A list of the most recent deficiencies for Covenant Shores Health Center. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-09-01 | 2023-09-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-01 | 2023-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-01 | 2023-09-29 | 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 | 2023-09-01 | 2023-09-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-01 | 2023-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-01 | 2023-09-29 | 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 | 2023-09-01 | 2023-09-29 | 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 | 2023-09-01 | 2023-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-29 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Meet other general requirements. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-30 | 2023-09-29 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-04 | 2023-04-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-04 | 2023-04-23 | Y |
| 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 | 2022-06-24 | 2022-07-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-24 | 2022-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-24 | 2022-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-24 | 2022-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-24 | 2022-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-07-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-24 | 2022-07-26 | 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 | 2022-06-24 | 2022-07-26 | 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 | 2022-06-24 | 2022-07-26 | 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 | 2022-06-24 | 2022-07-26 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-24 | 2022-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-24 | 2022-07-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-24 | 2022-07-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-24 | 2022-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-04 | 2021-10-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-29 | 2019-09-30 | 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 | 2019-08-29 | 2019-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-29 | 2019-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-29 | 2019-09-30 | 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 | 2019-08-29 | 2019-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-29 | 2019-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-29 | 2019-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-29 | 2019-09-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-08-29 | 2019-09-30 | 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 | 2019-08-29 | 2019-09-30 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-08-29 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-29 | 2019-09-30 | N |
