Cove's Edge INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident's care plan was developed to reflect the current needs of the resident for 2 of 16 residents reviewed for care planning (Resident #3, #35).Findings:1. Resident #3 was admitted in January 2025 with diagnoses to include complete heart block and presence of cardiac pacemaker.Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment, dated 10/19/25, indicates presence of cardiac pacemaker. Review of Resident #3's physician orders revealed an order with a start date of 7/31/25 for St. [NAME] pacemaker.A review of Resident #3's care plan, revised on 11/3/25, lacked evidence that goals and interventions were developed and implemented for the pacemaker. On 1/7/2025 at 12:07 p.m. during an interview, Registered Nurse (RN) #5 reviewed Resident #3's care plan and confirmed that it had not been developed or implemented in the area of the pacemaker. 2. Resident #35 was admitted in November 2025 with diagnoses to include…

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 observations, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure foods were labeled and dated in the reach in refrigerator for 2 of 2 kitchen tours. (1/5/26 and 1/5/26)Findings:1. On 1/5/26 at 9:06 a.m., observation of the kitchen with the Dietician and the Food Service Director (FSD) the following findings were observed and confirmed.- The walk-in freezer ceiling had built up ice in front of the fans, the floor was littered with food and bagged food/packages including French fries, frozen yogurt/ice cream single serve cup and several packages of an unknown food product. Under the shelving unit was a built up ice mound in the right back corner. There were open unlabeled/dated bag of waffles and a bag of personal pizzas.- The stand up mixer had dried food/debris on the mixing arm, the protective cage and the shield. At this time the FSD and the cook stated the last time the mixer was used was Friday (3 days ago) for…

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 observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). In addition, facility failed to demonstrate staff competency for Infection Control in the areas of TBP and EBP in 2 of 2 units (Periwinkle and hummingbird). Findings: 1. On 1/6/26 at 9:52 a.m., during a medication administration observation for Resident #6 on the Periwinkle Unit with Certified Nursing Assistant-Medication Tech (CNA-M) #7, a Contact Precautions sign that indicated a gown and gloves are to be worn when entering the room and a Personal Protective Equipment (PPE) storage bag was hanging on the front of the door. At this time, the surveyor asked CNA-M #7 to verify the type of precautions in place, and CNA-M #7 stated Resident #6 is not on precautions but that his/her roommate…

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 observations and interviews, the facility failed to provide care for a resident in a dignified manner when a Certified Nursing Assistant (CNA#1) was observed transporting a resident in a shower chair when a resident wasn't provided a cover in a dignified manner exposing their bottom in a facility hallway (Resident #3). Findings: On 1/5/26 at 11:39 a.m., observation of CNA #1 transporting Resident #3 in a shower chair from Periwinkle Place unit, past the front entrance of the facility and nurses station down onto the adjacent unit shower room. Resident #3 had a sheet over his/her lap; however, his/her bottom was visible/exposed, hanging out from under the commode seat as well as his/her foley catheter. At this time, the surveyor intervened, discussing that Resident #3 was left exposed during the transport. CNA #1 stated he/she must have moved the sheet from his/her lap.On 1/5/26 at approx.11:45 a.m., the above observation was discussed with the Director of Nursing.

Based on record reviews and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed for care planning (Resident #35).Finding:Review of Resident #35's clinical record revealed an MDS admission Assessment was completed on 11/25/25. Further review of Resident #35's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment.On 1/7/26 at 12:46 p.m. the above finding was discussed during an interview with the Director of Nursing (DON) and Registered Nurse (RN) #5. At this time, RN #5 stated that she documents the IDT meeting notes in the resident's electronic medical record (EMR). RN #5 then reviewed Resident #35's EMR and confirmed that an IDT meeting was not held following the above assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of medication administration and treatments for 2 of 19 sampled residents (Residents #35 and #2).1. On 1/6/26 at 11:56 a.m. observed Registered Nurse (RN#3) push the medication cart to R#2's room, proceeded to pull the medications out of the cart and then crushed them without verifying the medications to the resident's chart. The surveyor questioned the practice, but RN#3 stated she did it by memory and that the order is on the resident's Treatment Administration Record (TAR). Even after surveyor intervention RN#3 did not review the TAR before giving the resident the medications. On 1/6/26 at 12:00 p.m. the above finding was confirmed with RN#3. 2. Resident #35 was admitted in November 2025 with diagnoses to include heart failure and chronic lower extremity edema. On 1/5/26 at 9:05 a.m. during an interview, Resident #35 stated he/she needs help from the staff applying his/her compression socks…

