Deficiency Records for Covenant Shores Health Center
Updated as of September 01, 2022
This is not the most recent data for Covenant Shores Health Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-03-05 | 2021-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-15 | 2021-01-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-05-08 | 2020-06-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-05-08 | 2020-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-14 | 2020-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2020-01-04 | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-09 | 2018-08-10 | 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 | 2018-07-09 | 2018-08-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-07-09 | 2018-08-10 | 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 | 2018-07-09 | 2018-08-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-09 | 2018-08-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-09 | 2018-08-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-09 | 2018-08-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-07-09 | 2018-08-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-09 | 2018-08-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-07-09 | 2018-08-10 | 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 | 2018-07-09 | 2018-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-09 | 2018-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-02 | 2018-07-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-02 | 2018-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-02 | 2018-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-02 | 2018-07-09 | 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 | 2018-07-02 | 2018-07-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-02 | 2018-07-06 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-07-02 | 2018-07-06 | N |
