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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Gardens Care Center during CMS and state inspections, most recent first.
A resident, admitted with rhabdomyolysis, muscle weakness, and altered mental status and later discharged after a short stay, had a written request for all medical and billing records submitted by a legal firm. Over a month later, surveyors found the unprocessed request on the Medical Records Director’s desk with a note indicating urgency. The MRA reported she had recently assumed the role, had not checked that stack of papers, and did not know the required timeframe, while the DON and Administrator also reported not knowing a specific federal timeframe. Facility policy stated that residents must have access to records within 48 hours and non‑personal representatives such as legal firms within 30 days, but this timeframe was not met for the request.
A resident with severe cognitive impairment, a history of falls, an acetabular fracture, and total dependence for ADLs was incorrectly scored as a moderate fall risk on admission when an LVN incompletely and inaccurately completed the fall risk assessment, omitting bed rail use, mis-scoring medications, and continence. The DON and MDS nurse later confirmed that these factors should have placed the resident in a high-risk category. Because the fall risk score was wrong, the fall care plan contained only basic, non-individualized interventions that did not fully reflect the resident’s diagnoses, medication regimen, mobility deficits, and need for two-person transfers, and the resident subsequently experienced a fall while apparently being assisted by only one CNA.
A resident with moderate cognitive impairment and recent fractures was mistakenly prepared and transported to a cancer treatment appointment that was not scheduled for her, due to staff failing to verify the appointment list and follow proper procedures. The error was discovered at the clinic, and it was confirmed that the resident did not have a cancer diagnosis or need for such treatment. Staff interviews revealed that required verification steps were not followed, resulting in unnecessary distress for the resident.
A resident with multiple health conditions and at risk for skin breakdown was found to have a low air loss (LAL) mattress set at 450 lbs, despite weighing only 78 lbs. Nursing staff and the DSD confirmed the setting did not follow manufacturer instructions, as required by facility policy and job descriptions. This failure resulted in services not meeting professional standards of quality.
A resident with respiratory and cardiac conditions was provided continuous oxygen therapy using an oxygen concentrator that was missing its required dust filter. Nursing staff and the DON confirmed that the device should not be operated without the filter, and facility policies, as well as the manufacturer's manual, required regular cleaning and filter use. This failure to follow infection control protocols resulted in a deficiency.
Two residents experienced unwitnessed falls resulting in injuries that required hospital transfer, but the facility did not report these incidents to CDPH within the required timeframe. Both residents had significant cognitive and physical impairments, and staff interviews confirmed that the falls should have been reported according to policy and regulation.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. A resident received a multivitamin without minerals and senna plus instead of plain senna, contrary to physician orders. The LVN did not verify medication labels properly, and the ADON and DON highlighted the importance of following the seven rights of medication administration.
The facility was found non-compliant with regulations by accommodating eight residents in four adjoined rooms, exceeding the maximum of four residents per room. Despite the facility's policy and the Administrator's assertion of adequate space and privacy measures, the arrangement did not meet federal and state requirements.
A resident was admitted to a facility for IV antibiotic therapy but was not administered the medication due to the absence of an RN on duty. The resident, who required vancomycin for MRSA bacteremia, had to be sent back to the hospital shortly after admission. The facility's admissions policy was not followed, as the necessary nursing staff was not available to provide the required care.
Failure to Timely Fulfill Resident Medical Record Request
Penalty
Summary
The facility failed to fulfill a medical record request for one resident when it did not provide copies of the resident’s records after receiving a written request from a legal firm. The resident had been admitted with diagnoses including rhabdomyolysis, muscle weakness, and altered mental status, and was discharged after a 28‑day stay. A written request from an attorney’s office, dated 11/5/25, asked for production of all medical and billing records for this resident, stated that the office would contact the facility on or about 11/7/25, and requested production of the records on or before 11/14/25. On 12/16/25, surveyors observed the request form on top of the Medical Records Director’s desk with a sticky note reading “ASAP Need within five days! $.10 per page,” indicating it had not been processed. During interviews, the Medical Records Assistant (MRA) stated this was her first week full‑time in the position, that she had been part‑time for the prior three weeks, and that there had been a Medical Records Director (MRD) in place from 10/30/25 until 12/2/25, during which time all record requests went to the MRD. The MRA reported she had not checked that pile of papers and was unaware of the exact timeframe in which the request needed to be filled, though she acknowledged it should have been completed per federal guidelines. The DON and Administrator each stated they did not know of a specific timeframe for completing record requests or a federal regulation setting such a timeframe. Review of the facility’s “Release of Information” policy showed that residents may access their records within 48 hours of a request and that non‑personal representatives such as legal firms may have access within 30 days of a written request, which had not occurred for this resident’s request.
