Covenant Shores Health Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to initiate and/or thoroughly investigate the occurrences of events for 2 of 2 (Residents 10 & 5) sampled residents whose facility incident reports were reviewed. The facility failed to initiate an investigation for an injury of an unknown origin for Resident 10 and failed to thoroughly investigate falls for Resident 5. The failure to initiate and conduct thorough investigations left residents at risk for unidentified abuse and/or neglect, recurrence of events, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 4 of 5 residents (Resident 3, 5, 17, & 20) who were assessed to be dependent on staff for ADLs. Failure to provide ADL assistance as required left residents at risk of poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure acute medical delirium was ruled out prior to prescribing Antipsychotic (medications used to treat psychosis) medications for 1 of 3 sampled residents with Dementia (a decline in mental ability that interferes with daily life) (Resident 5) and to assess for adverse side effects related to the use of psychotropic medications for 3 of 3 sampled residents (Residents 5, 13, & 3) who were prescribed an Antipsychotic reviewed for unnecessary medications. Failure to rule out acute medical delirium prior to prescribing Antipsychotic medications placed Resident 5 at risk of medical complications, unnecessary psychotropic medication use, and a diminished quality of life. [...]

Inspectors wroteBased on interview and record review the facility failed to log/report an allegation of neglect for 1 (Resident 10) of 1 residents reviewed. This failure placed residents at risk for unidentified neglect, avoidable pain, and other negative health outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessments submitted for a Level II PASRR assessment after the 30 day exemption expired for 1 of 5 sample residents (Resident 4) and were completed for new mood disorders requiring antipsychotic medication for 1 of 5 residents (Resident 5) whose PASRRs were reviewed. This failure left residents at risk of inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure person centered care plans were completed to address all aspects of resident care for 1 of 1 closed records resident (Residents 41) reviewed for death and 1 of 1 sample resident (Resident 5) reviewed for accidents. The facility failed to conduct care conferences for residents with their representatives and the applicable Interdisciplinary Team (IDT) members for 2 of 4 sample resident (Residents 9 & 20) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, a diminished quality of care, unmet care needs, unnecessary care, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were obtained and clarified for 3 of 14 sampled residents (Residents 41, 17, & 6) reviewed. These failures placed residents at risk of unmet needs, and ineffective/or delayed treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate and complete skin assessments for 1 of 2 sample residents (Resident 3) reviewed for skin, implement the bowel protocol for 1 of 1 sample resident (Resident 5) reviewed for constipation, and manage fluid retention for 1 of 1 closed records (Resident 40) reviewed for hospitalizations. Failure to accurately assess and document skin conditions placed Resident 3 at risk of skin breakdown, infection, and decreased quality of life. Failure to implement the bowel protocol for constipation placed Resident 5 at risk of unmet care needs, bowel obstruction, pain, and decreased quality of life. Failure to manage fluid retention placed Resident 40 at risk of respiratory distress and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure chemicals were stored safely for 1 (Rose Unit) of 3 units reviewed. The failure to ensure that chemicals were secured placed residents at risk of injury, an unsafe environment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured for 2 (Residents 20 & 37) observed with medications in their rooms and failed to ensure proper storage of drugs on 1 (Rose Medication Cart) of 2 facility medication carts. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed self-administration of medications by residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for residents with indwelling medical devices for 1 of 2 residents (Resident 20) reviewed with indwelling devices, properly store urinary catheter bags, and perform hand hygiene during catheter care for 1 of 2 residents (Resident 13) reviewed for urinary catheter use. Failure to implement EBPs, perform hand hygiene during urinary catheter care, and properly store a urinary catheter bag placed residents at risk of infection and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement a system by which residents received required written notices at the time of transfer or as soon as practicable for 3 (Residents 28, 5, & 7) of 4 residents reviewed for hospitalization. Failure to ensure notification to the resident and/or the resident's representative of the reason for transfer in writing and in a language and manner they understood, placed residents at risk for a transfer not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs requiring further assessment/treatment) assessment was accurately completed for 3 (Residents 33, 7, & 2) of 5 residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a medical device for 1 of 1 (Residents 31) residents reviewed for positioning, and 1 supplemental resident (Resident 26). The failure to provide informed consent placed residents at risk for loss of autonomy.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident's ability to self-administer their medications for 1 of 3 residents (Resident 29) reviewed. This failure placed residents at risk for overdose or under dose of medical treatment when self-administering of the wrong dose, frequency, route, and time.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 2 (Residents 31 & 2) of 3 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate a fall for 1 (Resident 88) of 3 residents reviewed for accidents, and rule out abuse/neglect for 2 (Resident 23 & 33) of 3 sampled residents reviewed for abuse. Facility failure to complete thorough investigations placed residents at risk for further falls, potential abuse, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive Care Plans (CPs) for 5 (Residents 5, 31, 33, 7, & 23) of 12 sample residents whose CPs were reviewed. The failure to develop and/or implement comprehensive CP interventions left residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a formal assessment prior to use of a Tilt-in-Space wheelchair (a specialty wheelchair with a seat and back that can be readjusted by a second party to reposition the user for comfort and/or pressure relief) for 1 of 2 residents (Resident 26) reviewed for accommodation of needs, and 1 of 1 residents (Resident 31) reviewed for positioning. The failure to ensure residents' Tilt-in-Space wheelchairs prior to use placed residents at risk for use of an inappropriate wheelchair, discomfort, and loss of bodily autonomy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications and biologicals were secured for 3 (Residents 14, 29, & 88) of 12 sample residents. The failure to ensure medications were not left at the bedside with residents not assessed to be able to self-medicate placed residents at risk for receiving the wrong medications, incorrect dosages, and non-assessed, self-administration of medications by residents.

