Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Covenant Post Acute during CMS and state inspections, most recent first.
A resident with dementia, CKD, and hypertensive heart disease, assessed as severely cognitively impaired, experienced an unwitnessed bathroom fall and was initially alert with stable VS. Neuro checks over the next hour documented a progressive decline in BP and level of consciousness, with disorientation, drowsiness, and unresponsiveness noted by 30 minutes post-fall. Despite this significant change in condition after a fall, the physician was not notified until the resident became unresponsive with markedly low BP, at which point an order was given to transfer the resident to the hospital. Interviews with nursing staff and leadership confirmed that the provider should have been contacted at the earlier change in mental status and that required notification and documentation under the facility’s change-in-condition policy did not occur as required.
A resident with diabetes, fibromyalgia, muscle weakness, gait abnormalities, and a history of repeated falls was placed on a bed alarm after multiple unwitnessed and witnessed falls. The resident was cognitively intact and reported not wanting the alarm, describing it as very loud, embarrassing, and an invasion of privacy, and stated she stayed in one position in bed to avoid triggering it. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged the alarm was used to alert staff of unassisted transfers and bathroom use, and that it could be heard by everyone, but they did not consider it a restraint and did not obtain informed consent. Record review showed an order and care plan for the bed alarm as a fall-prevention measure, but no documentation of resident or RP consent, no assessment of the alarm as a restraint, and no attempt at one-on-one supervision. The facility’s restraint and alarm policies required that alarms be assessed to determine if they met the definition of a restraint and that restraints be used only for medical symptoms with a physician’s order and consent, yet the alarm was used for staff notification and fall prevention, resulting in the resident restricting her own movement to avoid setting it off.
A resident experienced an unwitnessed fall in a shared room while a CNA was assisting the roommate behind a privacy curtain. An LVN responded, found the resident on the floor between the beds with left hip and lower back pain, facial grimacing, and inability to move the legs due to pain, and arranged transfer to the hospital per physician order. The Director of Business Development confirmed with the hospital that the resident had sustained a hip fracture and required surgery and reported this information to the DON and Administrator. Although facility policy required reporting unusual occurrences affecting resident welfare to appropriate agencies within 24 hours, the Administrator and DON did not report the fall with hip fracture to the state agency until two weeks after they were informed of the serious injury.
A resident with intact cognition and multiple chronic conditions was housed in a room where the shared bathroom toilet remained nonfunctional for an extended period, forcing reliance on an uncovered bedside commode and resulting in a strong urine odor. The toilet was observed covered with a plastic bag and labeled out of order, with visible feces in the bowl and urine discoloration on the floor, while staff acknowledged the persistent odor and the resident’s ability and preference to use a regular toilet. Multiple staff, including CNAs, maintenance, social services, and the administrator, confirmed awareness of the broken toilet and unpleasant bathroom conditions, which conflicted with facility policies requiring a safe, clean, comfortable, and homelike environment and proper odor control in resident bathrooms.
A resident with severe cognitive impairment, PTSD, dementia, and a documented history of sudden physical aggression toward peers and staff was care planned and ordered for continuous 1:1 supervision when out of the room, with staff required to follow at a safe distance. On the day of the incident, a new CNA on orientation was informally told to follow this resident but was not clearly informed that she was responsible for uninterrupted 1:1 supervision. When lunch trays arrived, the CNA left the resident unattended in his room to help pass trays. During this lapse in supervision, the aggressive resident left the room unnoticed, approached another wheelchair-bound, cognitively intact resident with bilateral below-knee amputations from behind near the therapy area, and punched him in the mouth, causing a split, swollen upper lip with a scratch and bleeding that required first-aid treatment. Staff interviews and records confirmed that the resident’s need for 1:1 supervision was known and in place prior to the altercation, but the supervision was not maintained or clearly communicated to the assigned CNA.
A resident with severe cognitive impairment and involuntary movements was found with a black eye of unknown origin, but staff did not immediately report the injury to the DON, administrator, or required authorities as per facility policy. Multiple staff observed the injury and assumed others had reported it, resulting in a two-day delay before the incident was reported to state agencies and the ombudsman, and documentation of timely notification was lacking.