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 observations, record reviews, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Residents #24, #35, and #41). In addition, the facility failed to ensure physician orders were obtained and provided proper monitoring for 1 of 5 residents (Resident #6) receiving oxygen therapy and failed to ensure that physician orders were followed for 1 of 4 residents (Resident #24) receiving oxygen therapy.2. On 1/5/26 at 9:33 a.m. and on 1/6/26 at 8:14 a.m. a surveyor observed the following: Resident #24 seated in his/her recliner chair, wearing nasal cannula (NC) oxygen tubing, dated 1/3/26, with the oxygen concentrator set to 2.5 liters per minute (L/min). Resident #24's unbagged, undated NC oxygen tubing attached to a portable oxygen tank stored in the pocket on the back of his/her wheelchair. The nasal cannula prongs were in direct contact with the surface of the wheelchair. A review of Resident #24's clinical…

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 observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards, as is possible, related to a patient lift on 2 of 2 units (Periwinkle and Hummingbird) and for 1 of 3 days of survey. (10/21/24) Findings: 1. On 10/21/24 at 6:16 a.m., during a tour of the Periwinkle unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on an arm. 2. On 10/21/24 at 6:23 a.m., during a tour of the Hummingbird unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on the an arm. The surveyor reported the unsafe lifts to nursing at approx. 6:38 a.m. on 10/21/24. He/she stated that the Maintenance Director would be notified when he arrives. On 10/21/24 at 7:23 a.m., the above missing safety clips were discussed with the Senior Facilities Manager. On 10/21/24 at 7:26 a.m., observation of the Periwinkle easy lift to have both safety clips in place. On 10/21/24 at 7:33 a.m., during an interview, the Senior…

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, facility policy, record review and interviews the facility failed to adequately ensure medications were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed. Finding: On 10/21/24 at 11:45 a.m., a surveyor observed the medication refrigerator temperature logs with Registered Nurse (RN). Review of these temperature logs from 7/2024 through 10/2024 showed temperatures were not being monitored properly, with the following information missing: > July 2024 temperatures are documented out of range for 30 out of the 30 days > August 2024 is missing temperature readings for 5 out of 31 days and temperatures are documented out of range for 31 out of 31 days > September 2024 is missing temperature readings for 3 out of 30 days and temperatures are documented out of range for 30 out of 30 days > October 2024 is missing temperature readings for 5 out of 21 days and temperatures are documented out of range for 21 out of 21 days reviewed. Facility policy and procedure for Storage of Medications dated 5/1/2018 states under procedure subsections J…

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 interviews and record review, the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 2 residents reviewed for rehabilitative services. (#43) Findings: On 10/21/24 at 2:12 p.m. during an interview, Resident #43, stated that he/she was admitted to the facility on [DATE], and thought he/she was there for rehab but had not seen anyone from Physical Therapy (PT) or Occupational Therapy (OT). Review of the medical record contained a Physician order dated 10/7/24 for PT and OT evaluation. On 10/22/24 at approximately 11:30 a.m., in an interview with the PT/OT staff that were working on the unit, a surveyor asked if they had provided therapy for Resident #43. They stated that they could not because he/she is waiting for an evaluation prior to starting his/her therapy. On 10/22/24 at approximately 11:45 a.m., in an interview with the Admissions Coordinator, she stated the…

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 the facility's Food Receiving and Storage Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, the surrounding ceiling, and a food disposal unit. Additionally, the facility failed to ensure foods were dated and labeled in the walk-in refrigerator and the walk-in freezer for 1 of 1 tour. Findings: Review of the facility's Food Receiving and Storage Policy (last reviewed 4/4/23) noted: II. Scope: he Dietary Director, Dietary Supervisor, and Cooks are responsible for receiving and storing all food and non-food items. These tasks are delegated as needed. III. Policy/Procedure: 6) All opened foods and beverages, prepared foods and leftovers are dated. On 8/7/23 from 9:10 a.m. to 9:50 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: > There were 4 ceiling vents, along with the surrounding ceiling areas, that were dirty/dusty throughout the kitchen. These ceiling vents were above clean dish storage areas, food…

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.