Covenant Living of Golden Valley Care & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Covenant Living of Golden Valley Care & Rehab CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 22, 2021

  Based on observation, interview, and document review, the facility failed to ensure staff were wearing appropriate personal protective equipment (PPE), specifically eye protection per Centers for Disease Control and Prevention (CDC) requirements. This had the potential to affect all residents residing on the Fireside Unit. In addition, the facility failed to ensure proper hand hygiene when provided during care for 1 of 4 residents (R39) and failed to ensure proper hand hygiene was performed when handling oral medications for 1 of 4 residents (R9). Findings include: During observation on 4/20/21, at 1:19 p.m. […]

• No harm, potential for more than minimal, isolatedF627May 9, 2025

  Based on interview and document review, the facility failed to discuss discharge instructions with resident and resident representative upon discharge for 1 of 3 resident (R1). Additionally, the facility failed ensure correct disposition of medications for 2 of 3 residents (R1) when R1 received R2's medications upon discharge. Findings include: R1's face sheet, undated, indicated admitted to the facility of [DATE]. R1's diagnoses included atrioventricular block and unspecified diastolic (congestive) heart failure. R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition and no verbal behaviors during the assessment period. R2's face sheet, undated, indicated admitted to the facility of [DATE]. […]

• No harm, potential for more than minimal, isolatedF842May 9, 2025

  Based on interview and record review, the facility failed to maintain confidential clinical records for 2 of 3 residents (R1 and R2) when two of R2's Pharmacy Cards were sent with R1 who was discharging home. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's February 2025 Medication Administration Record (MAR) did not indicate an order for sulfamethoxazole or lisinopril. R2's MDS dated [DATE], identified intact cognition. R2's February 2025 MAR indicated an order for sulfamethoxazole 800 milligrams one tablet oral two times daily and lisinopril 20 milligrams one tablet by moth two times daily. […]

• No harm, potential for more than minimal, isolatedF755Feb 27, 2025

  Based on interview and document review, the facility failed to ensure physician-ordered medication was acquired and provided in a timely manner to reduce the risk of pain and complication for 1 of 1 resident (R1) reviewed whose pain medication was sent from the pharmacy however, was never provided as ordered. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact had medically complex diagnosis, surgical wound with surgical wound care, ulcerative colitis (an inflammatory bowel disease that causes chronic inflammation and ulcers in the superficial lining of the large intestine). […]

• No harm, potential for more than minimal, isolatedF554Aug 31, 2023

  Based on observation, interview, and document review, the facility failed to ensure the multidisciplinary team was involved for 2 of 3 residents (R111and R257) reviewed for self administration of medications(SAM). Finding include: R111's face sheet undated, indicated R111's diagnoses included chronic obstructive pulmonary diease (COPD) and a personal history of pulmonary embolism. R111's admission Minimum Data Set (MDS) dated [DATE], indicated R111 was moderately cognitively impaired, independent with eating after set-up, and required extensive assistance with the rest of his activities of daily living. During initial observation and interview on 8/28/23 at 1:20 p.m., two inhalers were noted at bedside. […]