CMS Inspection Results for COVENANT AT SOUTH HILLS

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 12/10/2008 Health Survey for COVENANT AT SOUTH HILLS

Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm

 

• 12/02/2008 Fire Safety Survey for COVENANT AT SOUTH HILLS

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm

 

• 12/06/2007 Health Survey for COVENANT AT SOUTH HILLS

Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Widespread	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm

 

• 12/04/2007 Fire Safety Survey for COVENANT AT SOUTH HILLS

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
portable fire extinguishers.	Pattern	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Pattern	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm

 

• 01/12/2007 Health Survey for COVENANT AT SOUTH HILLS

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm

 

• 01/10/2007 Fire Safety Survey for COVENANT AT SOUTH HILLS

Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Pattern	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
properly maintained smoke detectors.	Pattern	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Potential for minimal harm