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Deficiency Records for Covenant Village Care Center
A list of the most recent deficiencies for Covenant Village Care Center. 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 Covenant Village Care 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-18 | 2024-06-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-06-18 | 2024-06-25 | 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 | 2024-06-12 | 2024-06-20 | 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 | 2024-06-12 | 2024-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-12 | 2024-06-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-02 | 2022-06-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-14 | 2019-07-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-14 | 2019-07-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-14 | 2019-07-17 | 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 | 2019-06-14 | 2019-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-14 | 2019-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-14 | 2019-07-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Develop a communication plan. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-24 | 2018-10-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-24 | 2018-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-24 | 2018-10-29 | N |
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