Above 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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Point Healthcare & Wellness Centre Lp during CMS and state inspections, most recent first.
Two residents with pressure ulcers received wound care from an LVN who failed to change gloves and perform hand hygiene between dirty and clean tasks, contrary to facility policy. The DON and Administrator confirmed the importance of glove changes to prevent cross-contamination.
A resident's medication, empagliflozin 10 mg, was sent to the facility 26 times without a physician's order being verified. Despite the facility's policy requiring verification of orders from non-attending physicians, the nursing staff did not inform the primary physician or the pharmacy. The medication was not administered, as it was not listed on the MAR, and was consistently removed and destroyed by LVNs. The facility's DON and administrator expected staff to follow policy, but this was not done, resulting in a deficiency.
A facility failed to maintain a medication error rate below 5%, with a 5.71% error rate observed. A resident with glaucoma did not receive prescribed medications, as an LVN documented administration without actually giving them. The DON and Administrator expected adherence to medication policies, which was not followed.
The facility failed to maintain a boiler system, resulting in a lack of hot water for resident showers. The boiler's burner tray was full of dust and debris, leading to its non-functioning state. Staff, including the MD and DSD, were aware of the issue but could not resolve it promptly, leaving residents without scheduled showers. The facility's policies on maintaining water temperatures and reporting service interruptions were not followed.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents with pressure ulcers. The first resident, admitted with a stage 3 sacral pressure ulcer, was observed receiving wound care from an LVN who did not change gloves or perform hand hygiene after removing a soiled dressing before handling clean supplies. This was contrary to the facility's policy, which required glove changes and hand hygiene between dirty and clean tasks. Interviews with the LVN, Infection Preventionist, Director of Nursing, and Administrator confirmed that the LVN should have changed gloves after removing the dressing to prevent cross-contamination. The second resident, with a history of Alzheimer's disease and severe cognitive impairment, also had a stage 3 coccyx pressure ulcer. During wound care, the same LVN removed a soiled dressing and proceeded to clean the wound without changing gloves or performing hand hygiene. The LVN considered the removal of the dressing and the cleaning of the wound as a single step, thus not requiring a glove change. However, the Director of Nursing and Regional Quality Assurance Nurse stated that the LVN should have followed the facility's policy by changing gloves and washing hands after removing the soiled dressing. The facility's failure to adhere to its infection control policies during wound care was acknowledged by the staff, including the Administrator, who emphasized the importance of changing gloves between dirty and clean tasks. The deficiency was identified through observations and interviews, highlighting a lapse in following established procedures to prevent infection and ensure resident safety.
Failure to Clarify Medication Order with Physician
Penalty
Summary
The facility failed to ensure that licensed nursing staff clarified a medication order with the physician for a resident. The pharmacy sent empagliflozin 10 mg to the facility 26 times over several months, but the nursing staff did not inform the physician that the medication was being delivered. The facility's policy required that any order from a prescriber other than the attending physician be verified with the current attending physician, which was not done in this case. The resident involved had a medical history of hypertensive heart disease and type 2 diabetes mellitus. Despite the medication being sent regularly, there was no evidence of a physician order for empagliflozin 10 mg in the resident's records, and it was not listed on the Medication Administration Record (MAR). Licensed Vocational Nurses (LVNs) observed the medication in the resident's medication cup but did not administer it due to the lack of a physician's order. The medication was consistently removed and destroyed by the nursing staff, but no communication was made to the pharmacy or the physician to clarify the order. Interviews with the pharmacy consultant, pharmacist, and the resident's primary physician revealed that the medication was ordered by the resident's cardiologist, but the facility's primary physician was not informed. The Director of Nursing (DON) and the facility administrator stated that their expectations were for the nursing staff to follow the facility policy by contacting the pharmacy and physician when a medication was received without an order. However, this protocol was not followed, leading to the deficiency.
Medication Error Rate Exceeds 5% Due to Non-Administration
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 5.71% error rate during a survey. This deficiency was identified through observation, interview, and record review, where two medication errors were noted out of 35 opportunities. The errors involved Resident #28, who was admitted to the facility with a medical history of primary open-angle glaucoma. The resident had active orders for an ophthalmic solution and a vitamin C tablet, both of which were not administered as prescribed. During a medication administration observation, LVN #1 did not administer the prescribed medications to Resident #28 but documented them as given in the electronic medication administration record. The LVN acknowledged the failure to administer the medications during an interview. The Director of Nursing and the Administrator both stated their expectations for nurses to verify medication orders and adhere to the facility's medication administration policy, which was not followed in this instance.
Failure to Maintain Boiler System Leads to Lack of Hot Water for Resident Showers
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically one of the three boiler systems used to heat water for residents' shower rooms and room sink faucets. The boiler's burner tray was found to be full of dust, debris, and water deposits, which contributed to the boiler system's non-functioning state. As a result, scheduled showers for residents on a specific date were not provided due to the lack of hot water. Interviews with various staff members, including the Maintenance Director (MD), Director of Staff Development (DSD), and the Administrator (ADM), revealed a breakdown in communication and response to the issue. The MD was informed of the lack of hot water on a Saturday and attempted to address the problem by contacting plumbing companies, but they were unavailable until the following Monday. The DSD informed the nursing staff not to provide showers due to the lack of hot water, and the ADM was made aware of the issue but did not receive further communication on the matter until Monday. The MD admitted to not knowing when the boiler was last checked by an outside vendor for maintenance and lacked the expertise to inspect the inside of the boiler. The facility's policies and procedures indicated that water temperatures should be maintained to meet residents' needs and that interruptions of essential services should be reported to appropriate agencies. However, the facility failed to meet these standards, resulting in residents not receiving showers at a comfortable water temperature.
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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) |
|---|---|---|---|---|
| The Terraces At San Joaquin Gardens Village | 0.3 mi | ★★★★★ | 0 | 0 |
| Horizon Health & Subacute Center | 2.4 mi | ★★★★★ | 5 | 0 |
| Keystone Post-acute | 2.7 mi | ★★★★★ | 1 | 0 |
| Oakwood Gardens Care Center | 3 mi | ★★★★★ | 2 | 0 |
| Covenant Post Acute | 3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.