Coventry House Inn

Inspectors wroteBased on interview and record review, the facility failed to employ a staff member with appropriate credentials to supervise and manage the dietary department resulting in the potential for food service sanitation failures, food borne illness and for clinical areas of dietary needs of all residents being compromised and unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen and the resident refrigerator resulting in the potential to spread food borne illness to residents that consume food from the kitchen and the resident refrigerator. Findings Include:During the kitchen tour on 1/6/2026 at 9:14 AM with Food Service Director (FSD) J, the following was observed:The reach in refrigerator in the kitchen:2 large plastic bowls with salad with no label and date. Another reach in refrigerator contained the following:1 container of liquid eggs on bottom of the refrigerator (not on shelf), slightly open with no label and date. During a tour of the kitchenette with FSD J on 1/6/2026 at 9:28 AM, the following was found:1 ketchup bottle, opened with no label and date. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #1, Resident #17) of 2 residents reviewed for dignity/respect, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on interview and record review the facility failed to ensure resident participation in care planning for 1 (Resident #12) of 1 resident reviewed for participation in care planning, resulting in feelings of anxiety, frustration, and a fear of uncertainty with the course of treatment while staying in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (Resident #2) of 12 sampled residents reviewed for care planning, resulting in the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 1 (Resident #1) of 12 sampled residents reviewed for care plans, resulting in an inaccurate reflection of the resident's advance directive wishes and the potential for the resident's advance directives wishes not to be honored.

Inspectors wroteBased on interview and record review the facility failed to ensure showers were provided as scheduled in 1 of 3 residents (Resident #12) reviewed for activities of daily living (ADLs) care, resulting in the potential for embarrassment and diminished self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide appetizing and palatable food products to 2 (Resident #1, Resident #21) of 3 residents reviewed for food palatability, resulting in dissatisfaction with meals and the potential for decreased food acceptance and nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 (Resident #21) of 12 sampled residents reviewed for complete and accurate medical records, resulting in incomplete documentation of blood sugar checks and insulin administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper use of personal protective equipment for enhanced barrier precautions during high contact care activities; 1.) wound care for 1 (Resident #8); 2.) intravenous medication administration for 1 (Resident #22); and 3.) transfer, bed mobility, and dressing for 1 (Resident #46) of 12 sampled residents resulting in the potential for the spread of infection and disease transmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Clean non-food contact surfaces; 2. Label and date cooked potentially hazardous food products with a prepared and discard date; 3. Repair or replace a water-damaged temperature gauge on the dish machine; 4. Ensure dish machine was at proper temperature prior to use; 5. Ensure food products reached safe internal temperature prior to service; and 6. Ensure prepared food was properly cooled. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness for all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food products were served at a palatable temperature for 2 of 12 sampled residents (Resident #22 and #133) reviewed for food palatability, and 5 of 6 residents from the confidential resident meeting, resulting in dissatisfaction with meals, and the potential for decreased food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration for 1 resident (Resident #84) of 7 residents reviewed for medication administration, resulting in medication being administered without a physician order, and the potential for less than therapeutic effects of medications, and the worsening of medical conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received coordination of care in accordance with physician orders and professional standards for skin conditions in 1 resident (Resident #13) of 1 resident reviewed for skin conditions, resulting in burning pain, the potential for an exacerbation of stasis dermatitis and an increased risk for infection due to compromised (weakened) skin integrity.

Inspectors wroteThis citation pertains to intake #MI00146244. Based on interview, and record review, the facility failed to maintain professional standards of care for 1 resident (Resident #83) of 1 resident reveiwed for accidents and hazards, from a total sample of 12 residents, resulting in the potential for unidentified internal bleeding when Resident #83, who was taking an antiplatelet medication (which decreases blood clotting ability) was not sent to the hospital after sustaining head trauma following a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations for 1 (Resident #2) of 5 residents reviewed for medications, resulting in the registered pharmacist's recommendations not being addressed in a timely fashion and the potential for negative medication side effects as a result of unaddressed recommendations.

Inspectors wroteBased on interview and record review, the facility failed to discontinue psychotropic medications (drugs that alter brain chemistry and can affect mood and behavior) prescribed on an as needed (PRN) basis after 14 days and/or document rationale to extend PRN psychotropic medication use in 2 of 5 residents (Resident #2 and #134) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the standards of infection control for hand hygiene and glucometer (handheld machine used to check blood sugar level) cleaning for 3 residents (Resident #84, #8, and #85) of 3 residents receiving blood sugar assessments, resulting in the potential for cross contamination and the spread of disease to a vulnerable population.

Inspectors wroteBased on interview, and record review, the facility failed to employ an Activity Director who possessed the required qualifications for the position, resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 27 residents within the facility.

Inspectors wroteBased on observation and interview, the facility failed to: 1. properly date and discard food items, 2. securely store packaged food product after opening, 3. clean food and non-food contact surfaces, 4. properly store clean cooking utensils and pans to prevent bacterial harborage and contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use it's resources to effectively administer the facility to attain and maintain the highest practicable physical, mental, and psychosocial well-being for all 27 residents that resided at the facility. This deficient practice resulted in a staff member holding a position without the required qualifications, and a potential for unmet psychosocial needs.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and ensure the storage of medications and biologicals were in locked medication carts for 2 of 2 medication carts reviewed for medication storage, resulting in the potential for diversion and/or misappropriation of medications.

Inspectors wroteThis citation has 2 Deficient Practice Statements (DPS) A & B. DPS A Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection for all the 27 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to educate all residents regarding the benefits and potential side effects of 23-valent pneumococcal polysacaride (PPSV 23) vaccination and offer PPSV23 vaccination to those residents who were eligible, therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 1 of 3 residents (Resident #128), reviewed for dignity, resulting in the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 of 3 residents (Resident #9) reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's privacy during wound care for 1 resident (Resident #226) of 3 residents reviewed for wound care of a total sample of 12, resulting in the potential for embarrassment, humiliation, frustration and anger.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a baseline care plan for 1 resident (Resident #124) reviewed for care plans, resulting in the potential for inappropriate care and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan in 1 of 12 residents (Resident #8) reviewed for comprehensive care plans, resulting in Resident #8's diuretic therapy not being care planned and the potential for unrecognized medication side effects and a lack of resident-centered interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate less than 5% (error rate was 16% - 4 errors in 25 opportunities) in 2 (Resident #226, and Resident #9) of 7 residents reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of infections, adverse reaction/side effects, medication errors, and medications not being stored in a secure manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively clean and maintain the resident privacy curtains, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.