Inaccurate Fall Risk Assessment and Non-Individualized Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate fall risk assessment for a resident on admission, which led to the resident being categorized as a moderate rather than a high fall risk. The resident was admitted with diagnoses including an unspecified acetabular fracture, abnormalities of mobility and gait, and a history of falling. An MDS assessment showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident’s Functional Abilities Collaboration documented that the resident was dependent on staff for all ADLs, including bathing, hygiene, transfers, and bed and chair mobility, and required two-person assistance for transfers. On admission, the LVN supervisor completed a Fall Risk Assessment (FRA) that assigned the resident a score of 14, placing him at moderate fall risk. During later interviews and record review, the LVN acknowledged that the FRA was completed inaccurately. She stated that she left the bed rail question incomplete, did not correctly answer the medication-related question, and inaccurately documented the resident’s continence status. The DON also stated that the medications the resident was taking placed him at a higher risk for falls, that the bed rail question was left unanswered despite the resident having one side rail, and that these errors meant the resident should have been categorized as high risk for falls instead of moderate. The inaccurate fall risk assessment directly affected the development of the resident’s fall risk care plan. The MDS nurse stated that the care plan interventions were based on the fall risk assessment, diagnosis history, and ADL status, and that the interventions included were basic and not individualized to the resident’s needs. The MDS nurse further stated that because the fall risk assessment incorrectly indicated a moderate fall risk, the care plan interventions were also inaccurate and not properly tailored to the resident’s specific risks, including his medication regimen, diagnoses, bed rail use, and safety needs. Facility policies on comprehensive person-centered care plans and fall risk management required that assessments be thorough, ongoing, and used to derive individualized interventions based on identified risk factors such as history of falls, multiple medications, gait and balance disorders, cognitive impairment, and environmental hazards. The resident experienced a fall on the morning of 11/15/25, when staff found him on the floor resting on his left side with his feet slightly under the bed and arms at his sides, able to move all extremities without noted pain or gross misalignment at that time. The IDT Fall Progress Note described the resident as presenting with unpredictability and attempting to function beyond ADL limitations. The ADON stated that the resident required two-person assistance for transfers, but it appeared only one CNA was assisting him when he fell. The DON and MDS nurse both stated that the inaccurate fall risk assessment could have contributed to potential interventions not being utilized and to the inability of nursing staff to properly identify individualized interventions required to prevent falls and injury, linking the inaccurate assessment and care planning to the circumstances surrounding the resident’s fall.
Resident Mistakenly Sent to Unscheduled Medical Appointment Due to Failure in Appointment Verification
Penalty
Summary
The facility failed to ensure compliance with its policies and procedures regarding resident appointment coordination and verification, resulting in a resident being mistakenly prepared and transported to a medical appointment that was not scheduled for her. The resident, who had a history of fractures to the cervical vertebrae and pelvis, osteoporosis, and moderate cognitive impairment due to dementia, was admitted following a fall at home. The resident's family member was not informed of any scheduled appointment at a cancer treatment center and confirmed that the resident did not have a cancer diagnosis or require cancer treatment. On the day of the incident, the facility's Order List Report did not list the resident as having a scheduled appointment, but two other residents, including the resident's roommate, were scheduled. The ward clerk, responsible for tracking and communicating appointments, did not indicate that the resident had an appointment, and the nursing staff failed to verify the appointment list. The nursing staff prepared the resident for transport based on incorrect information and did not follow the required procedure of verifying the resident's face sheet, doctor's orders, and appointment location before sending her out. The error was discovered when the cancer clinic identified that the wrong resident had been sent, prompting the facility to arrange transport for the correct resident. Interviews with the DON, ward clerk, and LVN confirmed that staff did not follow established procedures for verifying and preparing residents for appointments, leading to the resident experiencing unnecessary physical and emotional distress.
Failure to Set LAL Mattress According to Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident's low air loss (LAL) mattress was not set according to the manufacturer's recommendations. The resident, who was admitted with multiple diagnoses including squamous cell carcinoma of the skin, an open wound to the left cheek, muscle weakness, protein-calorie malnutrition, chronic pain syndrome, and anxiety disorder, had a physician's order for a LAL mattress due to redness in the coccyx area. The care plan also identified the resident as being at risk for skin breakdown and included the use of an air mattress as an intervention. During an observation and interview, it was found that the LAL mattress was set to 450 lbs, while the resident's actual weight was 78 lbs. Both the registered nurse and the director of staff development confirmed that the mattress setting should match the resident's weight, as indicated by the manufacturer's instructions. They acknowledged that the incorrect setting could worsen the resident's coccyx redness and potentially lead to discomfort and increased risk for falls. The facility's policy and procedure on support surface guidelines required staff to follow manufacturer guidelines for air support surfaces. Job descriptions for both registered nurses and licensed vocational nurses included responsibilities to ensure compliance with established policies and procedures. The manufacturer's user manual also specified that the mattress pressure should be adjusted according to the patient's weight and height. Despite these requirements, the mattress was not set appropriately, resulting in a failure to meet professional standards of quality for the resident's care.