Inspectors wroteBased on observation, interview, and record review the facility failure to ensure food was prepared and served in accordance with professional standards of safety. Facility failure to ensure ready-to-eat foods were covered and kitchen staffs' hair was secured as required left residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise Care Plans (CPs) as needed to maintain accuracy for 9 of 14 (Residents 3, 13, 9, 11, 16, 6, 189, 1 & 29) sample residents. Failure to review and revise CPs when changes were required left residents at risk for unmet care needs, unnecessary care, and other frustrations.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure medications and biologicals were dated when opened; dispose of timely expired and/or discharged resident medications for 1 of 2 medication carts and 1 of 1 medication room reviewed; and ensure medications were secured for 1 of 2 medication carts observed. These failures placed residents at risk for receiving expired medications, medication errors, adverse side effects of medications, or not receiving the full effect of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Infection Prevention and Control Program (IPCP) was followed during observance of Transmission Based Precautions (TBP) for Residents 16 & 22 on Contact Enteric Precautions; transport and delivery of resident's personal clothing; maintenance of Resident 140 & 6's wheelchair equipment; and hand hygiene with wound care for Resident 29 and during medication administration. These failures placed residents at risk for exposure to infections and a decreased quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure 6 of 14 (Residents 9, 3, 15, 1, 16 & 6) residents Minimum Data Set (MDS- an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intelectual disabilty needs which required further assessment/treatment) assessment was obtained to reflect the residents' mental health conditions for 1 of 6 (Resident 9) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive Care Plans (CPs) for 5 of 14 (Residents 3, 13, 11, 139 & 6) sample residents. Failure to develop comprehensive CPs for refusals (Resident 3), dementia care (Residents 13 and 11), catheter care (Residents 139), and implement CP interventions identified related to antipsychotic medication use (Residents 6) left residents at risk for unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow/implement Physician's Orders (POs) for 3 (Residents 13, 189, & 21) of 14 sample residents reviewed, and failed to clarify POs for 2 (Residents 11 & 141) of 14 sample residents reviewed. These failures left residents at risk for unmet care needs, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, monitor, and/or treat wounds for 2 of 3 (Resident 1 & 239) residents reviewed for non-pressure skin issues. These failures placed residents at an increased risk for infection, untreated skin impairments, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and provide interventions to prevent the development of a pressure injury for 1 of 3 (Resident 29) sampled residents reviewed for pressure ulcers. This failure resulted in the development of pressure injuries, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper positioning approaches were provided for 1 of 2 (Resident 3) residents reviewed for positioning. Failure to provide proper positioning left residents at risk for contractures (irreversible tightening of a joint), discomfort, and pain.

Inspectors wroteBased on interview and record review, the facility failed to implement the fall management policy for 1 of 3 (Resident 15) sample residents reviewed for falls. This failure left residents at risk for falls, injuries, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: (1) follow Physician Orders (POs) and ensure the correct dose was administered, and (2) provide proper care of nasal tubing for oxygen concentrator (a breathing therapy that pumps oxygen into the lungs through the nose or mouth) for 1 of 1 (Resident 4) resident reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, and related respiratory complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and treat 1 of 2 (Resident 29) residents reviewed for pain management. Failure to assess and implement interventions to relieve pain resulted in Resident 29 experiencing episodes of uncontrolled pain during daily movement and wound care treatments which placed the resident at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free of unnecessary psychotropic medications for 2 of 5 (Residents 13 & 6) sample residents whose medications were reviewed for unnecessary psychotropic medications. Failure to: (1) identify the adequate indications for use/extended use, and (2) adequately monitor and document excessive sedation behaviors as adverse consequences placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related Adverse Side Effects (ASE), and a diminished quality of life.