Waters of Covington, The

In the surveyor’s words

From the most serious findings on record at Waters of Covington, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 20, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when staff ignored a resident's continued reports of acute pain and his request to be sent to the hospital which resulted in prolonged pain and a delay of treatment for 1 of 3 residents reviewed for neglect (Resident B). The immediate jeopardy began on 9/24/25 at 10:00 p.m., when Certified Nursing Aide (CNA) 3 observed Resident B to be sweaty and he complained of acute pain. CNA 3 reported his concerns to Licensed Practical Nurse (LPN) 4. CNA 3 and CNA 8 reported to LPN 4 around 1 or 2 a.m., that Resident B was still in pain and wanted to see the nurse. LPN 4 failed to assess the resident or report the resident's change of condition to a physician. […]

• Immediate jeopardy, isolatedF684Oct 20, 2025

  Based on interview and record review, the facility failed to ensure a resident with constipation, no recent bowel movements (BM), and reporting pain was monitored and treated timely resulting in the resident having a delay in treatment and requiring interventions under anesthesia for a severe fecal impaction for 1 of 5 residents reviewed for quality of care related to their bowel management program (Resident B), and the facility failed to ensure an effective protocol was put in place for the ongoing monitoring of 5 of 5 residents reviewed for quality of care related to the bowel management program (Residents B, E, F, G, and H). The Immediate Jeopardy (IJ) began on 9/24/25 when Resident B began to experience and complain of acute pain. His last recorded BM was 9/19/25 at 11:17 a.m. […]

• Immediate jeopardy, isolatedF695Aug 4, 2023

  Based on observation, record review, and interview, the facility failed to ensure a resident's bilevel positive airway pressure (BIPAP) equipment (machine used to provide assistance during inspiration and expiration) was implemented upon hospital discharge, and failed to assess the resident's change in condition after not receiving a BIPAP for 3 days for 1 of 4 residents reviewed for quality of care (Residents B). Based on observation, record review, and interview, the facility failed to ensure a resident with a continuous positive airway pressure (CPAP) machine had physician orders and a plan of care for the CPAP machine for 1 of 4 residents reviewed for quality of care (Resident E). […]

• Actual harm, isolatedF689Jul 23, 2025

  Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for and safely transferred in a mechanical lift resulting in actual harm when the resident fell from the mechanical lift sling during a transfer and sustained a fracture to the right tibia (bone in the lower leg) (Resident B), failed to ensure residents were appropriately transferred in mechanical lifts using the correct slings (Residents B and D), and to ensure a resident with multiple falls received updated interventions to prevent further falls (Resident C) for 3 of 4 residents reviewed for accidents. Findings include:1. […]

• Actual harm, isolatedF603Dec 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from involuntary seclusion (separation of a resident from other residents or from the resident's room or confinement to resident's room against the resident's will, or the will of the resident representative) for 4 of 6 residents reviewed for abuse, when staff confined the residents in their room by tethering the door handles to the handrails in the hallway (Residents G, H, J, and K). Using the reasonable person concept, it is likely that this would lead to mental anguish including anger, distrust, and chronic or recurrent fear and anxiety. […]