Covenant Living at Inverness

In the surveyor’s words

From the most serious findings on record at Covenant Living at Inverness, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 10, 2026

  Based on observation and interview, the facility failed to maintain a clean ice machine and service meals in a manner which limited the risk of cross contamination. The DON identified 39 residents ate meals prepared in the kitchen and served from the satellite kitchen. Findings: On 07/06/26 at 2:15 p.m., the ice machine in the kitchen was observed with the kitchen manager and Maintenance #1. The front panel was removed, and the front panel and the mechanical area of the ice machine was observed. There was a grey tube which ran downward and into the water reservoir. A green substance, speckled with brown and with brown and green edges, was observed under the water line and in the bend of the grey tube. […]

• No harm, potential for more than minimal, patternF700Sep 26, 2024

  Based on observation, record review, and interview, the facility failed to ensure informed consent was obtained prior to the utilization of bed rails for two (#13 and #25) of two sampled residents reviewed for bed rails. The administrator identified 40 residents whose beds were equipped with a bed rail of any type. Findings: 1. Res #13 had diagnoses which included dementia, abnormalities of gait and mobility, and muscle weakness. A physician order, dated 07/07/23, documented the resident could use assist handle to assist with turning or repositioning. An admission assessment, dated 07/13/23, documented the resident was severely impaired in cognition, required extensive assistance with bed mobility, and had one fall with injury. […]

• No harm, potential for more than minimal, patternF620Dec 16, 2021

  Based on record review and interview, the facility failed to ensure a claim for outpatient hospital services was submitted /paid as Medicare Part A, consolidated billing for one (#131) of one sampled residents whose records were reviewed for Medicare Part A, consolidated billing. The administrator identified five residents who received Medicare Part A services. Findings: The Skilled Nursing Facility Agreement, dated December 2019, read in part, .Medicare/Medicare Supplemental Polices. […]

• No harm, potential for more than minimal, patternF656Dec 16, 2021

  Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan related to insulin and [CONDITION(S)] medications for two (#18 and #79) of five sampled residents whose care plans were reviewed for medications. The Resident Census and Conditions Report identified 17 residents on [CONDITION(S)] medications. The administrator identified two residents who received insulin. Findings: The undated Care Plans, Comprehensive Person-Centered policy, read in parts, .The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Care plan interventions are chosen only after careful data gathering .careful consideration… […]

• No harm, potential for more than minimal, patternF657Dec 16, 2021

  Based on observation, record review, and interview, the facility failed to ensure the care plan was revised to include antibiotic therapy and contact isolation precautions for one (#19) of one sampled residents whose care plans were reviewed for antibiotic therapy and contact isolation precautions. The Resident Census and Conditions Report identified five residents on antibiotics. The DON identified two residents on contact isolation precautions. Findings: Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's quarterly MDS assessment (a resident assessment tool used to identify resident care needs), dated 10/27/21, documented the resident was cognitively intact, required extensive assist with toileting, and was occasionally incontinent of urine. […]