Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Community Subacute And Transitional Care Center during CMS and state inspections, most recent first.
Daily nurse staffing information was posted behind nursing stations where residents and visitors could not access it, and the posted report did not include the actual hours worked by RN, LVN, or CNA staff. The DSD and DON confirmed the staffing information was not in a prominent readily accessible area and that actual daily staffing hours were not posted after being calculated.
A resident with a urinary catheter had a drainage bag observed outside the dignity bag and touching the floor, contrary to staff statements and facility policy requiring the bag to be covered and kept off the floor. In a separate event, an LPN used the same medication tray for multiple residents on EBP, including residents with a gastrostomy tube and other high-contact care needs, without disinfecting the tray between uses; the IP stated soap and water alone did not disinfect reusable equipment and that designated disinfectant wipes were required.
A resident with schizophrenia, epilepsy, chronic pain, and moderate cognitive impairment was observed unclothed in his room on multiple occasions, including while in bed, eating, and sitting in a wheelchair, with the door open and the privacy curtain not drawn. Staff stated he preferred to be naked and that it comforted him, but also acknowledged the curtain should have been pulled to prevent others from seeing him and to preserve his dignity and privacy. The care plan noted his preference to remain unclothed and directed staff to use the door and privacy curtain when needed to maintain dignity.
An LVN left a medication cart unattended in the hallway while administering meds in a resident’s room, and the cart’s computer screen displayed the resident’s MAR profile, including identifying and clinical information, to the hallway. The LVN stated he did not log off or lock the screen, and the DON confirmed resident privacy and confidentiality were violated because the MAR was visible from the hallway.
Failure to Complete PASRR Level II Evaluations After Positive Level I Screens: Two residents had PASRR Level I screens positive for SMI, but the required Level II evaluations were not completed. One resident had diagnoses including cerebral infarction and major depressive disorder, and the other had intracerebral hemorrhage, depression, obstructive and reflux uropathy, chronic pain, and moderate cognitive impairment by BIMS. DHCS notices showed attempts to complete the Level II evaluations were closed after facility staff were unresponsive, and facility leadership confirmed the Level II PASRRs were not completed.
The facility’s diet manual did not align with resident diet orders or current nutrition guidance. A resident with DM had an RCS diet order, but the manual used an obsolete approach instead of a consistent carbohydrate plan, and the RD acknowledged the standard was outdated. Another resident had a physician order for small portions, but the manual did not contain a small portion menu; during meal service, the DA plated a reduced portion based on the ticket, while the RD stated the small portion diet should have been included in the manual.
Dietary staff failed to follow food service hygiene standards when one aide had longer hair not fully covered and no hairnet while handling trays, beverages, and meal carts, and another aide had uncovered facial hair while mixing Juven and preparing resident beverages and food. The CDM confirmed the facility policy required hair coverings at all times and hairnets when facial hair is present.
The facility failed to follow professional standards for food service safety by not adhering to diet orders for three residents and lacking an air gap under the food preparation sink. The Dietary Aide used incorrect portion sizes, potentially affecting residents' weight, while the absence of an air gap posed a risk of food contamination. These issues were confirmed by the Dietary Manager and Building Maintenance Supervisor, respectively.
A facility failed to ensure resident privacy and dignity in three incidents. A nurse administered medication and checked blood pressure without closing privacy curtains or doors, affecting two residents. Another resident's privacy curtain was tied in a knot, preventing its use. Staff interviews confirmed these actions did not respect residents' rights to privacy.
The facility failed to maintain complete and accurate medical records for three residents, as their POLST forms were incomplete and lacked essential information such as preparation and completion dates. This deficiency was identified during interviews and record reviews with staff, including the DON and nurses. The incomplete forms could potentially lead to the residents' healthcare treatment preferences not being honored.
A resident's MDS assessment failed to accurately reflect their use of antipsychotic medication, Olanzapine, despite being prescribed for unspecified psychosis. The MDS Coordinator acknowledged the oversight, and both the DON and administrator emphasized the need for accurate MDS assessments. The facility's policies and job descriptions also highlighted the importance of accurate and timely MDS completion.
