Covered Bridge Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Ombudsman that residents were discharged from the facility for 3 of 3 discharged residents' records reviewed. (Residents 63, 64, and 65) Findings include:1. The clinical record for Resident 63 was reviewed on [DATE] at 11:53 A.M. The resident was admitted to the facility on [DATE]. A Progress Note, dated [DATE] at 6:07 A.M., indicated the resident experienced a change of condition and was sent to the local hospital's emergency department for evaluation.A Progress Note, dated [DATE] at 5:21 P.M., indicated the resident was admitted to the hospital. The Census section of the resident's Electronic Health Record (EHR) indicated the resident was discharged from the facility on [DATE] and the resident was not anticipated to return. The Discharge Report sent to the Ombudsman for [DATE] was provided by the Director of Nursing (DON) on [DATE] at 11:44 A.M. The report did not include Resident 63.2. The clinical record for Resident 64 was reviewed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to follow manufacturers guidelines related to priming an insulin pen for 1 of 2 insulin pens observed. (Resident 55)Findings include: Medication administration was observed on 02/11/2026 at 11:03 A.M., with Qualified Medication Aide (QMA) 5. The QMA prepared insulin for Resident 55 using an insulin pen and indicated the resident was to receive 3 units of lispro (Humalog) insulin per the sliding scale. The QMA removed the insulin pen from the medication cart, checked the label, removed the pen cap, cleaned the end of the pen with an alcohol wipe, applied the needle, and removed the cap of the needle. She turned the pen dose selector to two units, primed the pen holding the pen tip facing parallel to the floor, squirted out the two units of insulin, turned the pen dose selector to 3 units, donned gloves, and went into the resident's room. The QMA administered the insulin into the resident's abdomen. During an interview, with QMA 5, immediately following the procedure, she indicated she was not trained on how to hold the pen when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, that facility failed to follow a physician's order related to a blood thinning medication administration for 1 of 6 residents reviewed for unnecessary medications. (Resident 20)Findings include:The clinical record for Resident 20 was reviewed on 02/09/2026 at 11:46 A.M. An admission Minimum Data Set (MDS) assessment, dated 01/09/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hip and knee replacement and deep vein thrombosis (blood clot - DVT). A Hospital Discharge summary, dated [DATE], indicated the resident had a total right hip replacement on 12/30/2025. The resident was to be given Lovenox (blood thinning medication) 40 milligrams (mg) once a day until the resident's INR (International Normalized Ratio, a standardized blood test result that measures how long it takes for your blood to clot) level was greater than 2.0. The resident had problems with deep vein thrombosis. The resident's next INR level was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed. (100 Hall Medication Cart)Findings include: On 02/09/2026 at 10:57 A.M., the 100 Hall Medication Cart was observed with RN 4 and contained the following:- A small round white pill was lying loose in the bottom of the second drawer along with dust and paper debris and- A half of a small oval green pill was lying loose in the bottom of the third drawer along with dust and paper debris.During an interview, on 02/09/2026 at 10:58 A.M., RN 4 indicated she didn't know what the pills were or who they belonged to, pills should not be loose in the medication cart. The current facility policy, titled Medication Storage dated 11/01/2022, was provided by the Director of Nursing (DON) on 02/12/2026 at 11:50 A.M. The policy indicated, .Medications must be stored under proper conditions to protect against degradation .3.1-25(o)

Based on record review and interview, the facility failed to transcribe a physician order on admission for 1 of 16 resident records reviewed. (Resident 20)Findings include:The clinical record for Resident 20 was reviewed on 02/09/2026 at 11:46 A.M. An admission Minimum Data Set (MDS) assessment, dated 01/09/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hip and knee replacement, hypertension, osteoporosis, malnutrition.A hospital discharge record, dated 01/27/2026, indicated the resident was to receive Coumadin (a blood thinning medication) 3 milligrams (mg) on Sunday, Monday, Wednesday, and Friday. An physician's order, with a start date of 01/27/2026, indicated the resident was to receive Coumadin 3 mg once a day on Monday, Wednesday, and Friday. During an interview, on 02/10/2026 at 11:24 A.M., RN 2 indicated when a resident was admitted from the hospital she would get report from the hospital, put the resident in the facility computer system, assess the resident, get their vital signs, and transcribe the orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow the physician's orders related to the treatment for a pressure ulcer for 1 of 2 residents reviewed for pressure ulcer treatments. (Resident 47) Findings include: During an observation on 01/21/25 at 11:06 A.M., Resident 47's dressing change was observed. The resident's pressure wound, located on her right upper buttock, was observed with the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Coordinator. The ADON and MDS Coordinator donned gowns and gloves prior to entering the resident's room. The ADON indicated the current treatment was to cleanse the wound with wound cleanser, apply collagen powder, then Anasept gel (an antimicrobial), and cover the wound with a border dressing. The staff members entered the room, raised the bed, pulled the covers back, pulled the resident's brief down, then rolled the resident to her left side. The resident's wound was uncovered and open to air. The ADON removed her gloves and washed her hands. The wound was quarter sized and had a dark red wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure fall preventative devise interventions were in place as ordered for 1 of 3 residents reviewed for accident hazards. