A list of the most recent deficiencies for Covenant Woods Nursing Home. 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? |
|---|---|---|---|---|
| Perform COVID19 testing on residents and staff. | Health | 2023-01-23 | 2023-03-08 | 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 | 2022-04-21 | 2022-06-03 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-21 | 2022-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-15 | 2021-05-06 | 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 | 2021-03-15 | 2021-05-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-15 | 2021-05-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-25 | 2021-04-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-25 | 2021-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-25 | 2021-04-08 | 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 | 2021-02-25 | 2021-04-08 | 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 | 2021-02-25 | 2021-04-08 | 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 | 2021-02-25 | 2021-04-08 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-10 | 2019-08-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-07-10 | 2019-08-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-10 | 2019-08-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-10 | 2019-08-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-10 | 2019-08-27 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-06-27 | 2019-08-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-06-27 | 2019-08-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-27 | 2019-08-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-27 | 2019-08-11 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-06-27 | 2019-08-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-27 | 2019-08-11 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-06-27 | 2019-08-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-27 | 2019-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-27 | 2019-08-11 | 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 | 2019-06-27 | 2019-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-27 | 2019-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-27 | 2019-08-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-27 | 2019-08-11 | 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 | 2019-06-27 | 2019-08-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-27 | 2019-08-11 | N |
| Post nurse staffing information every day. | Health | 2019-06-27 | 2019-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-27 | 2019-08-11 | 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 | 2019-06-27 | 2019-08-11 | 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 | 2019-06-27 | 2019-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-27 | 2019-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-08-11 | N |
