Covenant Village Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF656May 15, 2025

  Based on observations, interviews and record reviews, the facility failed to initiate a care plan for monitoring behaviors and side effects for 2 of 5 sampled residents on psychotropic medications (Resident #268 and Resident #33). Facility also failed to initiate a care plan for monitoring pain for 1 of 5 sampled residents on narcotic medications (Resident #268). The findings included: 1. A record review showed that Resident #268 was admitted on [DATE] with diagnosis of Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side and Epilepsy, not intractable, without status epilepticus. […]

• No harm, potential for more than minimal, isolatedF755May 15, 2025

  Based on observation, interviews, record review and policy review, the facility failed to remove narcotics from 2 of 3 medication carts for residents who have no current orders for the narcotics. The findings included: The facility's policy titled Discarding and Destroying Medications revised 10/2014 revealed Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. On 05/15/25 at 12:05 PM, medication cart east was reviewed with Staff C, Registered Nurse (RN). Upon review of the as needed (prn) narcotics, Resident #4's medication card for Alprazolam 0.25 milligrams (mg) was in the narcotic locked box with no current order and last given on 03/11/25. […]

• No harm, potential for more than minimal, isolatedF757May 15, 2025

  Based on observations, interview, and record review, the facility failed to implement interventions to monitor side effects and behaviors related to antidepressant medication for 1 out of 5 residents reviewed for Unnecessary Medications (Resident # 13). The findings included: Record review for Resident # 13 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Dementia, a condition characterized by a progressive decline in affecting memory, thinking, language, and behavior and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident # 13 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated that she was moderately cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF759May 15, 2025

  Based on observation, interview, record and policy review, it was determined that the medication error rate was 7.14 percent, 2 medication errors were identified while observing a total of 28 opportunities, affecting Resident #323. The findings included: The facility's policy titled Medication Administration implemented 01/2001 and revised 04/2019 revealed Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. On 05/15/25 at 10:04 AM, Staff B, Registered Nurse (RN) was observed preparing medication for Resident #323. […]

• No harm, potential for more than minimal, isolatedF761May 15, 2025

  Based on observation, interview and policy review, the facility staff failed to lock the medication cart during medication administration for 1 of 9 residents observed for medication administration and failed to properly dispose a wasted drug during medication administration. The findings included: The facility's policy titled Medication Labeling and Storage revised 02/2023, revealed Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transfer such items are not left unattended if open or otherwise potentially available to others. […]