A list of the most recent deficiencies for Covenant Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-10-11 | 2023-11-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-27 | 2023-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-27 | 2023-07-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-27 | 2023-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-27 | 2023-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-27 | 2023-07-13 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-17 | 2023-05-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-27 | 2023-04-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-27 | 2023-04-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-27 | 2023-04-19 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-27 | 2023-04-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-27 | 2023-04-19 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-27 | 2023-04-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-27 | 2023-04-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-27 | 2023-04-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-27 | 2023-04-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-03-27 | 2023-04-19 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-27 | 2023-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-27 | 2023-04-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-03-27 | 2023-04-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-27 | 2023-04-19 | N |
| Keep all essential equipment working safely. | Health | 2023-03-27 | 2023-04-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-28 | 2023-04-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-07 | 2023-03-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-15 | 2023-03-01 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-15 | 2023-03-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-17 | 2023-02-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-08 | 2022-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-11-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-10 | 2022-09-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-10 | 2022-09-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-04 | 2022-06-13 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-04 | 2022-06-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-17 | 2022-04-29 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-17 | 2022-04-29 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-17 | 2022-04-29 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-03-08 | 2022-04-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-08 | 2022-04-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-08 | 2022-04-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-08 | 2022-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-04 | 2022-04-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-01 | 2022-03-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-31 | 2021-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-23 | 2019-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-23 | 2019-04-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-23 | 2019-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-23 | 2019-04-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-23 | 2019-04-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-23 | 2019-04-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-23 | 2019-04-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-23 | 2019-04-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-23 | 2019-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-23 | 2019-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-23 | 2019-04-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-24 | 2019-02-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-24 | 2019-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-24 | 2019-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-24 | 2019-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-01 | 2018-01-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-12-01 | 2018-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2017-12-01 | 2018-01-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2017-12-01 | 2018-01-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2017-12-01 | 2018-01-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2017-12-01 | 2018-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-01 | 2018-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-01 | 2018-01-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2017-12-13 | 2018-01-02 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2017-12-13 | 2018-01-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-12-13 | 2018-01-02 | N |