A medication cart in the Transitional Unit contained a resident's Fluticasone Propionate without an open date and beyond use date, contrary to facility policy and professional guidelines. The LVN stated the facility followed the pharmacy's expiration date, while the DON confirmed the medication was used daily. Facility policy required labeling with the date opened, which was not adhered to, posing a risk of administering expired medication.
A resident's call light was repeatedly found out of reach, wrapped around a television arm, and on the floor, making it inaccessible. Despite staff acknowledging the importance of having the call light within reach, it remained inaccessible, potentially delaying care. The resident had serious medical conditions, and the facility's policy required accessible call systems, which was not followed.
Daily Nurse Staffing Information Not Publicly Posted
Penalty
Summary
The facility failed to ensure daily nurse staffing information was posted in a prominent, readily accessible place and failed to include the actual hours worked by RN, LVN, and CNA staff. During observation, the daily staffing documents titled, "Report of Nursing Staff Directly Responsible for Resident Care," were seen behind nursing station 1 in Transitional Care and behind nursing station 2 in Sub-Acute Care. The documents were not posted in areas accessible to residents and visitors, and they did not show the actual hours worked by RNs, LVNs, or CNAs. During interview and record review, the DSD stated the staffing information was posted behind the nursing stations and that only facility staff had access to those areas. The DSD stated residents and visitors were not allowed behind the nursing stations and that the facility's total, or anticipated, staffing information was not posted in a prominent readily accessible place for residents and visitors to view. The DSD also stated actual hours worked by RNs, LVNs, and CNAs were not included in the posted information, and that actual staffing hours were calculated the following day for accuracy. The DON confirmed that the total, or anticipated, daily nurse staffing information was posted behind nursing station 1 and nursing station 2, which were not accessible to residents or visitors. The DON also stated actual daily nurse staffing information was not posted after it was calculated. The report further noted that the facility had 99 out of 99 residents admitted within the facility affected by the restricted public access to the staffing information.
Urinary drainage bag left on floor and reusable medication tray not disinfected between resident uses
Penalty
Summary
A urinary drainage bag for a resident admitted with lumbar vertebrae fracture, right pubis fracture, and benign prostatic hyperplasia was observed in the resident’s room without the dignity bag correctly covering it, and the drainage bag was touching the floor. During the observation, an LVN stated the dignity bag should cover the entire urine bag and should not touch the ground, and a CNA stated the catheter bag must be covered and should not touch the floor because germs could get onto the bag and infect the resident. The IP and DON also stated the catheter bag should not touch the floor, and the facility policy required the catheter tubing and drainage bag to be off the floor at all times and the urinary drainage bag to be covered with a modesty bag. Reusable medication trays were observed being used for medication administration to three residents on EBP without being disinfected between uses or after contact with the residents and their environment. An LVN carried a medication tray into one resident’s room, placed it on the bedside table, administered medication through a gastrostomy tube, touched the tray with a gloved hand after handling the tube, and did not disinfect the tray before placing it on another resident’s bedside table or before taking it out of the room. The same tray was then used in another resident’s room and later in a third resident’s room, with no observation of disinfection after each use. The record review showed the three residents were on EBP due to increased risk for MDROs. During interview, the LVN stated she could not remember whether she cleaned or disinfected the tray and said she typically cleaned it with soap and water in the resident restroom before exiting the room. The IP stated soap and water would clean visible debris but would not disinfect the tray, and that designated wipes with a 2-minute dwell time were required to disinfect reusable equipment before use with the next resident. The DON stated all reusable medical equipment needed to be disinfected after use and that the facility’s policy and procedures were not followed when the tray came into contact with the residents and their environment without being disinfected.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of one resident when he was observed from the hallway without any clothing on two occasions. During a concurrent observation and interview, the resident was seen in bed covered only by a sheet and holding it to his chin, and later was observed sitting on the side of his bed eating his meal without wearing any clothing while his door was open and the privacy curtain was not pulled. On another concurrent observation and interview, he was seen in his room without any clothing in his wheelchair, and staff acknowledged he was often naked in his room. The resident had been admitted with diagnoses including non-traumatic subarachnoid hemorrhage, schizophrenia, epilepsy, and chronic pain. His MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Staff stated the resident did not like wearing gowns and clothes, preferred laying down naked, and that being naked comforted and calmed him and helped him sleep. Staff also stated he came out of his room naked in his wheelchair and that his curtain should have been drawn so no one could see him naked in his room. The resident’s care plan stated that he preferred to remain unclothed while in bed, which may affect dignity, privacy, safety, and temperature regulation, and that staff should ensure the door and privacy curtain were drawn when needed to maintain dignity. The DON stated it was important to preserve the resident’s dignity whenever he was naked by ensuring he had his sheet to cover himself, making sure his curtain was pulled, and redirecting him if needed. The Administrator also stated staff should remind residents to cover themselves and that it was important to have the curtain drawn to respect the resident’s dignity.
