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 The Terraces At San Joaquin Gardens Village during CMS and state inspections, most recent first.
A deficiency was identified when a licensed nurse did not perform or document a complete skin assessment using the SBAR tool after a resident's family member reported an abuse allegation. The resident, who had severe cognitive impairment and multiple medical conditions, was unable to provide details about the incident. Despite facility policy requiring assessment and documentation after such reports, no evidence of a thorough assessment or SBAR note was found in the EMR.
The facility failed to maintain a safe and sanitary environment in the laundry room, as the tumble dryers were not maintained per the manufacturer's recommendations, leading to debris accumulation on the dryer's vent and pipes. This posed a potential fire hazard, risking the safety of all residents. The Director of Buildings and Grounds and the Administrator acknowledged the issue, noting that the facility's maintenance schedule did not align with the manufacturer's guidelines.
A facility failed to develop timely baseline care plans for three residents, leading to potential health risks. One resident with severe cognitive impairment and dental issues did not have a care plan addressing their dental needs. Additionally, two residents requiring oxygen therapy did not have this included in their care plans, risking hypoxia and respiratory failure. The facility's policy required care plans within 48 hours of admission, but this was not met, leaving staff without guidance for immediate health needs.
The facility failed to develop comprehensive care plans for two residents. One resident, admitted with a sling and splint, did not have a care plan for these orthopedic needs, leading to a lack of guidance for CNAs. Another resident on antibiotics for C. diff also lacked a care plan, risking continuity of care. The facility's policy requires immediate care planning upon admission, but this was not followed, resulting in deficiencies.
Two residents in a facility experienced deficiencies related to oxygen administration and repositioning orders. One resident received less oxygen than prescribed, while another had an incorrect oxygen flow rate set. Additionally, there was a failure to obtain an order for repositioning every two hours, as indicated in the provider's notes. These issues were confirmed by nursing staff and highlighted the importance of following physician orders to prevent respiratory distress and pressure ulcer worsening.
The facility failed to properly label and store medications, leading to potential errors. Discontinued medications were not separated from active ones, and a partially used insulin vial lacked an open or discard date. Staff acknowledged these oversights, which could lead to medication errors.
The facility failed to maintain a sanitary environment, as nasal cannulas for three residents were found on the floor, posing infection risks. Additionally, Enhanced Barrier Precautions were not implemented for two residents with medical conditions requiring such measures. Staff interviews revealed a lack of adherence to infection control protocols, increasing the risk of infection transmission.
A facility failed to accurately code a resident's surgical wound on the MDS assessment, despite the resident having undergone open heart surgery. The MDS Coordinator confirmed the error, acknowledging that the assessment should have indicated the presence of a surgical wound. The facility's policy requires accuracy in MDS assessments, and the Administrator emphasized the importance of this expectation.
The facility failed to ensure residents were free from unnecessary drugs, as one resident received ondansetron exceeding the maximum daily dose, and another was given apixaban without proper side effect monitoring. The ondansetron orders were not clarified, leading to a potential overdose, while the apixaban monitoring was not documented, risking unmonitored bleeding. Interviews confirmed these deficiencies, highlighting a lack of adherence to medication management policies.
A resident with severe cognitive impairment and poor dentition was not provided timely dental care upon admission, despite visible signs of decay and broken teeth. Facility staff acknowledged the oversight, noting the resident had not been evaluated by a dental hygienist or seen by a dentist. The facility's policy for dental services was not followed, resulting in the resident experiencing embarrassment and dietary changes due to her dental condition.
A resident on a mechanical soft-chopped diet was served inappropriate food, including roasted red potatoes, instead of the prescribed mashed potatoes, placing them at risk for choking. Interviews with staff revealed a breakdown in the meal preparation and delivery process, with CNAs responsible for plating food and ensuring diet orders are followed. The facility's policies for mechanical soft-chopped diets were not adhered to, as confirmed by the DON and RD.
The facility failed to document food allergies in the care plans of three residents, leading to a risk of severe allergic reactions. One resident had an allergic reaction to shrimp, requiring emergency care. Interviews with staff confirmed that the facility's policy on documenting food allergies was not followed.
A resident with a documented shrimp allergy was mistakenly served shrimp due to a failure to list the allergy on their meal ticket. This led to an allergic reaction requiring emergency treatment. The error occurred because the CDM did not enter the allergy into the meal ticket system, which is separate from the EHR.