A facility's infection prevention and control program was compromised when a boiler malfunction led to laundry being washed in temperatures below the required 71-77°F. The boiler's gas valve failure resulted in cold water washing, contrary to the facility's P&P. The Director of Maintenance and Director of Nursing confirmed the deviation, with the Infection Preventionist on vacation. This placed 117 residents at risk for cross-contamination.
A boiler system failure in the facility resulted in a lack of hot water for three days, affecting resident hygiene and kitchen operations. Residents were unable to shower or received cold bed baths, and kitchen staff had to use cold water for handwashing, increasing the risk of cross-contamination. The facility's maintenance policy was not followed, as routine maintenance was not scheduled for the boilers.
A resident in an LTC facility received a cold bed bath due to a non-functional boiler system, which left the facility without hot water. The CNA assigned to the resident was unaware of an alternate hot water source in the breakroom, leading to the resident experiencing discomfort and chills. Despite in-services provided to staff about using the breakroom's hot water dispenser, the information was not effectively communicated, resulting in a violation of the resident's right to a homelike environment.
The facility failed to ensure accurate MDS assessments for four residents, leading to deficiencies in documenting medical conditions and treatments. A resident with a central venous catheter, another using a BiPAP machine, a third receiving insulin and antibiotics, and a fourth on antipsychotic medication all had inaccuracies in their MDS documentation. The MDS Coordinator and DON acknowledged these oversights, emphasizing the importance of accurate documentation for proper care planning.
A facility failed to complete and transmit a discharge MDS assessment for a resident discharged to an acute hospital. The MDS Coordinator overlooked the assessment, which should have been completed and submitted according to CMS guidelines. The resident had a history of type 2 diabetes and was last assessed in September before discharge in December.
A facility failed to implement proper infection control measures during wound care for a resident with a surgical wound. Despite policies requiring enhanced barrier precautions (EBP) for residents with open wounds, no signage or PPE was available, and nursing staff did not wear gowns. Additionally, reusable equipment was not disinfected after use. The deficiency was attributed to a lack of communication and adherence to protocols by the staff and Infection Preventionist (IP).
A resident's medications were left unattended at the bedside by an LVN, contrary to facility policy, which requires medications to be administered within an hour of the scheduled time. Additionally, a medication cart was found unlocked and unattended, posing a risk of unauthorized access. The DON confirmed these actions violated the facility's protocols, emphasizing the importance of secure medication administration.
Failure to Promptly Notify Physician After Resident’s Post-Fall Decline
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a physician of a significant change in condition following a resident’s fall. The resident had dementia, chronic kidney disease, hypertensive heart disease, and osteoarthritis of the hip, and was assessed as severely cognitively impaired on the MDS BIMS. On the evening in question, the resident, known to be at high risk for falls due to attempts at self-transfer, was found on the bathroom floor around 9:00 p.m. and was initially documented as alert and responsive, with a blood pressure of 145/92 at 9:15 p.m. Neuro checks were initiated following the unwitnessed fall. Subsequent neuro check documentation showed a progressive decline in the resident’s condition between 9:15 p.m. and 10:00 p.m. At 9:15 p.m., the resident remained oriented and responsive, but by 9:30 p.m. the blood pressure had dropped to 135/92 and the level of consciousness changed, with disorientation, drowsiness, and unresponsiveness documented, and no response to name, pain, or environment. At 9:45 p.m., the blood pressure further declined to 97/49 with continued disorientation, drowsiness, and unresponsiveness. By 10:00 p.m., the blood pressure was 60/42, and the resident remained disoriented, drowsy, and unresponsive. Despite these documented changes, the physician was not notified until around 10:00 p.m., at which time an order was given to send the resident to the acute care hospital, and EMS transported the resident at approximately 10:45 p.m. Interviews with LVN staff indicated that the physician should have been contacted immediately when the resident’s mental status changed at 9:30 p.m., especially given the unwitnessed fall and potential for head injury. The DON acknowledged that the neuro checks showed a decline in blood pressure and level of consciousness starting at 9:30 p.m., and that although she stated providers had been notified earlier, this was not documented. The NP reported not being aware of the fall or any call that night and stated that a fall with new disorientation, drowsiness, or significant blood pressure drop would warrant immediate ED evaluation. The facility’s policy required prompt notification of the attending physician for accidents, significant changes in condition, or need for hospital transfer, and required documentation of such notifications, which did not occur in this case as required.
