Inspection Reports for Covenant Living at the Samarkand

The inspection was an unannounced annual facility inspection conducted to review compliance with licensing requirements, including emergency disaster plans, infection control, medication audits, fire safety, and facility conditions.

The inspection found the facility to be generally in good repair and clean, with passing fire safety inspections and adequate food supplies. The inspection was not fully completed and will continue at a later date.

The inspection was conducted as an unannounced complaint investigation visit triggered by allegations that staff falsified residents' medical documentation and billed residents for services not rendered.

The investigation found insufficient evidence to support the allegations of falsified medical documentation and billing for services not rendered. Records, therapy notes, billing invoices, and staff schedules were reviewed and found consistent. The allegations were deemed unsubstantiated.

The complaint alleged staff falsified records for Physical and/or Occupational Therapy and billed residents for services not rendered. No specific residents or contact information were provided by the reporting parties. Interviews, document reviews, and resident statements were conducted. The complaint was unsubstantiated.

An unannounced annual inspection was conducted to evaluate the facility's compliance with regulatory standards.

The facility was found to be clean, safe, sanitary, and in good repair with functioning safety equipment and accessible outdoor areas. The medication record review was initiated but not completed due to time constraints, and the inspection will be continued at a later date.

An unannounced infection control annual inspection was conducted to evaluate compliance with infection control policies and procedures.

No deficiencies were observed during the visit; all infection control requirements were being followed, including screening, isolation, testing, PPE use, and staff background clearance.

An unannounced Annual Infection Control Inspection was conducted to evaluate compliance with criminal background fingerprint clearance requirements and other regulatory standards.

The inspection found that criminal background fingerprint clearances were not conducted for several staff members (S1, S2, S5), and that staff S3 and S4 were not properly associated with the facility, posing immediate health and safety risks. Civil penalties were issued and a plan of correction was required.

An unannounced continuance of an Annual Inspection and Infection Control Inspection visit was conducted to complete the annual visit due from the inspection conducted on 4/25/2022.

The facility was inspected for compliance with licensing requirements including infection control. A health and safety tour of the campus was conducted. Deficiencies noted were addressed in a Case Management report on 4/26/2022.

An unannounced one-year infection control inspection visit was conducted as a required annual inspection of the facility.

No deficiencies were cited at the time of the visit. Additional follow-up is needed due to time restraints, and the Licensing Program Analyst will return at a later date to continue the investigation.