview and record review with the Director of Nursing (DON), it was confirmed that no new care plan interventions were implemented following the second fall. The DON acknowledged the importance of care plans as a guide to prevent incidents from recurring and ensure resident safety. The facility's policy on care plans, revised in March 2022, states that care plans should be revised when there is a significant change in the resident's condition or when desired outcomes are not met. Despite this policy, the care plan for the resident was not updated after the second fall, indicating a deficiency in the facility's care planning process.
Food Safety and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper food production and storage practices, increasing the risk of foodborne illness for 71 residents. During a kitchen tour, it was observed that the ice machine lid did not close tightly, leaving a gap that could lead to cross-contamination. Additionally, leftover food temperatures were not documented on a cool-down log, and the Registered Dietitian (RD) confirmed that macaroni and cheese and rice were improperly refrigerated without proper cooling and temperature documentation. Further deficiencies were noted in the incomplete documentation of refrigerator and freezer temperature logs, thermometer calibration logs, and daily cleaning schedules. The Dietary Operations Manager (DOM) acknowledged that these logs were not completed, which could result in unsafe food temperatures and sanitation. During a trayline observation, it was found that temperatures were not taken for all foods prior to meal service, with 10 hot and 10 cold food items served without temperature documentation. The DOM and the administrator both recognized the importance of these practices to prevent foodborne illness, as outlined in the facility's policies.
Infection Control Lapses in Catheter and Wound Care
Penalty
Summary
The facility failed to ensure safe infection control practices in two specific instances. First, two residents with urinary catheters, Resident 41 and Resident 43, were observed with their catheter bags lying on the floor. This was noted during multiple observations over several days. Staff members, including a CNA, a Licensed Nurse, the Infection Prevention Nurse, and the Director of Nursing, acknowledged that the catheter bags should not have been on the floor as it could lead to cross-contamination and infection. The facility's policy on catheter care explicitly states that catheter tubing and drainage bags should be kept off the floor. In the second instance, a Licensed Nurse (LN 11) failed to perform proper hand hygiene during a wound treatment for Resident 22, who was admitted with cellulitis of the right leg. During the dressing change, LN 11 did not perform hand hygiene between glove changes after removing the old dressing and before cleansing the wound. This lapse was acknowledged by LN 11, who admitted forgetting to perform hand hygiene, and was confirmed by the Infection Prevention Nurse and the Director of Nursing, who emphasized the importance of hand hygiene as part of standard infection precautions. The facility's hand hygiene policy requires hand hygiene after handling used dressings and after removing gloves. These deficiencies highlight lapses in adherence to the facility's infection control policies, which are designed to prevent the spread of infection among residents. The observations and interviews with staff members indicate a need for improved compliance with established protocols to ensure resident safety.
Failure to Assess and Document Skin Conditions
Penalty
Summary
The facility failed to ensure proper skin assessments and follow-up for two residents, leading to delays in treatment. Resident 15, who was admitted with dementia, exhibited leg discoloration that was not documented or assessed upon admission. Despite a CNA reporting the discoloration to a nurse, there was no record of this in the nursing assessments. The Director of Nursing acknowledged that the baseline skin condition was not documented, making it difficult to identify and treat potential issues such as venous insufficiency or infection. Resident 71, admitted with sepsis, had a dressing on his neck that was not assessed or changed by the staff. The resident reported that the dressing had not been checked since admission, and interviews with LNs revealed a lack of documentation and follow-up regarding the dressing. The Director of Nursing confirmed that the LNs were expected to assess skin conditions upon admission and obtain physician orders for any issues, which was not done in this case. The facility's policy on resident examination and assessment, which requires documentation of skin conditions and physician notification of abnormalities, was not followed. This oversight resulted in a lack of timely assessment and treatment for the residents' skin conditions, as evidenced by the absence of documentation and follow-up actions in the residents' medical records.
Failure to Implement Non-Pharmacological Interventions for Resident
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPIs) for a resident with behavioral health needs, specifically for a resident diagnosed with an unspecified mood disorder. The resident exhibited behaviors such as yelling and restlessness, which were managed with the administration of Ativan, a medication for anxiety, without documented attempts of NPIs. Observations and interviews revealed that the resident frequently placed objects in his mouth and was often agitated, yet staff did not consistently attempt or document NPIs like repositioning or reducing stimuli before administering medication. Interviews with staff, including a CNA, LN, ADON, and DON, indicated a lack of individualized NPIs for the resident. The staff acknowledged that NPIs should be attempted before medication administration, but there was no evidence of such attempts in the resident's records. The facility's policy on psychotropic medication use emphasized the importance of NPIs to minimize medication use, but this was not adhered to in the case of the resident, leading to a potential risk of overuse of medication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amaya Springs Health Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Bella Vista Health Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Lemon Grove Care And Rehabilitation Center | 3.2 mi | ★★★★★ | 27 | 0 |
| Brighton Place Spring Valley | 3.3 mi | ★★★★★ | 4 | 0 |
| La Mesa Healthcare Center | 3.7 mi | ★★★★★ | 2 | 0 |
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