Other·October 24, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public HealthLicensing and Certification during an Abbreviated Survey for Facility Reported Incident (FRI) CA 00593826. Representing the California Department of Public Health-Licensing and Certification by Federal ID: 38961, RN, HFEN. The Abbreviated Survey was limited to the specific incident investigated and does not represent the findings of a full inspection of the facility. Facility Reported Incident CA 00593826: One deficiency was issued.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/15/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE environment was free of accident hazards when 29 of 106 resident beds ( Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30) had exposed rough, jagged metal on the lower end of the side rails. This failure resulted in a 14 centimeter (measurement of length) laceration (cut) to Resident 1's right leg that required transfer to the General Acute Care Hospital (GACH) and placement of 17 staples to close the wound and placed other residents at risk for injury. Findings: Review of Resident 1's admission record (document containing resident personal information) indicated Resident 1 was 78 years old and was admitted to the skilled nursing facility (SNF) on 6/5/18 with diagnoses that included anemia (a deficiency of red blood cells or iron), pain, and osteoporosis (thin, fragile bones). Review of Resident 1's minimum data set (MDS, a resident assessment tool used to plan care) assessment dated 6/29/18 indicated a Brief Inventory of Mental Status (BIMS) score of 15 points out of a possible 15 points which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning) intact. Review of Resident 1's progress notes dated 7/2/18, untimed, indicated, "During transfer resident [Resident 1] leg was caught on the bottom of the side rail where the right front calf had a laceration. 9/10 for pain [on a scale from 0 to 10 where 0 is no pain and 10 is the worst imaginable pain]. Minimal bleeding present...Reported to primary care clinician...Family/healthcare agent notified...7/2/18 12:45 p.m." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's physician orders dated 7/2/18 at 12:39 p.m. indicated, "Transfer/Discharge...She [Resident 1] needs stitches...Services available at the receiving facility to meet the resident need(s): [GACH] one time only for acute injury for 1 day." Review of Resident 1's transfer/discharge report (document that accompanies a resident upon transfer to another facility) dated 7/2/18 at 12:45 p.m., indicated Resident 1 was transferred to the GACH for an "acute [sudden onset] injury." On 7/18/18 at 9:30 a.m., during a concurrent observation and interview in Resident 1's room, the maintenance supervisor (MS) stated he was informed by the administrator (Adm) on 7/2/18 at 12:30 p.m. about Resident 1's injury during the transfer from her bed to her wheelchair. The MS stated on 7/2/18 Resident 1's upper side rail was missing a black plastic cap that covered the exposed metal on the bottom of the side rail. The MS stated Resident 1's leg was cut by the exposed metal on 7/2/18 during the transfer. The MS stated he replaced the missing black plastic cap on Resident 1's side rail after the Adm informed him of the injury. The MS demonstrated the presence of a black cap on the bottom of the side rail of Resident 1's bed. The MS toured seven resident rooms and observed 16 resident beds ( Residents 7, 8, 11, 12, 13, 15, 16, 20, 21, 22, 23, 24, 25, 28, 29, 30) missing one or more black plastic caps at the bottom of the side rails. The MS stated his job duties included maintaining and repairing resident beds. The MS stated he was aware for the past month and a half of black plastic side rail caps missing in numerous resident rooms leaving the rough metal edges exposed. The MS stated, "I should have paid more attention to the missing caps FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE after the incident with Resident 1 and replaced all the missing caps immediately to prevent injury to other residents." The MS stated all side rails should have protective plastic caps in place. On 7/18/18 at 10 a.m., during an interview, the MS stated he had a list of other resident beds missing plastic protective caps on the bottom of the side rails. The MS produced a list which indicated 12 additional resident beds ( Residents 2, 3, 4, 5, 6, 9, 14, 17, 18, 19, 26, 27) missing one or more plastic protective caps on the bed side rails. On 7/18/18 at 10:15 a.m., during an interview, certified nursing assistant (CNA) 1 stated on 7/2/18 Resident 1 wanted to go to her room for lunch. CNA 1 stated she wheeled Resident 1 into her room and lifted the bed side rail up toward the headboard. CNA 1 stated she transferred Resident 1 from her wheelchair to her