Coventry Court Health Center

In the surveyor’s words

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

• Actual harm, isolatedF694Jan 4, 2022

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure the peripheral intravenous (IV, an intravenous catheter that is threaded into a peripheral vein) site was maintained and assessed as per the facility's P&P for one of two sampled residents (Resident 1). * Resident 1 had a peripheral IV inserted on the left foot which was left for seven days without a physician's order to leave the IV catheter longer than 72 hours. In addition, the facility failed to ensure the IV site was assessed for complications and patency. This failure resulted in Resident 1 developing an unstageable pressure injury at the IV site on the left foot. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2023

  Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the ice machine's ice maker was free from black residue. * The facility failed to ensure the quaternary sanitizing strips to measure the concentration of ammonium compound the sanitizing solution for the manual ware washing and sanitization buckets were not expired. * The facility failed to ensure the kitchen equipment was clean. […]

• No harm, potential for more than minimal, patternF880Jul 29, 2025

  Based on interview, facility document review, and facility P&P review, the facility failed to establish and maintain an infection control program designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the monthly infection surveillance documents were summarized and analyzed accurately reflect the total number of CAI (Community-Acquired Infection) in the facility for April and May 2025. * The facility failed to develop a water management program which included the process to identify, test, and prevent Legionella (a bacteria which can cause a serious type of lung infection) and other opportunistic waterborne pathogens. […]

• No harm, potential for more than minimal, patternF812Aug 1, 2024

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the kitchen utensils and equipment were clean and stored in sanitary conditions. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the personnel entering the kitchen donned hair covering in the kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the fan unit inside the walk-in refrigerator was clean and free of buildup. […]

• No harm, potential for more than minimal, patternF880Aug 1, 2024

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for August 2023 through June 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. […]