A resident was discharged with medications belonging to another resident, resulting in the resident not receiving her prescribed medications for four days. The error was due to the LVN's failure to verify medications with current orders and review them with the resident or family member.
Failure to Assess and Document After Abuse Allegation
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow professional standards of practice after a resident's family member reported an allegation of abuse. The family member informed the nurse that the resident had stated someone was hitting her at night. The resident, who had a history of severe cognitive impairment as indicated by a low BIMS score, was unable to provide further details about the alleged incident during an interview. Despite the report, there was no documentation that a complete skin assessment was performed or that the findings were recorded using the facility's SBAR communication tool, as required by policy. The resident involved had multiple medical conditions, including a recent fracture, aphasia following a cerebral infarction, hypertensive heart disease, chronic kidney disease, and a history of falls. The resident's cognitive status was severely impaired, making it difficult for her to communicate details about the alleged abuse. Staff interviews confirmed that the resident was often confused, emotional, and frequently cried, but no prior signs or symptoms of abuse had been observed by the staff. Interviews with the DON and Administrator revealed that their expectations were for the nurse to ensure the resident's safety, perform a thorough skin assessment to check for signs of abuse, and document the assessment in the EMR using the SBAR format. However, both the DON and Administrator were unable to locate any documentation of such an assessment or SBAR note in the resident's record. The facility's policy required detailed observation and documentation in the event of a significant change in a resident's condition, which was not followed in this case.
Failure to Maintain Safe and Sanitary Laundry Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry room, as observed during a survey. The three tumble dryers in the laundry room were not maintained according to the manufacturer's recommendations, resulting in a layer of gray and white debris accumulating on the back of the dryer's vent and pipes. This accumulation of debris had the potential to create a fire hazard, putting all 50 residents at risk for displacement. During an interview, the Director of Buildings and Grounds (MAIN) and the laundry staff (LAU) acknowledged the presence of dust and debris, although LAU initially stated that the dust did not appear to be problematic. MAIN later confirmed that the facility was not following the manufacturer's guidelines for monthly maintenance of the dryer exhaust system. Further investigation revealed that the facility's maintenance schedule for the dryer exhaust ductwork was semi-annual, contrary to the manufacturer's recommendation for monthly cleaning. The Administrator (ADM) also acknowledged that the laundry room should not have dust due to the risk of contamination and fire hazards. A review of the facility's policies indicated that laundry equipment should be maintained according to the manufacturer's instructions to prevent microbial contamination. The failure to adhere to these guidelines and policies resulted in the deficiency noted in the report.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents within 48 hours of their admission, leading to potential health risks. Resident 17, who had severe cognitive impairment and a history of cancer treatments, was admitted with broken teeth and visible signs of tooth decay. Despite the evident dental issues, no specific care plan interventions were put in place to address these needs. Interviews with staff revealed that they relied on care plans to guide resident care, and without a care plan addressing Resident 17's dental needs, staff were unsure of the appropriate actions to take. Additionally, the facility did not include physician-prescribed oxygen therapy in the baseline care plans for Residents 197 and 247. Both residents required oxygen therapy due to their medical conditions, which included acute respiratory failure and dependence on supplemental oxygen. Observations and interviews indicated that the absence of oxygen therapy in the care plans could lead to the residents not receiving the necessary treatment, posing a risk of hypoxia and respiratory failure. Staff interviews highlighted the importance of care plans in ensuring that residents receive the correct treatments and monitoring. The facility's policy required baseline care plans to be completed within 48 hours of admission, including instructions for effective, person-centered care. However, the care plans for the residents in question were not completed within this timeframe, resulting in a lack of guidance for staff on how to address the residents' immediate health needs. The failure to include critical interventions in the care plans demonstrated a lapse in adhering to professional standards of quality care, as outlined in the facility's policies and procedures.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 347, who was admitted with a sling on the left arm and a splint on the left foot. Despite being admitted with these orthopedic precautions, there was no care plan initiated for these needs until several days after admission. Interviews with CNAs revealed a lack of communication and guidance from licensed nurses regarding the care of the sling and splint, which were crucial for Resident 347's recovery from a dislocated shoulder and foot drop. The Infection Preventionist and Minimum Data Set Coordinator acknowledged the oversight and confirmed that care plans should have been initiated immediately upon admission. Similarly, the facility did not create a care plan for Resident 24, who was on an antibiotic treatment for Clostridium difficile. The resident was readmitted with a diagnosis that included malnutrition, muscle weakness, and a pressure ulcer, yet there was no care plan for the antibiotic use. The Infection Preventionist admitted that a care plan should have been developed when the antibiotic was initiated to ensure continuity of care and effective communication among the nursing staff. The Director of Nursing and the Administrator both stated that it was the responsibility of the licensed nurses to initiate care plans upon admission, with follow-up by the Director of Nursing and the Minimum Data Set Coordinator. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented for each resident, reflecting recognized standards of practice. However, in these cases, the facility failed to adhere to its own policies, resulting in deficiencies in care planning for the residents involved.
