Mount Miguel Covenant Village

In the surveyor’s words

From the most serious findings on record at Mount Miguel Covenant Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF688Aug 7, 2025

  Based on observation, interview, and record review, the facility failed to provide Range of Motion (ROM-the extent or limit to which a body part can be moved; the totality of movement a joint is capable of doing. ROM is gauged as passive PROM {needs assistance} or AROM {independent}, exercises for three of four residents .(7, 52, 78), reviewed for Mobility and Positioning. This failure had the potential for Residents 7, 52, and 78 to have a reduction in mobility and flexibility, causing them to become more dependent on staff for activities of daily living. (Cross Reference F641)Findings: 1. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2025

  Based 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. Findings:1. During an initial tour of the kitchen, an observation was conducted on 8/4/25 at 8:04 A.M., of one kitchen freezer (labeled #4) with the Registered Dietitian (RD). On the left side of the freezer, on the second shelf was a clear sealed plastic bag containing eight hot dogs. […]

• No harm, potential for more than minimal, patternF812Jun 20, 2024

  Based 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. Findings: On 6/17/24 at 8:23 A.M., a tour of the kitchen, document review and interview was conducted with the Registered Dietitian (RD). 1. […]

• No harm, potential for more than minimal, patternF880Jun 20, 2024

  Based 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. Findings: 1a. […]

• No harm, potential for more than minimal, patternF880May 11, 2023

  Based 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. Findings: On 5/11/23 at 11:59 A.M., an interview was conducted with the facility's two Infection Preventionists (IP 1 and IP 2). IP 1 stated both infection surveillance and antibiotic use for residents was tracked on the same facility form; the Infection Prevention and Control Surveillance Log (IPCSL). […]