Health inspection·October 11, 2023

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. Residents Affected - Few This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During an interview on 9/29/23, at 2:05 p.m., with Resident 1, inside Resident 1's room, Resident 1 stated, On 8/18/23, the Social Services Director (SSD) 1 and Business Manager (BM) came to my room and gave me a copy of the Discharge Notice and they told me that the facility found a Residential Care Facility (RCFE, a homelike environment designed to promote resident independence and self-direction to the greatest extent possible in a residential, non-medical setting.) that is willing to care for me and I will be discharged on September 17, 2023. I told them that I have an on-going Workers Compensation claim against my former employer and they should be responsible in paying for my nursing home expenses. I got injured while at work. My next Workers Compensation hearing is on October 26, 2023. I am paraplegic (inability to voluntarily move the lower parts of the body), diabetic (elevated blood sugar), hypertensive (high blood pressure), chronic pain (persistent pain that lasts for months to years) and depressed (a persistent feeling of sadness and loss of interest). I need nursing care 24/7. I am bedbound During a concurrent interview and record review on 9/29/23, at 2:20 p.m., with the Social Services Director (SSD) 2, Resident 1's Interdisciplinary Team Note (IDT), dated 8/18/23 was reviewed. The IDT note indicated, . IDT REVIEW OF 30-DAY NOTICE OF DISCHARGE . [Resident 1] was given a notice of discharge secondary to non-payment . IDT recommendations: Social Services and Activities support visits x [for] 72 hours starting next business day, nursing to monitor x 72 hours for psychological distress . refer for psychological evaluation . IDT attendees: SSD 1, DON, Activity Director, and Business Office Manager . SSD 2 stated Resident 1 refused to participate in planning his discharge to a RCFE. SSD 2 stated there was no record of psychological evaluation being completed. SSD stated without the psychological evaluation completed by a qualified provider, Resident 1's psychological condition and readiness for discharge was not determined and discharge to another health care setting could be unsafe. During an interview with the Acting Director of Nursing (ADON) on 10/4/23, at 3:00 p.m., the ADON stated Resident 1 should have a psychological evaluation by a qualified provider to determine his (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055996 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covenant Post Acute 3408 East Shields Avenue Fresno, CA 93726 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)