Covington Court Health and Rehabilitation Center

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, observation and interview, the facility failed to ensure a Bilevel Positive Airway Pressure (BiPAP) mask [used to assist with breathing], and oxygen use was care planned for one (Resident #178) of two residents reviewed for oxygen.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure oxygen was administered only when ordered by a physician to prevent potential respiratory complications for 1 (Resident #17) sampled resident reviewed for oxygen therapy.

Inspectors wroteBased on observations, interviews, record review, and policy review, it was determined that the facility failed to ensure dignity while dining for Resident #1 of 13 sampled residents. This failed practice had the potential to affect all sampled residents who are dependent while dining to maintain dignity.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 121 residents who receive meals from the kitchen (total census:124) as documented on a list provided by Dietary Supervisor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a licensed administrator was responsible for the overall operation of the facility. The failed practice had the ability to affect all 124 residents who currently reside in the facility according to the census list which was provided by the Assistant Administrator on 7/10/23 at 11:04 AM.

Inspectors wroteBased on interview and observation the facility failed to ensure that laundry was processed in a manner that minimized the risk cross contamination. The failed practice has the ability to affect all 124 residents whose clothing and linen are processed by the facility laundry according to the census list which was provided by the Assistant Administrator on 7/10/22 AT 11:04 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff promptly assisted a resident who required assistance with incontinent care and failed to maintain privacy and dignity for 1 (Resident #51) of 3 (Residents #50, #51, and #103) sampled residents who required assistance with incontinent care on Southwest Hall and failed to ensure a catheter bag was covered to maintain dignity for one resident (Resident #110) of four (Residents #50, #51, #103, and #110) sampled residents who have an indwelling catheter.

Inspectors wroteBased on observations, interview and record review, the facility failed to administer medications as ordered by the physician, and failed to accurately document the medications provided for 1 (Resident #106) of 11 (Residents #7, 9, 20, 44, 55, 67, 79, 98, 104, 118, 333) sampled residents that were administered medications by Licensed Practical Nurse (LPN)#1 and failed to provide appropriate hygiene care for for 1 (Resident #333) of 2 (Residents #5, 333) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen flow rates were administered per physician orders, and humidifier bottles were present according to physician's order for 2 (Resident #3 and #51) of 11 (Residents #2, #3, #5, #9, #11, #44, #51, #52, #100, #106, & #333) sampled residents who received respiratory therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications being administered to residents in a safe, secure, and sanitary manner.

Inspectors wroteF761 Based on observation, interview, and record review, the facility failed to date and store over the counter medications being administered to residents in a manner following currently accepted professional principles in 1 (Central) of 5 (Northeast, Southeast, Central, Rehab S, Rehab N) medication carts used in the administration of prescribed medications in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practices had the potential to affect 24 residents who received their meal trays in their room, on Southeast Hall, 20 residents who receive trays in their room on North East Hall, 15 residents who receive trays in their room on North [NAME] hall, 10 residents who receive their meal trays in their room on South [NAME] Hall, and 10 residents who receive their meal trays in their room on Central Hall, as documented on a list provided by the Dietary Supervisor on 7/13/2023 at PM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diets as documented on the List Dietary Supervisor provided by the Food Service Supervisor on 7/13/2023.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents' meals were consistently served at regularly scheduled times to provide residents with a dependable eating schedule for 2 of 2 meal services observed. The failed practice had the potential to affect all 121 residents who received meals from the kitchen (total census: 124), According to the list provided by the Dietary Supervisor dated 7/13/2023.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean, well maintained, homelike environment. The failed practice has the ability to affect 6 of 6 sampled residents (R#9, #81, #79, #385, #55, #41) with rooms in need of cleaning or repair.

Inspectors wroteBased on observation and interview the facility failed to ensure the kitchen was free of pests and failed to ensure the room meal experience was free from pest for 4 (Resident #333, #104, #63 and#51) of 4 residents who had flies in their room or in their food items or their body during the noon meal in 1 of 1 facility. The failed practice had the potential to affect 121 residents who received food from the kitchen, according to the list provided by the Dietary Supervisor on 7/13/2023 at 9:49 A.M.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure devices were put into place to prevent worsening of contracture for 1 (Resident #11) of 5 (Residents #5, #11, #52, #55, and #76) sampled residents with contractures.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure devices were put into place to prevent worsening of contracture for 1 (Resident #11) of 5 (Residents #5, #11, #52, #55, and #76) sampled residents with contractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who smoke were assessed for smoking safety upon admission to determine interventions necessary to maintain their safety for 1 (#52) of 5 (#6, #44, #52, #103 and #104] sampled residents who smoke. On 07/11/23 at 8:51 AM Resident #52 was lying in bed asleep. The resident's cigarettes and lighter were lying on the bedside table. The resident had oxygen in place in his room. On 07/11/23 at 1:46 PM observed a cigarette lighter on top of the bedside table in Resident #52 room. The resident was not in his room. Review of the physician orders summary for July 2023, revealed a wound care order for a left abdominal burn and wound care orders for a left 3rd finger burn. [...]