Covenant Village Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper sanitation of equipment when two of two ice machines for resident use had brown and yellow discoloration in the machines. This failure had the potential to contaminate the ice distributed to residents and the potential for residents to become ill.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper infection control practices for 1 of 4 sampled residents (Resident 5) when the nurse did not use Enhanced Barrier Precautions (EBP as gown, and gloves), while administering medications and a bolus feeding through a gastrostomy tube (G-tube- a small, soft tube that is inserted through the skin directly into the stomach, and is used to give food, water or medicine). This failure increased the risk of spreading germs amongst all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that four of four sampled residents (Resident 299, Resident 35, Resident 1, and Resident 18) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when:1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person centered Care Plan (a document that outlines a personalized approach to an individual's healthcare and support needs) for two of two sampled (Residents 6 and 20) when:1. Resident 20 had no Care Plan created for the use of their mobility rails (rails on the side of the bed which help a resident turn and move in bed)This failure had the potential to cause Resident 20's use of mobility rails to not receive proper monitoring or support to ensure they were used safely.2. Resident 6 did not have a care plan developed for ordered padded side rails. This failure had the potential to result in harm to Resident 6 if the padded side rails were removed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of five sampled residents (Resident 8, Resident 5 and Resident 12) when:1. For Resident 8, there was no documented evidence of the removal of the previously applied medication patches from the residents' back. This failure to track and document patch removal had the potential to result in overmedication and adverse effects.2. Social Service Director (SSD) did not have a system in place to monitor Resident 8 for a follow up dental appointment. This failure had the potential to result in Resident 8's dental care to not be completed.3. Resident 5 did not have a running total of daily fluid intake calculated and documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper pharmaceutical services were provided to meet the needs of residents when the facility did not have an effective system in place to periodically reconcile all controlled substances in the facility. This failure had the potential for diversion, mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 8 percent. There were 25 opportunities for errors and two medication errors occurred for two of four sampled residents (Resident 28, and Resident 12) when:1. Resident 28's diclofenac 1% gel (topical pain medication) dose was not correctly measured.2. Resident 12's Refresh Classic 1.4-0.6% eye drops (medication used to treat dry eye disease) were administered incorrectly in both dosage amount and technique. The quantity exceeded the prescribed amount in the left eye and the drops were placed directly in the center of the eye. These failures to follow proper medication administration practices had the potential to result in reduced effectiveness of treatment or harm to Residents 28 and 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when:1. One bottle of Resident 17's latanoprost (medication used to decrease blood pressure in the eye) was stored in the Station 1 (Whispering [NAME]) medication cart did not have resident-specific label. This had the potential to result in medication administration errors, including administration to the wrong resident, which may adversely affect resident safety.2. Discontinued medications for Resident 17, Resident 28 and Resident 32 were stored in in the active medication section of the Station 1 medication cart. This had the potential to result in the administration of discontinued medications, placing residents at risk for receiving unnecessary or inappropriate treatment.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to be informed and make decisions about their care for one of four sample residents (Resident 1) when the facility did not obtain informed consent prior to increasing Resident 1's Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly) dosage. This failure had the potential to result in Resident 1 receiving psychotropic medication (medication that affects brain activities associated with mental processes and behavior) without proper understanding or consent, compromising their right to participate in medical decision-making.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to act upon the Pharmacist's recommendation to add a specific duration to as needed psychotropic medication for 2 (Resident #11 and Resident #37) of 5 residents sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to indicate the duration of an as needed antianxiety medication for 2 (Resident #11 and Resident #37) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment per the facility policy when not in use for 1 (Resident #3) of 1 sampled resident reviewed for respiratory care. The facility also failed to ensure enhanced barrier precautions were utilized during the provision of wound care for 1 (Resident #33) of 12 sampled residents. 1. A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, specified, 8. Keep the oxygen cannulae and tubing used PRN [pro re nata, as needed] in a plastic bag when not in use. A Face Sheet revealed the facility admitted Resident #3 on 03/24/2022. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the recipe portion size for five of five sampled residents (Resident 21, Resident 37, Resident 18, Resident 193, Resident 22) when: the Dietary [NAME] (DC) served 2.2 ounces (dry unit of measurement) of braised Swiss steak instead of serving four ounces for one lunch meal. This failure placed Resident 21, Resident 37, Resident 18, Resident 193 and Resident 31 at risk for nutritional inadequacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to prevent cross contamination (the transfer of germs from one surface to another) when: 1. A used nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) laid on top of Resident 9's nebulizer machine. The mask was unmarked. 2. An out dated nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient) laid on top of a concentrator (a medical device used to deliver oxygen which purifies the surrounding air) dated 6/2/19. These failures had the potential for bacteria to grow. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate personal privacy for one of 10 sampled residents (Resident 4) when: Resident 4's privacy curtain was not drawn around his bed while he rested and exposed his undressed body below the waist line. This failure violated Resident 4's right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: there were 82 medication pass opportunities for error and 10 errors resulted in a medication error rate of 12.2 percent. This failure resulted in the significant medication error for Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 15 was free of a significant medication error when Licensed Vocational Nurse (LVN) 3 did not administer a morning dose of glipizide (medication used to treat high blood sugar). This failure placed Resident 15 at risk for complications from elevated blood sugar.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when: undated, opened bags of spices, hot dog buns, waffles, sugar, mayonnaise, chunk light tuna, chopped onions and an expired 1/4 milk gallon container were stored and available for use in the walk-in freezer, refrigerator and dry food storage areas. These failures to ensure effective dietetic service operations placed residents that received meal from the kitchen at risk for food borne illness and the growth of microorganisms.