Oxygen Concentrator Used Without Filter in Resident Care
Penalty
Summary
A deficiency occurred when a resident with multiple respiratory and cardiac diagnoses, including interstitial pulmonary disease and congestive heart failure, was observed receiving continuous oxygen therapy via an oxygen concentrator that was missing its required dust filter. The resident's medical records confirmed ongoing oxygen therapy orders, and the care plan specified the need for oxygen administration related to the resident's pulmonary condition. During an observation, the oxygen concentrator was found operating without the filter installed, a fact acknowledged by the attending RN, who stated that maintaining the cleanliness of the concentrator was the responsibility of licensed nurses. Interviews with facility staff, including the DON, confirmed that operating an oxygen concentrator without a filter was not acceptable and could lead to illness. Facility policies and job descriptions for nursing staff emphasized the importance of maintaining clean and safe resident care areas and adhering to infection control protocols. The manufacturer's manual for the oxygen concentrator specifically cautioned against operating the device without the filter and outlined weekly cleaning requirements. Despite these policies and procedures, the concentrator was used without the filter, constituting a failure to maintain an effective infection prevention and control program.
Failure to Timely Report Falls with Injury to State Agency
Penalty
Summary
The facility failed to report two unwitnessed falls with injury to the California Department of Public Health (CDPH) within the required time frame for two residents. In both cases, the residents were found on the floor in their rooms, had sustained injuries, and required transportation to the emergency department for a higher level of care. The facility did not initiate timely reporting to the state agency as required by regulation and facility policy. One resident, an 86-year-old male with dementia, Alzheimer's disease, and chronic respiratory failure, was found on the floor next to his bed after staff heard him yell. He complained of pain in his right leg and hip and was noted to have abrasions on multiple areas. Emergency medical staff observed that his leg was shortened and rotated, and he reported severe pain with movement. He was transported to the hospital for further evaluation and care. Another resident, a 77-year-old male with dementia and muscle wasting, was found on the bathroom floor with a scalp laceration and fractures to the pubic bone. His cognitive assessment indicated severe impairment. He was also sent to the hospital, where further injuries, including a sacral fracture, were identified. Interviews with facility leadership revealed that the decision not to report these falls was based on not knowing the extent of injuries at the time of transfer, despite facility policy and regulatory requirements to report such incidents.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.69% due to two medication errors out of 26 opportunities. This affected one resident who was observed during medication administration. The errors involved administering a multivitamin tablet without minerals and a senna plus tablet instead of the prescribed plain senna. The facility's policy required the individual administering medication to check the label three times to ensure the right resident, medication, dosage, time, and method of administration. Resident #26, who was affected by the medication errors, had a medical history of protein-calorie malnutrition and moderate cognitive impairment. The resident's care plan included interventions for nutritional problems, risk of dehydration, and complications with bowel regimen, all of which required accurate medication administration. During interviews, the LVN admitted to not verifying the medication labels against the orders, and both the ADON and DON emphasized the importance of following the seven rights of medication administration and physician orders.
Non-compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure that four adjoined rooms, each accommodating eight residents, complied with the federal and state requirements of holding no more than four residents per room. These rooms were connected by wide walkways, making them effectively one large room, which was observed during a recertification survey. Despite the facility's policy stating that each room should provide full visual privacy and be equipped for adequate nursing care, the arrangement of these rooms did not meet the specified requirements. The facility's Daily Census record confirmed that each of these adjoined rooms housed eight residents, exceeding the maximum allowed number. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility staff treated these adjoined rooms as two separate rooms of four residents each, despite the physical connection. The Administrator asserted that there was sufficient square footage for care and a homelike environment, and that privacy curtains were used to ensure resident privacy during care. However, the facility's practice of accommodating eight residents in these adjoined rooms was identified as a deficiency, as it did not align with the policy or regulatory standards.
Failure to Provide IV Antibiotic Therapy Due to Lack of RN
Penalty
Summary
The facility failed to implement its admissions policy and procedure when it admitted a resident from a general acute care hospital for intravenous (IV) antibiotic therapy without having a registered nurse (RN) on duty to administer the medication. This resulted in the resident not receiving the prescribed IV antibiotic medication and necessitated the resident's return to the hospital just three hours after admission. The resident was admitted with diagnoses including bacteremia, dementia, major depressive disorder, and anxiety, and required IV vancomycin every 12 hours for MRSA bacteremia. Interviews and record reviews revealed that the facility's staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), were aware of the resident's need for IV antibiotics but were unable to provide the necessary care due to the absence of an RN. The LVN, who was the charge nurse at the time, informed the DON and the resident's responsible party about the situation, leading to the decision to send the resident back to the hospital. The facility's Marketing Director/Admissions also acknowledged that the resident should not have been transferred to the facility without the availability of an RN to administer the medication. The facility's policy and procedure for admissions, which aims to ensure that residents who can be adequately cared for are admitted, was not followed in this instance. The failure to coordinate and ensure the availability of appropriate nursing staff to administer the required IV medication directly led to the deficiency. The facility's job description for the Admissions Director emphasizes the need to coordinate with the Director of Nursing to assure the appropriateness of facility admissions, which was not effectively executed in this case.
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Illustrative
What surveyors actually found near you
We read the 336 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
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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) |
|---|---|---|---|---|
| Covenant Post Acute | 0 mi | ★★★★★ | 5 | 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 |
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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 July 2026) and official state health department websites.