Improper Use of Bed Alarm as a Physical Restraint Without Assessment or Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from the use of a physical restraint when a bed position-change alarm was implemented without proper assessment, consent, or consideration of its impact on the resident’s freedom of movement. The resident was an alert and oriented individual with a BIMS score of 13/15, admitted with diagnoses including fibromyalgia, diabetes mellitus, muscle weakness, gait and mobility abnormalities, and a history of repeated falls. After a bathroom fall that resulted in a black eye, staff placed a bed alarm pad under the resident. The resident reported that she did not want the alarm, describing it as loud and stating she was scared to move because it would sound. Surveyor observations on multiple occasions found the resident lying flat on her back in bed, stating she remained in the same position to avoid triggering the alarm, which she found embarrassing and an invasion of her privacy. The alarm sounded with small movements or shifts in body weight, and staff acknowledged that it was very loud and could be heard by everyone. The resident stated that the alarm prevented her from moving or getting up on her own and that it bothered everyone because of the noise. These statements showed that the resident’s movement was effectively restricted by her fear of setting off the alarm. Record review showed an order to monitor the bed alarm each shift, initiated after a fall, and an IDT accident/fall note indicating that, due to multiple falls and co-morbidities, the team decided to implement a bed/chair alarm to alert staff of unassisted transfer attempts. The fall risk care plan documented the bed alarm as an intervention for fall prevention and early staff response, with a notation that the resident retained full freedom of movement. However, there was no documentation that the resident or responsible party had been informed of or consented to the alarm, and staff, including LVNs and the DON, stated that they did not consider the bed alarm a restraint and had not obtained informed consent. The facility’s own restraint policy required that restraints be used only to treat a medical symptom, never for staff convenience or fall prevention, and only with a physician’s order and consent, and its alarm policy required the IDT to assess and document whether an alarm met the definition of a restraint. Despite this, the alarm was used for fall prevention, without documented consent or assessment of its restraining effect, while the resident reported restricting her own movement to avoid triggering it. Interviews with nursing staff and the DON confirmed that the alarm was implemented after other fall interventions were deemed unsuccessful and that one-on-one supervision had not been attempted. Staff described the resident as impulsive and getting up without assistance, and the alarm was used to notify staff if she tried to get up or went to the restroom alone. The DON acknowledged that the alarm could restrict movement if a resident feared setting it off and that the nurse had spoken to the responsible party rather than the resident, despite the resident’s intact cognition with only intermittent confusion. The Administrator stated there was no process in place for obtaining bed alarm consents, even though the facility policies required assessment and, when applicable, consent for devices that could function as restraints. These actions and omissions led to the use of a bed alarm that functioned as a restraint for this resident, without proper assessment, medical justification, or informed consent. Overall, the facility failed to recognize and evaluate the bed alarm as a potential physical restraint under its own policies and regulatory definitions, failed to obtain informed consent from the cognitively intact resident or her representative, and continued to use the alarm despite the resident’s expressed objections and her reported restriction of movement to avoid triggering the alarm. This resulted in the resident remaining in one position for extended periods, feeling embarrassed and that her privacy was violated, in direct connection with the alarm’s use.