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 01/21/25 at 9:23 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/13/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, and malnutrition. A Fall Care Plan, with a start date of 07/12/24 and a revised date of 01/23/25, included but was not limited to, the following intervention: Highlighter tape to wheelchair brakes with a start date of 09/08/24. A Progress Note, dated 09/09/24 at 4:02 A.M., indicated the resident had a fall while trying to transfer herself into her wheelchair to go to the bathroom. The left side wheelchair brake was not locked upon inspection. The resident had no injuries. An Interdisciplinary Team (IDT) Note, dated 09/09/24 at 1:36 P.M., indicated the immediate intervention to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to have a medication error rate of less than 5% for 2 of 32 medication administrations observed. (Resident 3) Findings include: During an observation on 01/22/25 at 9:36 A.M., RN 6 prepared Resident's 3 morning medications. She placed all of Resident 3's morning prescribed (14) different medications in one medication cup. The resident's morning dose of Buprenorphine, 2 mg, was to be administered by sublingual (placing a drug under the tongue to dissolve and be absorbed directly into the bloodstream) administration. The RN retrieved the resident's prescribed eye drops, refresh tears and brimonidine, from the medication cart. The nurse took the prepared cup of medications, and the two types eye drops to the therapy gym where the resident requested to take the medications. The resident was given the cup of medications and took them whole with sips of her drink. The nurse then administered the eyes drops to the resident, one after the other, with no wait time in between. The resident's Buprenorphine was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to urinary catheter care for 2 of 3 residents reviewed for infection control. (Residents 10 and 15) Findings include: 1. On 01/16/25 at 1:40 P.M., Resident 10 was observed in her room sitting in a recliner. The resident's urinary catheter drainage bag was hanging from a pocket on the recliner, with two inches of the bottom of the bag resting on the floor. On 01/16/25 at 3:29 P.M., the resident was observed in her room sitting in the recliner. The resident's catheter drainage bag was hanging from the chair with two inches of the bottom of the bag resting on the floor. On 01/17/25 at 1:43 P.M., the resident was observed in bed. The bed was in a low position and the catheter bag was hanging on the left side of the bed. An inch of the bag was resting on the floor. Qualified Medication Aide (QMA) 2 observed the bag and indicated it shouldn't be touching the floor; it was probably because the bed was so low. She indicated she would adjust the position of the bag. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to report the misappropriation of money for 1 of 1 resident reviewed for personal property. (Resident 16) Findings include: During an observation and interview on 11/27/23 at 1:54 P.M., Resident 16 was sitting in his room on his wheelchair. The resident indicated on Thanksgiving Eve (11/22/23) he had $1,024.00 missing from his fanny pack. He had gone to the bathroom, located in his room, to get cleaned up and placed the fanny pack in his recliner with a blanket over it. The next morning, he realized the money was missing. He reported it to a nurse, and she called the police. He had not talked to the Administrator as she had been off work. During an interview on 11/28/23 at 2:50 P.M., RN 4 indicated on the morning of 11/23/23, Resident 16 came to her saying he was missing $900.00. She had him recount his money just to make sure and she sent a message to the DON (Director of Nursing). She didn't hear anything back from the DON, so she called the police, and they came and talked to the resident. During an interview on 11/29/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to label and store medications appropriately for 1 of 2 medications carts (200 Hall) and 1 of 1 medication rooms (Health Care Medication Room) observed. Findings include: 1. The 200 Hall Medication Cart was observed on 12/04/23 at 9:08 A.M., with RN 6 and contained the following: - a Lispro insulin pen for Resident 108, containing 100 units of insulin, with no open date, - an unopened Basalgar insulin pen for Resident 108 with a sticker that indicated to refrigerate until opened. The pen was in the same package as an opened Basalgar pen for the resident. The RN indicated the one pen was not opened and should have been in the refrigerator, - a Lantus insulin pen for Resident 40, containing about 30 units of insulin, with no open date, and - a Novolog insulin pen for Resident 37, containing 200 units of insulin, with no open date. RN 6 indicated the insulin pens were good for 28 days after they were opened and should have all been labeled with an open date. The current Humalog Insulin Lispro Instruction for Use was provided by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.