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Deficiency Records for Coventry House Inn
A list of the most recent deficiencies for Coventry House Inn. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Coventry House Inn. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-02 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2024-01-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-02 | 2023-12-08 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-02 | 2023-12-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-02 | 2023-12-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-02 | 2023-12-08 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-11-02 | 2023-12-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-02 | 2023-12-08 | 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 | 2023-11-02 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-12-08 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-02 | 2023-12-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-02 | 2023-12-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-02 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-31 | 2023-12-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-31 | 2023-12-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-31 | 2023-12-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-12-04 | 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 | 2023-05-16 | 2023-06-28 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-16 | 2023-06-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-20 | 2022-11-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-20 | 2022-11-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-20 | 2022-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-20 | 2022-11-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-20 | 2022-11-11 | 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 | 2022-10-20 | 2022-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-11-11 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-20 | 2022-11-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-20 | 2022-11-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-20 | 2022-11-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-20 | 2022-11-11 | 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 | 2021-08-05 | 2021-08-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-05 | 2021-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-08-31 | 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 | 2021-08-05 | 2021-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-05 | 2021-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-04 | 2021-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-04 | 2021-08-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-04 | 2021-08-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-04 | 2021-08-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-04 | 2021-08-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-04 | 2021-08-20 | N |
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