Covenant Woods Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to implement the comprehensive care plan for oxygen as ordered for Resident #34. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory failure with risks for complications increased by CHF. INTERVENTIONS: Administer oxygen as…

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 staff interviews, facility document review, and clinical record review, the facility staff failed to meet professional standards of quality for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff changed an indwelling urinary Foley catheter size from 16 fr (French) to 24 fr without a physician order. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) Review of the clinical record revealed the following nurse's notes: A nurses note dated, 9/11/2023, revealed, Resident had urologist appointment new order to change foley cath, collect urine for UA/CS and increase Eliquis [an anticoagulant medication] to 5 mg BID, RP made aware. A nurse's note…

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 staff interviews, clinical record review, and facility document review, it was determined that the facility staff failed to provide urinary catheter care and services in accordance with the physician's order for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to utilize the correct catheter size when changing the Foley catheter on 9/11/23. The physician ordered the catheter size to be 16 fr (French size), however the facility used 24 fr. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) A review of the clinical record revealed a physician's order dated 7/28/23 for the use of an Indwelling Catheter 16 fr. Further review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide respiratory care per physician orders for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to provide oxygen as ordered for Resident #34. The physician's order was for 1-2 liters per minute, however the oxygen was set to 3 liters per minute. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory…

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 resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to implement bed rail requirements for two of 28 residents in the survey sample, Residents #36 and #212. The findings include: 1. For Resident #36, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #36 was observed in bed with quarter bed rails on 3/11/24 at 1:20 PM, 3/12/24 at 10:53 AM, and 3/13/24 at 9:40 AM. Resident #36 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hemiplegia following cerebral vascular accident and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/19/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional…

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 staff interview and facility document review, it was determined the facility staff failed to assess the risks and benefits of side rails for one of 20 residents in the survey sample, Resident #52. The findings include The facility staff failed to evidence that Resident #52 had the risks / benefits reviewed for her use of side rails. Resident #52 was observed in bed with bilateral half side rails on 4/19/22 at 1:10 PM, 2:48 PM, 4:15 PM and on 4/20/22 at 8:30 AM. Resident #52 was admitted to the facility on [DATE]. Resident #52's diagnoses included but were not limited to: acute respiratory failure, chronic obstructive pulmonary disease 'COPD', atrial fibrillation and arthritis. Resident #52's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 4/8/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded…

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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care in a manner to maintain and promote resident dignity for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was covered during the residents bath on 2/24/21, to promote and maintain Resident #1's, dignity. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to Parkinson's disease (1), disorientation, dementia (2), and lack of coordination. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed mobility, transfers between surfaces, eating, toileting, and…

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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care in a safe manner for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was provide supervision during bathing on 2/24/21. Resident #1, who was assessed as at risk for falls, was left in the bathroom unattended, while seated and reclined in an elevated shower chair. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to Parkinson's disease (1), disorientation, dementia (2), and lack of coordination. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed…

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, resident interview, staff interview, facility document review and clinical record review, it was determined, that the facility staff failed to provide care for respiratory equipment in a sanitary manner for one of 20 residents in the survey sample, Resident #30. The facility staff failed to store Resident #30's BIPAP facemask in a sanitary manner when not in use. Multiple observations revealed Resident #30's BIPAP facemask in a basket uncovered wrapped in the BIPAP tubing and head strap. The findings include: Resident #30 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), chronic respiratory failure (2) and pneumonia (3). Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/2021, coded Resident #30 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Resident #30 was documented as receiving oxygen while a resident at the facility,…

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 staff interview, facility document review and clinical record review it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for two of 20 residents in the survey sample, Residents #6 and #30. 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility in their email or presented to the physician for action until 39 days later. 2. The facility staff failed to act in a timely manner on a medication regimen review for Resident #30. Resident #30's medication regimen review was completed on 9/17/2020 with recommendations to evaluate the as needed order for Klonopin (sedative medication) which was not reviewed by the physician until January of 2021. The findings include: 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility…

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 staff interview, facility document review and clinical record review it was determined that the facility staff failed to ensure one of 20 sampled residents, (Resident #6), was free from unnecessary medications. The facility failed to act in a timely manner on the on 1/17/21 pharmacy medication regimen review, with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications prescribed and administered to Resident #6. The 1/17/21, pharmacy gradual dose reduction recommendation was not discovered by the facility in their email or presented to the physician for action until 2/24/21, a period of 39 days. The findings include: Resident #6 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1), insomnia (2) and major depressive disorder (3). Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/27/2020, coded Resident #6, as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact…

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 staff interview and clinical record review, it was determined that the facility staff failed to label medications in one of three medication carts and dispose of biologicals upon expiration date in one of two medication rooms. The facility staff failed to label medications; two white pills were observed in a medication cup in second medication drawer on the Unit C Wing 1. The facility staff failed to dispose of biologicals upon expiration date. Eight bottles of expired tube feeding formula and three medication wound dressings were observed in the Unit C Wing 1medication storage room. The findings include: On 2/24/21 at 8:30 AM, an inspection of Unit C Wing 2 medication cart was conducted. The medication cart was unlocked and in the second medication drawer, two white round pills were observed in a 30-milliliter clear medication cup. There was no labeling of medication, dose, resident name or date on the cup. An interview was conducted on 2/24/21 at 8:30 AM, with LPN (licensed practical nurse) #1. 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.