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.

• Actual harm, isolatedF686Dec 10, 2024

  Based on closed medical record review, staff interviews, interview with Wound Nurse Practitioner (WNP) #175, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess and monitor residents' skin and failed to timely identify pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). […]

• Actual harm, isolatedF689Mar 9, 2022

  Based on medical record review, review of the hospital record, resident and staff interview, review of a [MEDICATION(S)] Plus Medical Encyclopedia document, and review of facility policy, the facility failed to safely and properly turn a resident during incontinence care. Actual Harm occurred when State tested Nursing Assistant (STNA) #50 rolled Resident #01 away from her with no guards and Resident #01 rolled out of a raised bed onto the floor resulting in bilateral femur fractures with a dislocated right ankle requiring a five day hospital stay. This affected one (Resident #01) out of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2026

  Based on observations, interviews, and policy reviews the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all residents consuming food prepared in the kitchen. No residents in the facility were nothing by mouth (NPO). The facility census was 104. Findings include:1. Observation on 06/08/26 at 8:55 A.M. of the ice machine located in the kitchen revealed small black spots on the inside upper lip of the ice machine. These black spots wiped off of this lip when rubbed with a clean paper towel.During an interview on 06/08/26 at 8:55 A.M. the Dietary Director (DD) #17 confirmed the existence of black spots on the inside upper lip of the ice machine which wiped off when rubbed with a clean paper towel. […]

• No harm, potential for more than minimal, patternF919Feb 8, 2024

  Based on medical record reviews, observations, resident interviews, staff interviews, and policy reviews, the facility failed to ensure resident call lights were in working order on the facility's 200-hall. This affected 12 residents (#12, #14, #19, #23, #32, #42, #54, #57, #59, #74, #91, and #94) of 27 residents reviewed for call lights. The facility census was 95. Findings include: 1. Review of the medical record of Resident #14 revealed an admitted [DATE]. Diagnoses included heart failure, weakness, macular degeneration, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition and required extensive assistance from staff with bed mobility and toileting and was dependent on staff for transfers. […]

• No harm, potential for more than minimal, isolatedF550Jun 11, 2026

  Based on observation, staff interview, and policy review the facility failed to ensure residents were treated with respect and dignity when staff stood over residents as they fed them lunch. This affected two residents (#26 and #48) of twenty four reviewed for dining observation. The facility census was 104.Findings include:1. Medical record review of Resident #26 revealed an admission date of 02/01/25 with diagnoses including; Huntington's disease, ataxia, and dysphagia. Review of the care plan dated 01/30/23 revealed Resident #25 was dependent for eating and required one person assistance with being fed.Review of the minimum data set assessment dated [DATE] revealed Resident #25 was severely cognitively impaired and was dependent upon staff for bringing food and/or drink to mouth.2. […]