Failure to Timely Report Unwitnessed Fall With Hip Fracture to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its written policy and procedure for timely reporting of an unusual occurrence when a resident sustained an unwitnessed fall with a serious injury. On the early morning of 3/4/26, a CNA was assisting the resident’s roommate behind a privacy curtain when the CNA felt something touch her back; upon turning, the CNA found the resident on the floor between the two beds. LVN 2 was called to the room at approximately 5:30 a.m., assessed the resident on the floor, and documented that the resident complained of lower back and left hip pain, had facial grimacing, and was unable to move her legs due to pain. LVN 2 kept the resident on the floor to avoid further movement, contacted the physician, and obtained an order to transfer the resident to the hospital via 911. The Director of Business Development (DBD) stated that, as part of her responsibilities, she contacted the hospital on 3/4/26 and confirmed that the resident had been admitted with a hip fracture due to the fall and was scheduled for surgery the following day. She reported that she notified both the DON and the Administrator of the hip fracture on that same day and later entered this information as a late entry progress note dated 3/9/26 for the events of 3/4/26. The hospital’s emergency department to hospital admission documentation indicated that imaging on 3/4/26 showed an acute fracture of the femoral neck with impaction and angulation, and that the resident underwent a left hip hemiarthroplasty. Despite the facility’s policy requiring that unusual occurrences affecting the welfare, safety, or health of residents be reported by telephone to appropriate agencies within 24 hours, the Administrator and DON did not report the fall with hip fracture to the California Department of Public Health (CDPH) until 3/18/26. The DON acknowledged that a hip fracture is a serious injury and stated that a report should be made to CDPH as soon as the facility knows a resident has an injury, and that they could have reported without having the hospital records. The Administrator confirmed he was responsible for reporting falls with severe injuries, acknowledged being notified on 3/4/26 that the resident had a hip fracture, and stated that the fall with fracture was reported to CDPH on 3/18/26. The facility’s incident report, completed on 3/18/26, documented the unwitnessed fall on 3/4/26, the resident’s complaints of pain and inability to move due to pain, the transfer to the hospital, and that hospital documentation was not received until 3/18/26.
Nonfunctional Toilet and Odorous Bathroom Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a cognitively intact resident whose bathroom toilet was not functional, requiring use of a bedside commode (BSC) instead of the toilet. The resident, admitted with polymyalgia rheumatica, asthma, COPD, and chronic respiratory failure, reported that the toilet in her room had not worked since she moved into the room and that she was unable to use it. Surveyors observed the bathroom shared between two rooms, noting a toilet completely covered with a tied plastic bag and an uncovered BSC placed across from the sink. The bathroom had a strong urine odor similar to ammonia. The resident stated she had reported the toilet problem to the prior Director of Maintenance, who told her it was fine, and that she had also informed the administrator, but the toilet still had not been fixed. She reported feeling useless, not cared about, and unimportant due to the ongoing toilet issue. Staff interviews and observations further documented the ongoing nature of the problem and its impact on the environment. A CNA confirmed that the resident usually used the bathroom or a BSC placed by the bed and acknowledged the strong urine smell in the bathroom, stating the BSC lacked a lid and that a functioning toilet and absence of strong odor would be more homelike. Another CNA stated that toilets in the facility frequently became clogged due to residents flushing excessive toilet paper or paper towels, confirmed that the resident was alert, oriented, and able to use the toilet, and noted that BSCs without lids can cause rooms to smell. The Director of Maintenance stated the resident’s toilet was clogged due to excessive wipes being flushed and that a plumber had been called to unclog it, but during observation the toilet remained bagged, with an “Out of Order” sign, a strong urine odor, discoloration on the floor likely from urine, and visible feces in the toilet bowl. Additional staff interviews corroborated that the toilet had been nonfunctional over time and that the bathroom environment was not acceptable. An LVN stated the toilet had been broken when the resident first moved into the room, that the prior maintenance director had said it was working again, and that a plumber had come a few days earlier to fix it, but the bathroom still had a bad odor. The Social Services Director reported that when the resident moved into the room it was discovered the toilet was not working, that it was later reported to have acted up again, and that she had noticed the plastic bag over the toilet during rounds; she stated the bathroom should not smell like that and emphasized the importance of a working toilet for the resident’s independence. The administrator acknowledged that the toilet had a weak flush with a blockage, that he was unsure if it was the resident’s preference to use the toilet, that the odor persisted despite housekeeping cleaning, and that the plumber had indicated the piping would need to be replaced. Facility policies on Resident Rights and Safe and Homelike Environment required a safe, clean, comfortable, homelike, and sanitary environment, including resident rooms and bathrooms, and minimizing odors, which were not met in this situation.
