A list of the most recent deficiencies for Mount Miguel Covenant Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-21 | 2024-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-27 | 2024-01-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-27 | 2024-01-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-11 | 2023-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-05 | 2023-06-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-11 | 2023-06-02 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-11 | 2023-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-11 | 2023-06-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-11 | 2023-06-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-11 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-02 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-11 | 2023-06-02 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-15 | 2023-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-23 | 2023-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-07-26 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-09-13 | 2021-10-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-13 | 2021-10-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-28 | 2021-07-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-07-03 | 2019-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-03 | 2019-08-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-03 | 2019-08-07 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-07-03 | 2019-08-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-03 | 2019-08-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-13 | 2019-07-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-13 | 2019-07-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-13 | 2019-07-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-13 | 2019-07-13 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-06-13 | 2019-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-13 | 2019-07-13 | N |
| Develop a communication plan. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-26 | 2018-08-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-18 | 2018-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-18 | 2018-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-18 | 2018-06-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-05-18 | 2018-06-26 | N |
