Covenant Post Acute

F-F584)

Findings:

During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely)

on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25.

During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with Laundry Aide (LA) 1, LA 1 was

in the clean linen area folding clothes. LA 1 stated when she came to work on 3/17/25, she was notified there was no hot water. LA 1 stated she washed the clothing and linens in cold water since no hot water was available.

During a concurrent observation and interview on 3/18/25 at 10:20 a.m., with the Housekeeping Supervisor (HKS), the HKS stated she was also the supervisor for laundry. The HKS stated the facility washed clothing and linens in chemicals designed for low temperature washing. The HKS reviewed the laundry detergent label and stated it could be used at low temperatures, the recommended temperature was 130 degrees ( ) Fahrenheit ( F-unit of temperature measurement on which water freezes at 32 and boils at 212 ) to 150 F.

The HKS stated the temperature was only recommended. There was a chemical dispenser on the wall next to the washers, the HKS stated it housed chlorine bleach, detergent and laundry sanitizer. The HKS stated

the chemicals were automatically mixed to the wash by the dispenser. The HKS stated only white linens used bleach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055996 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055996 B. Wing 03/18/2025

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)

F 0908 During an interview on 3/18/25 at 10:29 a.m. with Resident 1, Resident 1 stated he was notified there was no hot water on Saturday (3/15/25). Resident 1 stated his scheduled shower days were Tuesdays and Fridays. Level of Harm - Minimal harm or Resident 1 stated he showered on Friday (3/14/25) and the facility had hot water at that time. Resident 1 potential for actual harm stated he was given a bed bath earlier in the day and the CNA had not been notified there was an alternate source to get hot water for a bed bath. Resident 1 stated, she gave me a cold bed bath. It was like biting a Residents Affected - Many bullet. Resident 1 stated he was expecting warm water, then was washed with cold water which gave him chills throughout the bed bath and was not a thorough cleaning. Resident 1 stated because there was no hot water to wash dishes, the meals were coming in Styrofoam containers with disposable utensils.

During an interview on 3/18/25 at 10:35 a.m. Resident 2 stated his shower days were Saturdays and Wednesdays. Resident 2 stated he did not receive a shower or a bed bath on Saturday (3/15/25). Resident 2 stated he did not want a bed bath and had not bathed for 6 days.

During an interview on 3/18/25 at 10:37 a.m. with Resident 3, Resident 3 stated he was scheduled for showers on Wednesdays and Saturdays. Resident 3 stated he did not receive a shower or bed bath on 3/15/25 and washed himself using cold water in the sink.

During an interview on 3/18/25 at 10:40 a.m. with Resident 4, Resident 4 stated he was not told about the hot water outage until he had washed his face and brushed his teeth with cold water on 3/15/25. Resident 4 stated he asked a CNA and was told the hot water was not working. Resident 4 stated his shower days were Wednesdays and Saturdays. Resident 4 stated on Saturday he just cleaned himself up with cold water and did not get a bed bath.

During a concurrent observation and interview on 3/18/25 at 11:00 a.m. with the DOM, the facility ' s hot water boiler was observed and there was no heat coming from the boiler. The boiler for the facility ' s heater ventilation system was working and heat could be felt standing next to it, its thermometer read 160 F. The DOM stated the water boiler system supplied the entire facility ' s hot water, and the module had stopped working on Saturday (3/15/25). The DOM stated the VDR came out and replaced the module but discovered gas valve was not working. The DOM stated the VDR did not provide routine maintenance to the boilers but would come out when there was a transition in season requiring a change between the air conditioner and heater. The DOM stated they call the VDR when there is issue, but no routine maintenance was scheduled.