bed and then noticed Resident 1's right leg was bleeding. CNA 1 stated she looked at the side rail and noticed a piece of skin or tissue hung off the rail on the exposed metal at the bottom of the side rail. CNA 1 stated she reached down and felt the metal end of the side rail. CNA 1 stated the metal end of the side rail was jagged and the protective plastic cap was missing. CNA 1 stated Resident 1's right leg had a large, bleeding laceration. CNA 1 stated she immediately alerted the licensed nurse of Resident 1's laceration. CNA 1 stated the exposed metal ends of the side rails were rough and jagged and should be covered by plastic caps to protect the residents from injury. On 7/18/18 at 10:30 a.m., during an interview, CNA 2 stated she noticed missing caps on two resident beds two weeks before. CNA 2 stated she did not report the missing caps to anyone. CNA 2 stated "I should have reported the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE missing caps because of the hazard." CNA 2 stated some of the side rails with missing black plastic caps were sharp and jagged and could cause injuries to residents. On 7/18/18 at 10:45 a.m., during a concurrent observation and interview, Resident 1 was alert, lying in her bed with her legs covered by bed clothes. Resident 1 stated on 7/2/18 CNA 1 was assisting her from her wheelchair to her bed. Resident 1 stated during the transfer she felt something sharp brush her right leg and felt immediate pain. Resident 1 stated her right leg was cut during the transfer on 7/2/18 by sharp metal on the bed. Resident 1 stated she currently had pain of 4/10 on her injured right leg. On 7/18/18 at 11:15 a.m., during an interview, Resident 20 stated there were two missing plastic caps on the left side rail of her bed. Resident 20 stated she reported the missing caps and exposed metal edges to facility staff about a month ago. Resident 20 stated she was unable to recall which facility staff she informed about the missing caps. Resident 20 stated, "Nothing was done [about the missing plastic caps]." On 7/18/18 at 11:25 a.m., during an interview, the director of nursing (DON) stated there were still rooms with missing side rail caps. The DON stated the missing caps created an accident hazard for residents, family members and staff. The DON stated all missing caps should have been replaced immediately after Resident 1's accident with injury on 7/2/18. On 7/23/18 at 11:20 a.m. during a telephone interview, the Adm, stated she was walking down the hallway on 7/2/18 when CNA 1 came out of Resident 1's room looking for the licensed nurse. The Adm stated she observed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 had a cut to her right leg. The Adm stated she called the MS who brought a black plastic cap for the side rail and placed it on Resident 1's bed. The Adm stated there was a risk of injury to residents because the black plastic caps were missing on some beds, exposing residents to sharp, jagged metal edges. Review of Resident 1's GACH emergency department physician notes titled, "Final Report" dated 7/2/18 at 1:32 p.m. indicated, "Brief History: 78 year old female...BIBA [brought in by ambulance] presents to the ED [emergency department] s/p [status post] right leg laceration today. Pt [Patient] reports she lives in a SNF and her nurse was transporting her from wheelchair to bed when she somehow scraped her right leg against the railing of the bed...Description/repair: Laceration 14 cm [centimeters] in length right lateral [side] lower leg. Shape: curvilinear [long curve shaped]. Depth: superficial [near the surface of the body]... Anesthesia [medication to interrupt pain signals during a procedure] 10 ml [milliliters, a liquid measurement] 0.5% [percent] bupivacaine [local anesthetic given by injection into the skin]...Skin Closure: 17 staples. Notes: Patient tolerated procedure well and is advised to have staples removed in 10 days..." Review of facility document titled "Job Description" dated 10/2/13 indicated, "Job Title: Director Facilities Maintenance. General Purpose:... Responsible for establishing, directing, analyzing and monitoring systems for all aspects of services that focus on safety, physical plant, and preventative maintenance programs that meet or exceed all state and federal codes, regulations and permits...Directs and monitors safety compliance..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2T1H11 Facility ID: CA040000049 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055996 (X3) DATE SURVEY COMPLETED 09/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COVENANT POST ACUTE 3408 E Shields Ave Fresno, CA 93726 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 2T1H11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040000049 (X5) COMPLETE DATE If continuation sheet 7 of 7