Covenant Woods Nursing Home

In the surveyor’s words

From the most serious findings on record at Covenant Woods Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF656Mar 13, 2024

  Based on observations, resident interview, staff interview, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to implement the comprehensive care plan for oxygen as ordered for Resident #34. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF658Mar 13, 2024

  Based on staff interviews, facility document review, and clinical record review, the facility staff failed to meet professional standards of quality for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff changed an indwelling urinary Foley catheter size from 16 fr (French) to 24 fr without a physician order. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. […]

• No harm, potential for more than minimal, isolatedF690Mar 13, 2024

  Based on staff interviews, clinical record review, and facility document review, it was determined that the facility staff failed to provide urinary catheter care and services in accordance with the physician's order for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to utilize the correct catheter size when changing the Foley catheter on 9/11/23. The physician ordered the catheter size to be 16 fr (French size), however the facility used 24 fr. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. […]

• No harm, potential for more than minimal, isolatedF695Mar 13, 2024

  Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide respiratory care per physician orders for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to provide oxygen as ordered for Resident #34. The physician's order was for 1-2 liters per minute, however the oxygen was set to 3 liters per minute. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). […]

• No harm, potential for more than minimal, isolatedF700Mar 13, 2024

  Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to implement bed rail requirements for two of 28 residents in the survey sample, Residents #36 and #212. The findings include: 1. For Resident #36, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #36 was observed in bed with quarter bed rails on 3/11/24 at 1:20 PM, 3/12/24 at 10:53 AM, and 3/13/24 at 9:40 AM. Resident #36 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hemiplegia following cerebral vascular accident and dementia. […]