Oxygen Administration and Repositioning Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice for two residents, resulting in deficiencies related to oxygen administration and repositioning orders. For Resident 98, the oxygen flow rate was not administered according to the physician's order. During an observation, it was noted that the oxygen concentrator was set to 1 liter per minute, while the physician had ordered 2 liters per minute. This discrepancy was confirmed by both a Registered Nurse and a Licensed Vocational Nurse, who acknowledged the responsibility of licensed nurses to ensure the correct oxygen flow rate is administered. The Director of Nursing also emphasized the importance of monitoring the flow rate to prevent respiratory distress. Resident 247 also experienced a deficiency in oxygen administration. The oxygen concentrator was set to 1.5 liters per minute instead of the prescribed 2 liters per minute. This was observed during an initial tour and confirmed by a Licensed Vocational Nurse, who noted the risk of inadequate oxygenation if the provider's orders were not followed. The Director of Nursing reiterated the importance of checking the oxygen flow rate to prevent desaturation and respiratory distress. Additionally, there was a failure to obtain an order to turn and reposition Resident 247 every two hours, as indicated in the provider's notes. Despite the presence of a low air loss mattress, the provider's notes specified the need for repositioning to prevent the worsening of a pressure ulcer. The Licensed Vocational Nurse and Minimum Data Set Coordinator acknowledged the lack of a written order and the expectation for nurses to follow up on provider instructions. The Director of Nursing confirmed that repositioning every two hours is a standard practice and emphasized the importance of documentation to ensure the task is implemented.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential medication errors. During an observation, it was found that a resident's discontinued ondansetron was not separated from active medications in the west wing medication cart. The Licensed Vocational Nurse (LVN) acknowledged that discontinued medications should be removed from active medications to prevent errors. Similarly, in the south wing medication cart, another resident's discontinued benzonatate was not separated from active medications, and a partially used insulin lispro vial was not labeled with an open or discard date. The LVN confirmed that the insulin vial should have been dated to avoid administering expired medication. Interviews with the Director of Nursing (DON) and the facility's Consultant Pharmacist (CRPH) highlighted the importance of removing discontinued medications and properly labeling multidose vials to prevent medication errors. The facility's policies and procedures indicated that expiration dates should be checked before administering medications and that opened multidose containers should be dated. However, these procedures were not followed, leading to the potential for incorrect medication administration.
Infection Control Deficiencies in Oxygen Management and Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to potential infection risks for several residents. Specifically, the nasal cannulas of Residents 98, 197, and 247 were found on the floor in their respective rooms, which could lead to respiratory infections. Observations and interviews revealed that the oxygen tubing was not properly managed, with staff acknowledging that the tubing should not be on the floor due to infection control concerns. The residents involved were cognitively intact and dependent on supplemental oxygen due to various medical conditions, including acute respiratory failure and pulmonary edema. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Residents 197 and 247 upon admission, despite their medical conditions requiring such measures. Resident 197 had a colostomy, and Resident 247 had a sacral wound, both of which necessitate EBP to prevent the spread of multidrug-resistant organisms. The absence of EBP signage and procedures was confirmed through interviews with staff, who admitted that these precautions were not initiated as required. The facility's failure to follow proper infection control protocols extended to staff not adhering to EBP procedures when providing care to Resident 22. This oversight increased the risk of infection transmission among residents and staff. Interviews with various staff members, including CNAs, LVNs, and the Infection Preventionist, highlighted a lack of adherence to established infection control policies, which are crucial for preventing cross-contamination and ensuring resident safety.
