The Manor at Coventry Creek

The facility failed to ensure necessary referral and follow-up for a resident's acute and routine health care needs. Specifically, there was no documentation that a resident attended a required orthopedic appointment despite physician orders for a referral. The facility staff failed to follow up with the physician's office to confirm the appointment status.

The facility failed to ensure that snacks were offered or made available to all residents three times per day. Observations and interviews revealed that residents were not offered snacks after breakfast and the snack menu lacked specific service times.

The facility failed to ensure referred and follow-up health care needs were met for residents. Specifically, one resident had not attended a required orthopedic appointment despite physician orders for a referral to treat knee pain.

The facility failed to maintain readily retrievable records that accurately reconcile the receipt and administration of controlled substances. Specifically, for one resident, the medication administration records for Tramadol did not allow for accurate reconciliation of the drug's administration.

The facility failed to maintain readily retrievable and accurate records for the receipt and administration of controlled substances. Specifically, for Resident #2, there was a discrepancy of 21 Tramadol tablets that were not reconciled between the Medication Administration Record (MAR) and the Controlled Substance (CS) records. Documentation errors were also noted where the medication aide began recording usage on the incorrect line of the CS record.

The facility failed to maintain clean and well-repaired walls, ceilings, and floors. Specific issues included buckled linoleum in the dining room, broken baseboards, dust accumulation on air vents, and dirt/grime on floors in common areas and resident rooms. Additionally, inspections revealed broken window blinds and evidence of mold and water damage in bathrooms.

The facility failed to maintain clean and well-repaired walls, ceilings, and floors. Specific issues included buckled linoleum in the dining room, broken baseboards, dust accumulation on air vents, and dirt/grime buildup on floors in various common areas and resident rooms.