Failure to Maintain Required 1:1 Supervision for Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known physically aggressive behaviors. Resident 1 had severe cognitive impairment with a BIMS score of 3/15, diagnoses including dementia, anxiety disorders, alcohol abuse, and PTSD, and a documented history of resident-to-resident altercations and aggression toward staff and peers. The resident’s behavior care plan and behavior documentation indicated verbal and physical aggression, including punching, pushing, and grabbing, and required that when the resident ambulated throughout the facility, a designated staff member remain in close proximity at a safe distance to provide immediate redirection and ensure other residents were not placed at risk. Prior to the incident, Resident 1 had been agitated, pacing, yelling, and cursing at staff and peers, and had a history of repeated aggressive behaviors. On the day of the incident, Resident 1 was supposed to be on 1:1 supervision when out of his room due to his unpredictable and violent behavior. Staff interviews confirmed that Resident 1 was known to become suddenly violent, strike out at staff and residents, and that he required continuous 1:1 supervision for safety, with staff following at a safe distance because he became agitated if they walked next to him. The charge nurse assigned a new CNA (CNA 3), who was still on orientation, to follow Resident 1 and “just watch him” because he was combative. CNA 3 followed Resident 1 for a period until he returned to his room. When lunch trays arrived, CNA 3 left her observation of Resident 1 and began helping other CNAs pass meal trays, leaving Resident 1 unattended in his room despite his need for continuous supervision when out of his room and his known rapid mood changes and aggression. While Resident 1 was left without direct supervision, he left his room unnoticed, walked to an area near the therapy room and front window, and approached Resident 2 from behind. Resident 2, who was cognitively intact with a BIMS score of 15/15 and had significant physical impairments including bilateral below-knee amputations and osteomyelitis, was seated in his wheelchair near the therapy room. Resident 2 reported that Resident 1 came up very close behind him; he turned his wheelchair around and told Resident 1 not to approach from behind. At that point, Resident 1 punched Resident 2 in the mouth. Documentation and assessments indicated that Resident 2 sustained a split, swollen upper lip with a scratch on the top left side of the lip and bleeding, requiring cleansing with normal saline and application of triple antibiotic ointment. Multiple staff, including the Administrator, DON, Social Services Director, and rehabilitation staff, heard yelling and responded, observing Resident 1 striking Resident 2 in the facial area. The incident occurred at a time when Resident 1 was documented and acknowledged by staff and the care plan to require 1:1 supervision, but the assigned staff member had left the resident unattended to assist with meal tray distribution, resulting in the resident leaving his room undetected and physically assaulting another resident. Interviews with the Administrator, DON, CNAs, LVNs, and Social Services Director consistently confirmed that Resident 1 had a history of aggressive behaviors, frequent mood changes, and prior altercations with other residents, and that he required 1:1 supervision when out of his room. Staff also confirmed that on the morning of the incident, Resident 1 was agitated and that his usual anti-anxiety medication was not effective. Despite this, the new CNA assigned to follow Resident 1 was not clearly informed that she was responsible for providing continuous 1:1 supervision and left her assignment to help pass lunch trays. The facility’s own Safety and Supervision of Residents policy required that specific interventions, such as supervision levels, be communicated to all relevant staff, that responsibility for carrying out interventions be clearly assigned, and that interventions be implemented correctly and consistently. The failure to ensure that the assigned staff member maintained continuous 1:1 supervision of Resident 1, and the failure to effectively communicate and enforce this supervision requirement, directly led to Resident 1 leaving his room unsupervised and physically assaulting Resident 2, causing injury.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in accordance with its abuse policy and procedure for one of three sampled residents. A resident with Huntington's Disease and severe cognitive impairment was found with discoloration around the right eye, which was not reported to the California Department of Public Health (CDPH) and adult protective services until two days after the injury was discovered. The injury was unwitnessed, and the resident was unable to explain how it occurred, meeting the criteria for an injury of unknown source. Staff interviews revealed that multiple CNAs and LVNs observed the injury but did not immediately notify the abuse coordinator or administrator as required by facility policy. There was confusion among staff regarding who was responsible for reporting, and documentation was lacking to show timely notification to the appropriate authorities. The Director of Nursing (DON) and other staff acknowledged that the facility's policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case. The facility's own policy and the State Operations Manual both require that injuries of unknown source be reported immediately to the administrator and relevant agencies. In this incident, the report was not made to CDPH and the ombudsman until two days after the injury was discovered, and there was no documentation of timely notification to law enforcement. This delay resulted in a postponement of the investigation into the cause of the resident's injury.
