Covenant Shores Health Center

In the surveyor’s words

From the most serious findings on record at Covenant Shores Health Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Apr 4, 2023

  Based on observation, interview, and record review the facility failed to implement Infection Control (IC) practices to prevent transmission of Norovirus (a highly contagious virus that causes uncontrollable vomiting and diarrhea and can lead to dehydration, hospitalization , and even death) for 27 of 39 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, & 28) reviewed who experienced signs and/or symptoms of the preventable, highly transmissible, communicable disease. […]

• Actual harm, isolatedF689Oct 4, 2021

  Based on observation, interview and record review, the facility failed to serve tea at a temperature that prevented [CONDITION(S)], for one (Resident 1) of three Residents, reviewed for accident prevention. Failure to serve food at a temperature that prevented second degree [CONDITION(S)] caused harm to Resident 1, that required medical intervention and placed Resident #1 at risk for a diminished quality of life. Findings included: The 01/2016 FOOD & NUTRITION SERVICES policy and procedure for serving hot liquids, read in part, . For dining services in remote dining areas, the temperature of hot beverages and soups will be recorded by the dining room server at the time of meal service. […]

• Actual harm, isolatedF689Jan 15, 2021

  Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent an avoidable accident for one (#1) of four residents reviewed for falls with injuries. This failure resulted in a fall with multiple fractures when the resident opened an unsecured door to the stairwell and fell down a flight of stairs from the second floor (location of the resident) to the first floor of the facility. Findings included . RESIDENT #1 Review of 11/02/2020 Quarterly Minimum Data Set (MDS - an assessment tool) showed the resident was admitted on [DATE], assessed to have impaired cognition with confusion, required assistance from staff for Activities Daily Living (ADLs) including cueing, redirecting, transfers and toileting. […]

• No harm, potential for more than minimal, widespreadF623Dec 16, 2024

  Based on interview and record review, the facility failed to implement a system by which residents received required written notices at the time of transfer or as soon as practicable for 3 (Residents 28, 5, & 7) of 4 residents reviewed for hospitalization . Failure to ensure notification to the resident and/or the resident's representative of the reason for transfer in writing and in a language and manner they understood, placed residents at risk for a transfer not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the facility's October 2022 Transfer or Discharge, Facility-Initiated policy showed for emergent transfers, the resident and their representative would be provided a Notice of Transfer as soon as practicable. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2023

  Based on observation, interview, and record review the facility failure to ensure food was prepared and served in accordance with professional standards of safety. Facility failure to ensure ready-to-eat foods were covered and kitchen staffs' hair was secured as required left residents at risk of food contamination and food-borne illness. Findings included <Uncovered Food> Observation in the [NAME] dining room on 08/28/2023 at 12:02 PM showed dietary staff preparing lunch trays for distribution to residents. Staff placed slices of apple pie on each tray. The slices of pie were left on the trays uncovered while staff continued preparing the lunch. Staff then added bowls of soup to some of the trays. The soup bowls were also left uncovered on the trays. […]