Inaccurate MDS Assessment of Surgical Wound
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 a surgical wound. During an observation and interview, it was noted that the resident had a surgical wound on her midchest following open heart surgery. However, the MDS assessment did not code this surgical wound, which was confirmed by the MDS Coordinator during a review of the resident's admission assessment. The MDS Coordinator acknowledged that the assessment was incorrect and should have indicated the presence of a surgical wound. The facility's policy requires that each individual who completes a portion of the MDS assessment certifies the accuracy of their work. The Administrator expressed that the expectation was for MDS assessments to be accurate and timely. The failure to accurately code the surgical wound on the MDS assessment had the potential to result in unmet care needs for the resident. The professional reference manual used by the facility defines surgical wounds and outlines the steps for assessment, which includes examining the resident for any wounds or skin problems.
Failure to Monitor Medication Dosage and Side Effects
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs, as evidenced by two specific cases. In the first case, a resident was administered ondansetron for nausea, with active orders for both routine and as-needed doses. This resulted in a potential daily dosage that exceeded the manufacturer's recommended maximum of 24 mg per day. The resident's routine order was added after hospice care began, but the previous as-needed order was not discontinued, leading to a potential total of 28 mg per day if both orders were followed. Interviews with nursing staff and the Director of Nursing confirmed that the orders exceeded the maximum dose and that there was a lack of clarification on whether to continue or discontinue the old order. In the second case, another resident was administered apixaban, a blood thinner, without proper monitoring for side effects. The resident's care plan required monitoring for signs of bleeding and other side effects every shift, but there was no documentation in the Medication Administration Record to show that this monitoring was being conducted. Interviews with nursing staff and the Director of Nursing revealed that the monitoring was not documented, and it was acknowledged that monitoring for side effects was crucial due to the bleeding risk associated with apixaban. The facility's Consultant Pharmacist confirmed the risks associated with exceeding the maximum dose of ondansetron and the importance of monitoring for apixaban side effects. The manufacturer's package inserts for both medications highlighted the potential side effects and the need for careful monitoring. The facility's policy on medication management emphasized the need for appropriate dosing and minimizing adverse consequences, which was not adhered to in these cases.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident, identified as Resident 17, who was admitted with poor dentition characterized by visible signs of decay, missing, and broken teeth. Despite the resident's condition and her report of embarrassment due to her dental state, the facility did not ensure that she was referred to or assessed by a dental hygienist in a timely manner. This oversight was noted during a review of the resident's admission record and Minimum Data Set (MDS), which indicated severe cognitive impairment and obvious dental issues. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Social Services Director (SSD), and the Director of Nurses (DON), revealed that the resident had not been evaluated by a dental hygienist or seen by a dentist since her admission. The SSD acknowledged that the resident might have been overlooked during the transition from short-term to long-term care, and there was no process in place for residents to sign a refusal of treatment for dental issues. The DON confirmed that the resident should have been offered dental services immediately upon admission. The facility's policy and procedure for dental services, dated 2016, indicated that routine and emergency dental services should be available to meet residents' oral health needs. However, the policy was not followed in this case, as evidenced by the lack of dental evaluation and services provided to Resident 17. The failure to address the resident's dental needs was further highlighted by documentation from speech therapy indicating pain with swallowing and dietary changes made to accommodate her broken teeth.
Failure to Follow Mechanical Soft-Chopped Diet
Penalty
Summary
The facility failed to ensure that menus were followed for a resident on a mechanical soft-chopped diet, which placed the resident at risk for choking. During an observation, the resident was served roasted red potatoes, which were not consistent with the mechanical soft-chopped diet order. The resident's meal ticket indicated a diet order of mechanical soft-chopped, but the meal served did not comply with this order, as it included red roasted potato wedges instead of mashed potatoes. Interviews with facility staff revealed a breakdown in the meal preparation and delivery process. The Executive Chef stated that the kitchen prepares the food and delivers it to the satellite kitchen for plating by the nurses, while the Certified Dietary Manager (CDM) indicated that Certified Nursing Assistants (CNAs) are responsible for plating the food. The CNAs receive training on therapeutic diets, but there was a failure in ensuring the correct diet was served to the resident. The Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) confirmed that the tray line process involves checking the meal ticket for the correct diet order, but the oversight in this case led to the resident receiving an inappropriate meal. The Registered Dietician (RD) emphasized the importance of following therapeutic diets to minimize the risk of complications from diseases. The facility's policies and procedures outline the requirements for mechanical soft-chopped diets, which include ensuring that foods are fork-tender and meats are chopped. However, the facility did not adhere to these guidelines, as evidenced by the meal served to the resident. The Director of Nursing (DON) acknowledged that the failure to follow the menu could result in the resident not receiving the diet ordered by the physician, potentially leading to choking.