Resident MAR Visible on Unattended Medication Cart
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of one sampled resident’s personal and medical records when an LVN left a medication cart computer screen visible in the hallway during medication administration. During an observation, Medication Cart 3 was positioned next to the resident’s room with the drawers and computer screen facing the hallway while the LVN removed medication, donned PPE, and entered the room with the door closed. The cart was left unattended in the hallway, and the computer screen displayed the resident’s MAR profile, including the resident’s name, picture, identification number, isolation information, status, location, gender, date of birth, age, physician, allergies, code status, current vital signs, medication orders, enteral feed orders, non-pharmacological interventions for PRN medications, and heel protector orders. A later observation showed the same cart still unattended with the resident’s MAR profile visible from the hallway while the LVN exited the room and returned to the cart. In interview, the LVN stated he did not log off or lock the screen and acknowledged the resident’s MAR profile was visible while he was administering medications. Another LVN stated medication cart screens were expected to be logged off or locked when unattended to prevent unauthorized viewing of confidential resident information, and the DON stated resident privacy and confidentiality were violated when the MAR profile was visible from the hallway on an unattended cart. Facility policy required workstations to be logged off or locked when unattended and resident health information to remain private.
Failure to Complete PASRR Level II Evaluations After Positive Level I Screens
Penalty
Summary
The facility failed to ensure that two residents with positive PASRR Level I screens for serious mental illness received the required PASRR Level II evaluation. For one resident, the admission record showed diagnoses including cerebral infarction and major depressive disorder. The resident’s PASRR Level I screening was positive for SMI, and a Notice of Attempted Evaluation later documented that DHCS could not complete the Level II evaluation because facility staff were unresponsive to repeated attempts to communicate within 48 hours of the Level I screening, and the case was closed. During interview and record review, the MDS Coordinator Nurse stated the resident had not received a PASRR Level II screening and that the facility had not resubmitted a new Level I screening to reopen the case. The MDS Coordinator Nurse, Social Worker, DON, and Administrator each stated that a positive Level I screen required follow-up for a Level II evaluation by the state-designated authority and that the facility was responsible for ensuring completion of the process. The facility policy stated that if the Level I screening was positive for SMI, ID/DD, or RC, a Level II evaluation would be performed by the state-designated authority to determine the most appropriate placement and whether specialized services were needed. For the second resident, the record showed diagnoses including intracerebral hemorrhage, depression, obstructive and reflux uropathy, and chronic pain, and the MDS showed a BIMS score of 9, indicating moderate impairment. The resident’s PASRR Level I screening was positive for SMI, but the MDS Coordinator Nurse could not find documentation that a Level II assessment had been completed. A Notice of Attempted Evaluation stated that facility staff were unresponsive to repeated attempts to communicate within 48 hours of the Level I screening and the case was closed. The MDS Coordinator Nurse stated there was no documentation that DHCS had been contacted to follow up, and the DON and Administrator stated they expected positive Level I screens to be followed by completed Level II PASRRs.
