The Coventry

The facility failed to administer medications as ordered for a resident, resulting in a 24% medication error rate during an 8:00am medication pass. Specifically, Levothyroxine was documented as administered at 7:00am, even though observations showed the medication was actually administered during the 8:00am pass.

The facility failed to administer medications as ordered for one resident during the 8:00am medication pass. Specifically, a medication aide administered Levothyroxine and Liothyronine while the resident was eating breakfast, despite orders requiring these medications be taken on an empty stomach. This contributed to a medication error rate of 24% during the observed pass.

The facility failed to maintain the Special Care Unit in an uncluttered and hazard-free manner. Specifically, various personal care items such as razors, scissors, and lotions were stored in resident rooms, and hand sanitizer and disinfectant wipes were left unsecured on medication carts.

The facility failed to ensure that 3 of 6 exit doors accessible to residents were equipped with a sounding device. This deficiency put residents with a history of wandering or elopement at risk because the doors did not activate an alarm when opened.

The facility failed to ensure that 3 of 6 exit doors accessible to residents were equipped with audible sounding devices. This deficiency placed residents with dementia or exit-seeking behaviors at risk of eloping from the facility without staff knowledge.

The facility failed to ensure the reach-in ice machine in the assisted living kitchen was clean and free of contamination. Observations revealed a black and pink residue inside the machine, and interviews indicated that cleaning protocols were not being consistently followed.

The facility failed to ensure that water was served to all residents in the Special Care Unit (SCU) dining room in addition to other beverages. During lunch service, nine out of ten residents observed in the SCU were not served water.