COVENANT POST ACUTE

3408 EAST SHIELDS AVENUE
FRESNO, CA, 93726
5592274063
CCN: 055996
3
Overall
2
Health
2
Staffing
5
Quality
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (2)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
BODY CARE CENTER, CLINIC
1128b4
Excluded 2003-08-20
LAZARUS CARE, LLC
1128a2
Excluded 2018-08-20
Ownership
NameRole%
AHT HOLDINGS, LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
PAKHDAVOR, LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
UNGER, JACOB5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
WILLIAMS, JULIANNE5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
UNGER, JACOBCORPORATE OFFICERNOT APPLICABLE
AHT HOLDINGS, LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
EPPERSON, LUCILLEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (2)
DateTypeAmount
2023-03-27Fine$174K
2023-03-27Payment Denial18 days
Health Deficiencies (49)
2026-01-07 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2025-04-30 · Health
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
2025-03-18 · Health
F
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2025-02-06 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
2024-09-16 · Health
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
2024-03-07 · Health
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-10-11 · Health
D
F624 · Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
2023-05-17 · Health
D
F557 · Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
2023-03-27 · Health
E
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
F
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F849 · Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F
F814 · Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
E
F813 · Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F803 · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
E
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
E
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
G
F693 · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
E
F676 · Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
E
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F557 · Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-03-07 · Health
E
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
2019-01-23 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.60
3.68
RN Hrs/Resident/Day
0.32
0.54
LPN Hrs/Resident/Day
0.88
0.81
CNA Hrs/Resident/Day
2.39
2.33
PT Hrs/Resident/Day
0.08
0.12
Data as of 2026-03-01