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, widespreadF812Jun 27, 2025

  Based on observation, interview and record review, the facility failed to ensure proper sanitation of equipment when two of two ice machines for resident use had brown and yellow discoloration in the machines. This failure had the potential to contaminate the ice distributed to residents and the potential for residents to become ill.Findings: During a concurrent observation and interview on 6/23/25 at 2:34 p.m. with Director of Facilities Management (DFM) in the kitchen at the ice machine, DFM removed the front panel of the ice machine and observed brown and yellow staining around the perimeter of the inside of the ice machine. Surveyor conducted a tissue swipe of the areas with brown and yellow staining and brown debris was observed on tissue. […]

• No harm, potential for more than minimal, widespreadF880Jun 27, 2025

  Based on observation, interview and record review, the facility failed to follow proper infection control practices for 1 of 4 sampled residents (Resident 5) when the nurse did not use Enhanced Barrier Precautions (EBP as gown, and gloves), while administering medications and a bolus feeding through a gastrostomy tube (G-tube- a small, soft tube that is inserted through the skin directly into the stomach, and is used to give food, water or medicine).This failure increased the risk of spreading germs amongst all residents in the facility.Findings:During a review of Resident 5's admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other… […]

• No harm, potential for more than minimal, patternF605Jun 27, 2025

  Based on observation, interview and record review, the facility failed to ensure that four of four sampled residents (Resident 299, Resident 35, Resident 1, and Resident 18) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when:1. For Resident 299, Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly), was initiated without an appropriate indication, the facility did not document, implement, or monitor resident specific non-pharmacological interventions (ways to help someone feel better or manage a health problem without using medicine) prior to the initiation and continued used of Seroquel, include objective measurable… […]

• No harm, potential for more than minimal, patternF656Jun 27, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person centered Care Plan (a document that outlines a personalized approach to an individual's healthcare and support needs) for two of two sampled (Residents 6 and 20) when:1. Resident 20 had no Care Plan created for the use of their mobility rails (rails on the side of the bed which help a resident turn and move in bed)This failure had the potential to cause Resident 20's use of mobility rails to not receive proper monitoring or support to ensure they were used safely.2. Resident 6 did not have a care plan developed for ordered padded side rails.This failure had the potential to result in harm to Resident 6 if the padded side rails were removed.Findings: 1. […]

• No harm, potential for more than minimal, patternF658Jun 27, 2025

  Based on observation, interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of five sampled residents (Resident 8, Resident 5 and Resident 12) when:1.For Resident 8, there was no documented evidence of the removal of the previously applied medication patches from the residents' back.This failure to track and document patch removal had the potential to result in overmedication and adverse effects.2. […]