Inadequate Laundry Water Temperature Due to Boiler Malfunction
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when one of its two boiler systems malfunctioned, leading to laundry being washed in temperatures below the facility's policy and procedure (P&P) requirements. The boiler's ignition control module was replaced, but a failed gas valve could not be ordered until a later date, resulting in a lack of hot water. Consequently, laundry was washed in cold water, contrary to the facility's P&P, which required a minimum temperature of 71-77°F for low-temperature processing. The laundry aide and housekeeping supervisor confirmed the use of cold water, and the water temperature was measured at 66.9°F, below the required minimum. The Director of Maintenance and the Director of Nursing acknowledged the deviation from the P&P, with the latter noting that the Infection Preventionist, who would typically oversee such practices, was on vacation. The facility's P&P and a professional reference from the CDC were reviewed, both indicating the importance of maintaining specific water temperatures to reduce microbial contamination. The deficiency placed the 117 residents at risk for cross-contamination due to improperly washed and sanitized laundry.
Boiler Failure Leads to Lack of Hot Water
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition when one of its two boiler systems, responsible for heating water throughout the facility, was not monitored or maintained, leading to its failure from March 15 to March 18, 2025. This resulted in the facility being unable to provide hot water for showers, laundry, and kitchen use, affecting the hygiene and comfort of residents. The Director of Maintenance (DOM) reported that the boiler's ignition control module was replaced, but a failed gas valve, which was not in stock, prevented the boiler from functioning. Residents were directly impacted by the lack of hot water. Resident 1 reported receiving a cold bed bath, which was uncomfortable and not thorough, while Resident 2 did not receive a shower or bed bath for six days. Other residents, such as Resident 3 and Resident 4, had to resort to washing themselves with cold water. The facility's kitchen operations were also affected, with staff using cold water for handwashing and relying on a hot water dispenser for dishwashing, which posed a risk of cross-contamination and foodborne illness. The facility's maintenance policy required the Maintenance Department to keep equipment in a safe and operable manner, but routine maintenance was not scheduled for the boilers. The Vendor confirmed that they were only called for emergencies and seasonal transitions, not for regular maintenance. This lack of preventive maintenance contributed to the boiler's failure, leaving the facility without hot water and compromising the residents' hygiene and safety.
Resident Receives Cold Bed Bath Due to Boiler Failure
Penalty
Summary
The facility failed to provide a homelike environment for a resident when the boiler system was not functional, resulting in the resident receiving a bed bath with cold water. The issue began when the facility's boiler system, which heats water, became non-functional. The Administrator was informed by the Director of Maintenance that the boiler's ignition control module was replaced, but a gas valve had also failed and could not be ordered until a later date. Consequently, there was no hot water available for resident care. A resident, who was scheduled for showers on specific days, was given a bed bath with cold water by a CNA who was unaware of an alternate hot water source available in the breakroom. The resident expressed discomfort and chills during the bed bath, as the CNA had not been informed about the alternative hot water source. The CNA acknowledged feeling bad about the situation and noted that the resident was chilled and inquired about when hot water would be available again. Interviews with other staff members, including another CNA, the Director of Staff Development, and the Director of Nursing, revealed that in-services were provided to inform staff about using the hot water dispenser in the breakroom for bed baths. The facility's policy and procedure for bed baths emphasized the importance of using warm water to ensure resident comfort. However, the failure to communicate this information effectively to all staff members led to the resident receiving a cold bed bath, violating their right to a homelike environment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #217 was admitted with a central venous catheter (CVC) for intravenous (IV) medications, but the MDS did not indicate the type of IV access site. The MDS Coordinator and Director of Nursing (DON) acknowledged the oversight, confirming that the central line section should have been coded. Resident #19, who had obstructive sleep apnea, was using a BiPAP machine, a non-invasive mechanical ventilator, which was not documented in the MDS. The MDS Coordinator and DON both confirmed that the BiPAP should have been coded to ensure the resident's care plan accurately reflected their needs. Similarly, Resident #64, who was readmitted with type 2 diabetes and a foot ulcer, received insulin and antibiotics during the assessment look-back period, but these were not coded in the MDS. The MDS Coordinator admitted to the error, and the DON confirmed that the medications should have been properly documented. Resident #68, diagnosed with bipolar disorder, was taking an antipsychotic medication, quetiapine fumarate, which was not accurately coded in the MDS. The section related to antipsychotic medication review was incorrectly marked, causing the assessment to skip information on gradual dose reduction. The MDS Coordinator and DON acknowledged the mistake, emphasizing the importance of accurate MDS documentation for proper care planning and communication with the Centers for Medicare and Medicaid Services (CMS).