Therapeutic Diet Manual Did Not Match Resident Diet Orders
Penalty
Summary
The facility failed to ensure residents received a well-balanced diet that met daily nutritional and special dietary needs because its approved therapeutic diet manual did not reflect current standards of practice. For one resident with diabetes mellitus and major depressive disorder, the diet order was Reduced Concentrated Sweets (RCS) with regular texture and large portions of protein and non-starchy vegetables for weight gain. During meal service, the resident’s tray ticket reflected the RCS order, and the facility’s diet manual described carbohydrate modification as incorporating consistent carbohydrate intake, but the daily nutrient summary showed a wide variation in total caloric and carbohydrate intake from meal to meal and day to day. The registered dietitian stated the RCS diet was used to make carbohydrate intake as consistent as possible while allowing a more liberalized diet, and later acknowledged that the Academy of Nutrition and Dietetics Nutrition Care Manual identified the RCS diet as obsolete. The medical director stated he had signed off on the facility’s policies and diet manual, had not seen the RCS diet used at other facilities, and was not aware it was not considered standard of practice. He also stated he was familiar with concentrated carbohydrate or consistent carbohydrate diets recommended for diabetic residents. The facility’s policy stated the diet manual was to reflect current research and changing standards of care, and the current Nutrition Care Manual and American Diabetes Association position statement both identified no concentrated sweets/no sugar diets as obsolete or ineffective for glycemic management and described consistent carbohydrate meal planning as the preferred approach. The facility also did not have a small portion diet or menu in its diet manual for another resident whose physician order was for small portions. During lunch tray preparation, the dietary aide checked the meal ticket and plated 1.5 meatballs even though the ticket indicated three meatballs for small portions. The resident’s order summary listed regular diet, regular texture, and small portions for weight loss per RD recommendations. The RD stated small portion was a separate extension of the menu and acknowledged the facility did not have a small portion menu and that it should have been in the diet manual but was not.
Dietary Staff Failed to Fully Restrain Hair During Food Preparation
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when two dietary staff members did not have hair and facial hair fully restrained or covered during meal preparation and service. During lunch meal service, Dietary Aid 1 was observed in the kitchen wearing a baseball cap with longer hair in the back that was not fully covered and no hairnet, while calling out trays, checking meal tickets and meal trays with food, placing cold beverages on meal trays, and putting meal trays into food carts. During a separate observation, Dietary Aid 2 was wearing a surgical mask, but the side of the face had facial hair that was uncovered while he was mixing Juven, pouring diet cranberry beverages into cups, and preparing food for residents. The Certified Dietary Manager reviewed the facility policy titled Uniforms and Personal Hygiene, which stated that hair coverings must be worn at all times within the department and that hair must be restrained by a hair covering, and that hairnets must be worn if any facial hair is evident. The CDM stated that both dietary aides were not wearing hairnets during food preparation.
Deficiencies in Food Service Safety and Compliance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by two main deficiencies. Firstly, the cook did not follow the diet orders for three residents, resulting in incorrect portion sizes being served. During a lunch service, the Dietary Aide used a 1/2 cup serving scoop instead of the required 1/4 cup scoop for residents with small portion diet orders. This error was observed by the Dietary Manager, who confirmed that the wrong scoop was used, potentially leading to undesired weight gain for the residents. The facility's policy and procedure, as well as the job description for the Dietary Aide, emphasize the importance of following standard recipes and diet orders accurately. Secondly, the facility's kitchen was found to lack an air gap under the food preparation sink, which is necessary to prevent sewage backup and contamination of food. This was confirmed during an observation and interview with the Building Maintenance Supervisor, who acknowledged the absence of an air gap. The FDA Food Code requires an air gap to prevent backflow and contamination, highlighting the facility's failure to comply with these safety standards. These deficiencies pose a risk of exposing residents to contaminated food and not adhering to prescribed dietary needs.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by three specific incidents involving residents. In the first incident, a registered nurse (RN) administered medication to a resident without providing privacy, as the privacy curtain and door were not closed, allowing staff and other residents to see inside the room. The resident had no cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. In the second incident, the same RN checked another resident's blood pressure without closing the privacy curtain or door, again failing to provide privacy. This resident had a moderate cognitive deficit, with a BIMS score of 9 out of 15. The RN acknowledged the oversight and the importance of respecting residents' rights to privacy. The third incident involved a resident's privacy curtain being tied in a knot, preventing it from being used to provide privacy. Staff interviews revealed that the curtain should not have been tied, and it was unclear who was responsible for this. The Director of Nursing suggested the resident might have tied the curtain themselves, but staff generally agreed that the curtain should have been untied to ensure privacy and dignity for the resident.
Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards for three residents. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 6, 41, and 55 were found to be incomplete. The forms lacked essential information such as the preparation and completion dates, which are necessary for the forms to be considered valid and accurate. This deficiency was identified during a series of interviews and record reviews conducted with various staff members, including the Director of Staff Development, Licensed Vocational Nurses, Registered Nurse, and the Director of Nursing. The incomplete POLST forms were not readily available as part of the current medical records for Residents 6 and 55, which could potentially lead to their healthcare treatment preferences not being honored. Resident 6 was admitted with diagnoses including end-stage renal disease and heart failure, while Resident 55 was readmitted with a history of transient ischemic attack and schizophrenia. The facility's policy and procedure, as well as professional standards by the Centers for Medicare and Medicaid Services, emphasize the importance of complete, dated, and authenticated medical records, which the facility failed to uphold in these instances.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the use of antipsychotic medication. Resident 6, who was admitted with diagnoses including unspecified psychosis and end-stage renal disease, was receiving Olanzapine, an antipsychotic medication, as per the Order Summary Report. However, the MDS assessment did not reflect this medication use, as confirmed by the Minimum Data Set Coordinator (MDSC) during a review. The MDSC acknowledged that the resident's use of antipsychotic medication was not coded in the annual MDS assessment, which was an oversight. Interviews with the Director of Nursing (DON) and the administrator revealed that there was an expectation for MDS assessments to be accurate and for MDS nurses to ensure the accuracy of their assessments. The facility's job description for the RN MDS Coordinator and the policy and procedure for MDS Assessment and Care Planning both emphasized the importance of accurate and timely completion of MDS assessments. This inaccuracy in coding had the potential to result in unmet care needs for Resident 6.
Medication Labeling Deficiency in Transitional Unit
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy. During an observation and interview, it was found that a medication cart in the Transitional Unit contained a medication for a resident, Fluticasone Propionate, which lacked an open date and beyond use date (BUD). The Licensed Vocational Nurse (LVN) stated that the facility followed the expiration date provided by the pharmacy, which led to the medication not being labeled with the necessary dates. The Director of Nursing (DON) confirmed that the pharmacy labels the medication and that the medication was administered daily, suggesting it would be used before the expiration date. However, the facility's policy and procedure required that multi-dose vials be labeled with the date opened to ensure product integrity. The policy also stated that no expired medication should be administered, and a 'date opened' sticker should be placed on the medication. The manufacturer's guidelines for Fluticasone Propionate also indicated that a 'pouch opened' and 'use by' date should be written on the label, which was not done in this case.
Inaccessible Call System for Resident
Penalty
Summary
The facility failed to provide an accessible call system for one of its residents, identified as Resident 43. During multiple observations, it was noted that Resident 43's call light was out of reach, wrapped around the television arm behind the bed, and at one point, the call button was found on the floor. Interviews with staff, including Licensed Vocational Nurses (LVN) and Certified Nursing Assistants (CNA), revealed that the call light should always be within reach of the resident. Despite this, the call light was consistently found to be inaccessible to Resident 43, who had a history of serious medical conditions including nontraumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease, epilepsy, and schizophrenia. Interviews with the Director of Nursing (DON) and the Administrator (ADM) further highlighted the deficiency. The DON acknowledged that call lights should be placed next to residents to ensure accessibility, while the ADM suggested that Resident 43 might have moved the call light himself, although it was acknowledged that the call light should be as close to the resident as possible. The facility's policy and procedure on call systems emphasized the importance of providing each resident with a means to call for assistance, yet this was not adhered to in the case of Resident 43, leading to a potential delay in care during emergencies.
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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.
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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 | 0.6 mi | ★★★★★ | 2 | 0 |
| Covenant Post Acute | 0.6 mi | ★★★★★ | 5 | 0 |
| Keystone Post-acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Healthcare Centre Of Fresno | 2.5 mi | ★★★★★ | 25 | 0 |
| The Terraces At San Joaquin Gardens Village | 2.8 mi | ★★★★★ | 0 | 0 |
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