During a concurrent observation and interview on 3/18/25 at 11:05 a.m. with the DOM in the kitchen, there were three sinks observed, a dish washing sink, a hand washing sink and food preparation sink. The water temperatures were checked and indicated:

Dish sink-61.7 deg F

Food prep sink-64.6 deg F

Hand wash sink-63.3 deg F

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055996 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055996 B. Wing 03/18/2025

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)

F 0908 During an interview on 3/18/25 at 11:10 a.m. with [NAME] (CK) 1, CK 1 stated she used the hand washing sink with cold water and soap to clean her hands while working in the kitchen and would then use hand Level of Harm - Minimal harm or sanitizer to ensure she had clean hands. CK 1 stated the dishwasher was still able to reach the correct potential for actual harm temperature for sanitizing dishes, so they were able to wash the items they cooked with in hot water. CK 1 stated there was a dispenser for hot water which they used to make coffee, and they used the hot water from Residents Affected - Many there for any needs for hot water such as dish washing by hand and the sanitation bucket. CK 1 stated their hands and dishes had to be sanitized correctly and if they were not then, that is bad for residents, they could get sick from the food. CK 1 stated the lack of hot water placed the resident ' s food at risk for cross contamination.

During an interview on 3/18/25 at 11:15 a.m. with CK 2, CK 2 stated he washed his hands in cold water and soap then used gloves while cooking. CK 2 stated it was important to sanitize hands and dishes to prevent food borne illness (illness that comes from eating contaminated food).

During an interview on 3/18/25 11:20 a.m. with Resident 5, Resident 5 stated he had been washing his hands in cold water. Resident 5 stated he was a new admit and was not notified the facility did not have hot water.

During a concurrent observation and interview on 3/18/25 at 11:22 a.m. with the DOM, the sink temperature

in Resident 5 ' s room was checked. The temperature read 64.8. The DOM stated the sink temperatures should be approximately 105 deg F. Several water temperatures were checked throughout the facility as follows:

room [ROOM NUMBER]-bathroom sink- 65.8 F

Station 2 shower- 64.9 F

Station 1 shower- 66.0 F

Station 4 shower 66.4 F

Station 3 shower 60.4 F

room [ROOM NUMBER]-bathroom sink-65.8 F

room [ROOM NUMBER]-bathroom sink-65.8 F

Laundry room sink- 66.9 F

The DOM stated the water temperature, and the washing machine water temperature would be the same (66. 9) because they were on the same water line.

During an interview on 3/18/25 at 11:48 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when

she worked on Sunday, she was told the water heater was not working. CNA 1 stated they were instructed there was a hot water dispenser in the breakroom to get water for bed baths. CNA 1 stated they were using hand wipes to clean the residents ' hands as needed and before meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055996 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055996 B. Wing 03/18/2025

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)

F 0908 During an interview on 3/18/25 at 11:54 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated when she arrived at work, she was notified the boiler was not working, so there was no hot Level of Harm - Minimal harm or water. CNA 2 stated she gave Resident 1 a cold bed bath because she was not aware there was an potential for actual harm alternate source for hot water available in the breakroom. CNA 2 stated, I felt so bad. CNA 2 stated Resident 1 was chilled and asked her during the bed bath when the facility would have hot water again. CNA 2 stated Residents Affected - Many she should have used warm water for Resident 1 ' s bed bath.

During a telephone interview on 3/18/25 at 2:06 p.m. with the VDR, the VDR stated they were called out on Saturday 3/15/25 because the water heater boiler was not working. The VDR stated he sent a technician out to fix the problem. The VDR stated the ignition control module was replaced, and it was then discovered the gas valve was not functioning. The VDR stated the module was the brains of the system and the gas valve was controlled by the module. The VDR stated both parts had to work together for the boiler to work correctly. The VDR stated the company was not scheduled for routine, preventative maintenance of the boiler and were only called out for emergencies and twice a year when contacted, to switch the heater to air conditioning and the air conditioning back to the heater as the weather changed.

During a review of the Vendor ' s invoice to the facility dated 3/17/25, the invoice indicated, . pressure regulating gas V [valve-device for controlling passage] . Quantity 1 . IGN [ignition-firing something up] Module . Quantity 1 .

During a review of the facility ' s policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order . Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner .

During a review of the facility ' s P&P titled Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, . our facility reports unusual occurrences or other reportable events which affect the heath, safety, or welfare of our residents, employees or visitors . Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055996