Mount Miguel Covenant Village

indicated that the CN went to Resident 1's room to assess the resident after the unwitnessed fall.

The CN documented that Resident 1 had hit the left side of his head and sustained a bleeding laceration.

The CN also documented that Resident 1 was on blood thinner medications.

The Clinical Note indicated that Resident 1's bed was raised and the bed rails were not in place. A review of Resident 1's Clinical Notes, dated 7/12/25, indicated that Resident 1's left 4th finger was very red, swollen, warm to touch.

The Clinical Note indicated an x-ray of Resident 1's left hand was conducted at the facility which showed an acute comminuted fracture (where the bone breaks into three or more pieces) of the fourth distal phalanx, with associated soft tissue swelling.

The Clinical Note indicated Resident 1 was sent to the hospital and was admitted with an infection of the left fourth finger and left upper extremity cellulitis (infection of left upper arm). An interview with CNA 1 was conducted on 8/12/25 at 10:14 A.M. CNA 1 stated that he and the SNA were changing Resident 1 when the roommate's wife yelled out that her husband was vomiting. CNA 1 stated he immediately went to get the nurse and when they returned, Resident 1 had fallen out of bed. CNA 1 stated Resident 1's bed was set in a high position because they were in the middle of changing him. CNA 1 acknowledged that the SNA should not be left alone with the resident, and stated In this event, I should've sent her out instead of myself to reach out for the nurse. On 8/12/25 at 4:06 P.M. the SNA stated during an interview that she and CNA 1 were changing Resident 1 when the roommate's wife yelled out to get a nurse because her husband was throwing up. CNA 1 then rushed out to get the nurse, but as soon as he left, the resident turned and fell to the ground.

The SNA stated that Resident 1 tended to reach for the siderails, which were down at the time.

The SNA further stated, It happened really fast.

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