Failure to Document Food Allergies in Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered comprehensive care plan for three residents, specifically regarding their food allergies. Residents 1, 2, and 3 did not have care plans addressing their food allergies, which included shrimp, peanut butter flavor, and shellfish, respectively. This oversight placed these residents at risk of being served foods they were allergic to, with the potential for severe allergic reactions. The deficiency was identified during interviews and record reviews, where it was noted that the facility's policy and procedure for documenting food allergies in care plans was not followed. Resident 1 experienced an allergic reaction to shrimp, requiring emergency department transfer, highlighting the critical nature of the oversight. Interviews with facility staff, including an LVN, the Certified Dietary Manager, the Infection Preventionist, the Director of Nursing, and the Administrator, confirmed that the facility's policy on food allergies was not adhered to. The facility's policy required that food allergies be documented in the care plan upon admission and as part of the comprehensive assessment, but this was not done for the affected residents.
Resident Served Allergen Due to Documentation Error
Penalty
Summary
The facility failed to ensure that a resident with a documented shrimp allergy was served food that accommodated their allergies. On a specific date, the resident was mistakenly served shrimp for lunch, which was not listed as an allergy on their meal ticket. This oversight led to the resident experiencing an allergic reaction, including nausea, vomiting, and abdominal pain, necessitating a transfer to the emergency department for treatment. The incident occurred because the Certified Dietary Manager (CDM) did not enter the resident's shrimp allergy into the meal ticket system, which is separate from the electronic health record (EHR). As a result, the allergy was not printed on the meal ticket, and the resident was served shrimp. The CDM acknowledged the mistake, stating that the facility's process was to list all food allergies on meal tickets to prevent such occurrences. The dietary aide, who was responsible for checking the meal ticket for allergies before plating the food, also confirmed that shrimp was not listed as an allergy on the ticket. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), revealed that the resident began coughing and showing signs of distress shortly after consuming the shrimp. The LVN checked the resident's EHR and confirmed the shrimp allergy, which was not reflected on the meal ticket. The facility's policy and procedure documents emphasize the importance of documenting and communicating food allergies to prevent exposure, but in this case, the failure to do so resulted in the resident's allergic reaction.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice when an LVN discharged Resident 1 home with seven medications that belonged to another resident, Resident 2. This error resulted in Resident 1 not receiving her prescribed blood pressure medications for four days, placing her at risk for adverse effects of medication. The incident was discovered when Resident 1's family member (FM) noticed the error and reported it to the facility administrator (ADM). Resident 1 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus, hypertensive heart disease, hyperlipidemia, and osteoarthritis. The Minimum Data Set (MDS) assessment indicated that Resident 1 had a moderate cognitive impairment. During the discharge process, the LVN responsible for Resident 1's discharge failed to verify the medications with the current medical orders and did not review the medications with the resident or FM. As a result, Resident 1 was given medications intended for Resident 2, including blood thinners and high blood pressure medications, instead of her prescribed medications. Interviews with other LVNs and the Director of Nursing (DON) revealed that the facility had a triple-check process for discharging residents with medications, which was not followed in this case. The facility's policy and procedure for discharge medications required verification of medications with current physician orders and a review of medication instructions with the resident or FM before discharge. The failure to follow these procedures led to Resident 1 receiving incorrect medications, which could have resulted in serious health issues such as low blood pressure, unstable blood sugar, and bleeding.
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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) |
|---|---|---|---|---|
| North Point Healthcare & Wellness Centre Lp | 0.3 mi | ★★★★★ | 0 | 0 |
| Keystone Post-acute | 2.4 mi | ★★★★★ | 2 | 0 |
| Horizon Health & Subacute Center | 2.6 mi | ★★★★★ | 5 | 0 |
| Oakwood Gardens Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Covenant Post Acute | 2.7 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 July 2026) and official state health department websites.