Inspection Reports for
Covington Court Health And Rehabilitation Center

The facility failed to ensure oxygen was administered only when ordered by a physician, as Resident #17 was receiving oxygen therapy without a current physician order or care plan. The oxygen therapy was discontinued on 07/25/2024, and equipment was removed from the resident's room. Interviews confirmed lapses in updating care plans and order management.

The complaint investigation found that Resident #1 was not consistently assisted during meals, resulting in dignity concerns. The resident is cognitively intact but dependent on staff for feeding and tray set-up. Staff acknowledged the resident's needs but failed to provide protective coverings during meals on the observed date.

The facility failed to provide adequate assistance and dignity during meals for Resident #1, who was observed with dried oatmeal on her clothing and reported needing multiple requests for help. Staff interviews confirmed the resident's dependency for feeding and tray set-up, but protective coverings were not consistently provided.

The complaint investigation found that Resident #2 eloped from the facility undetected despite wearing an alarm bracelet and staff supervision. The alarm did not activate when the resident exited, and a visitor let the resident out a second door. The resident was found off premises and returned by police. The facility implemented corrective actions including one-to-one observation, staff assigned to exits, door alarm repairs, and staff in-service on elopement policy.

The facility failed to ensure adequate supervision and functioning alarm systems to prevent Resident #2, who was cognitively impaired and at risk for elopement, from leaving the facility undetected. This resulted in an Immediate Jeopardy finding with past non-compliance.

The facility was found deficient in ensuring resident funds were available on request, timely refund processing after discharge, accurate medication administration and documentation, and providing appropriate hygiene care, including use of moist wipes for residents with skin breakdown.

The facility was found deficient in multiple areas including failure to provide timely and dignified incontinent care, improper medication administration and documentation, inadequate nail and contracture care, failure to maintain appropriate oxygen therapy, unsafe medication storage practices, poor food handling and serving practices, delayed meal service, inadequate pest control, and lack of a licensed administrator. Environmental issues such as unclean and damaged resident rooms and laundry cross-contamination risks were also noted.

The facility failed to ensure that the floors in the nursing home were clean, with observations of dirty floors in the Dry Storage area, black spots on hallway floors, and debris under resident beds. Interviews revealed inconsistent cleaning frequencies reported by residents and staff.

The facility failed to ensure that residents' personal bathrooms were clean, sanitary, and in good usable condition for 4 of 5 sampled residents who depended on staff for cleaning. Observations revealed dried brown and black substances, hair, and dirt on toilets, sinks, and other bathroom surfaces, indicating inadequate cleaning practices.

The investigation was complaint-driven based on allegations of delayed call light responses, failure to notify representatives of hospital transfers, incomplete assessments, delayed medication administration, inadequate hygiene and grooming, delayed wound care, improper IV tubing labeling, oxygen therapy issues, food safety violations, and infection control breaches.

The facility was found deficient in timely response to call lights for multiple residents, failure to notify representatives of hospital transfers and bed hold policies, incomplete Minimum Data Set assessments, lack of care planning for anticoagulant use, delayed medication administration after admission, inadequate personal hygiene and grooming care, failure to provide daily wound dressing changes, unlabeled IV tubing, oxygen therapy not administered at prescribed flow rates with improper CPAP mask storage, food safety violations including unlabeled and undated food items and unsanitary kitchen conditions, and failure to enforce mask wearing by staff during a COVID-19 outbreak.