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for a resident who was discharged to an acute hospital. The facility's policy, revised in July 2017, mandates that the assessment coordinator or designee is responsible for submitting resident assessments to the CMS' QIES Assessment Submission and Processing system in accordance with federal and state guidelines. The CMS Long Term Care Facility Resident Assessment Instrument Manual specifies that a discharge assessment must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. Resident #30 was admitted to the facility on March 17, 2024, with a medical history of type 2 diabetes and was discharged to an acute hospital on December 7, 2024. The last completed MDS for this resident was a quarterly assessment on September 24, 2024, and no discharge assessment was completed. During interviews, the MDS Coordinator admitted to overlooking the completion of the discharge assessment, and the Director of Nursing confirmed that discharge assessments were expected to be completed by the MDS Coordinator once the facility was aware of the discharge.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the use of enhanced barrier precautions (EBP) and the cleaning and disinfection of reusable equipment. The deficiency was observed during wound care for a resident with a surgical wound on the right foot. The resident, who had a severe cognitive impairment, was readmitted to the facility with a history of surgical amputation and required regular wound care. Despite the facility's policy requiring EBP for residents with open wounds, no signage or personal protective equipment (PPE) was available in the resident's room, and the nursing staff did not don gowns during the procedure. During the wound care observation, two licensed vocational nurses (LVNs) entered the resident's room, performed hand hygiene, and donned gloves but failed to wear gowns as required by EBP. After completing the wound care, one of the LVNs placed the scissors used during the procedure back into the treatment cart without cleaning or disinfecting them. Interviews with the LVNs revealed a lack of awareness and adherence to EBP protocols, as well as a failure to communicate the resident's need for EBP to the Infection Preventionist (IP). The IP and Director of Nursing (DON) acknowledged the oversight, stating that EBP should have been implemented for the resident due to the open wound. The IP was responsible for initiating EBP, but there was a communication breakdown between the IP and the treatment nurse, resulting in the failure to implement necessary precautions. The facility's policies on EBP and equipment disinfection were not followed, leading to the observed deficiencies in infection control practices.
Medication Administration and Security Lapses
Penalty
Summary
The facility failed to ensure that licensed nurses administered medications in accordance with professional standards of practice for one of the residents. On a specific date, a resident's morning medications were left unattended at the bedside by a Licensed Vocational Nurse (LVN). The resident, who was cognitively intact, stated that the nurse left the medications on the table for him to take later, as he preferred to take them around lunchtime. The medications included apixaban, a blood thinner, and various dietary supplements. This action was against the facility's policy, which requires medications to be administered within an hour of the scheduled time and not left unattended. Additionally, the facility's policy was not followed regarding the security of the medication cart. During an observation, it was noted that the medication cart was left unlocked and unattended by an LVN. The LVN admitted that the cart might have been left open, which posed a risk as anyone, including residents and visitors, could access the medications. The facility's policy mandates that the medication cart should be locked when not in direct use to prevent unauthorized access. The Director of Nursing (DON) confirmed that the facility's policy was not adhered to in both instances. The DON emphasized the importance of not leaving medications at the bedside and ensuring the medication cart is locked when not in use. The failure to follow these protocols posed a safety risk, as other residents could potentially consume medications not prescribed to them, leading to adverse effects. The facility's policy and professional standards require that medications be administered safely and securely, which was not the case in these incidents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 333 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Gardens Care Center | 0 mi | ★★★★★ | 2 | 0 |
| Keystone Post-acute | 0.3 mi | ★★★★★ | 2 | 0 |
| Community Subacute And Transitional Care Center | 0.6 mi | ★★★★★ | 12 | 0 |
| The Terraces At San Joaquin Gardens Village | 2.7 mi | ★★★★★ | 0 | 0 |
| Healthcare Centre Of Fresno | 2.8 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Covenant Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.