Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Veterans Home Of California - Fresno during CMS and state inspections, most recent first.
A resident with a non-healing ulcer on the left ear did not receive wound care as ordered by the physician. Staff were observed cleansing the wound with normal saline and applying petroleum and a dry dressing instead of using mild soap and water as prescribed, and documentation showed use of an antibiotic cream without a corresponding order. An RN and an LVN acknowledged that the care provided did not follow the written orders, and leadership confirmed that treatments are required by policy to be administered as prescribed.
A resident with a non-healing left ear ulcer related to squamous cell carcinoma had physician orders for daily cleansing with mild soap and water, application of Vaseline, and coverage with a dry dressing, including PRN for soilage or dislodgement. Despite documentation indicating daily wound care, surveyors observed the dressing hanging off the ear, and staff reported seeing numerous maggots in the wound after a CNA first noticed a small white worm near the resident’s neck. An LVN and an RN stated that proper cleaning and secure dressing would have prevented fly access and maggot presence, and the DON acknowledged there should have been no maggots and that the facility lacked a wound care policy.
Lack of Licensed Pharmacist Oversight: The facility failed to provide required pharmaceutical services when it did not employ or obtain a licensed pharmacist. An SRN stated no pharmacist had been reviewing resident meds monthly since October, and the SNF admin confirmed the facility had no pharmacist for several months. The facility’s policy stated pharmacist services include consultative support for the development, coordination, supervision, and review of pharmaceutical services.
Failure to complete monthly pharmacist DRRs for four residents. A resident with dementia, DM, and HTN; a resident with dementia, HTN, and HLD; a resident with vascular dementia, HLD, and DM; and a resident with knee pain and aortic valve stenosis did not have evidence of required monthly DRRs. Staff stated the facility had no pharmacist for several months, no pharmacy reports were completed, and there was no structure in place to continue the reviews after the pharmacist stopped.
Unsafe Storage of Discarded Medications: Discontinued and expired meds were observed in containers placed in unlocked soiled utility rooms in two buildings, where staff stated the rooms were accessible to all facility staff. Nurses reported that non-controlled meds were bagged in the med room and moved across the hall for disposal, and one container was found tied in a plastic bag inside a bin labeled RCRA ONLY. The facility policy stated discontinued drug and biological containers were to be stored in a separate location identified solely for that purpose in the med room.
Failure to use gowns during EBP: staff provided high-contact care to three residents with indwelling urinary catheters without wearing gowns. A CNA and LVN assisted one resident with a transfer and catheter bag handling, an RN, SRN, and CNA provided care and a breathing treatment to another resident, and a CNA groomed hair and changed linens for a third resident without gown use. The residents’ care plans identified urinary catheters, and EBP signs were posted on the room doors.
A resident admitted with a compression fracture and HTN was discharged to an RCFE after goals were met, but the facility did not notify the State LTC Ombudsman of the discharge and did not document a discharge med rec or physician discharge med orders. Staff confirmed the ombudsman notification process was not followed, and the med rec/discharge med list was not completed.
A resident with an indwelling urinary catheter was observed with the drainage bag resting directly on the floor. RN staff confirmed the bag was on the floor and acknowledged the infection risk, and the IP and RN instructors stated the bag should not be on the floor. The facility reported it did not have a specific catheter maintenance policy and relied on the Lippincott Nursing Procedure Manual, which says not to place the drainage bag on the floor to reduce contamination and subsequent CAUTI.
The facility failed to use its QAPI process to address the known absence of a licensed pharmacist. The SNF Admin stated the facility had no pharmacist for several months, and the SCC stated the last QAPI meeting did not discuss pharmacy services, did not create a plan for pharmacy coverage, and did not include communication about the termination of services with the contracted pharmacy company.
A resident with left hemiplegia and severe mobility limitations was transferred using a Sara lift by a CNA without the required second staff member, despite facility policy and training mandating a two-person assist for such transfers. The resident reported feeling unsafe, and both therapy staff and care documentation confirmed the necessity of two-person assistance for all transfers.
A resident with severe cognitive impairment and a history of falls was not provided with a new intervention after a fall, despite being assessed as high risk. The IDT continued the existing care plan without changes, contrary to the facility's policy requiring new interventions for high-risk residents.
The facility failed to maintain proper sanitation and maintenance in the kitchen, leading to a build-up of grease and grime on equipment and floors. The fryer had significant grease accumulation, and the tile floor was missing grout with a build-up of food and grease. The Dietary Director acknowledged the need for more frequent cleaning, and the Director of Plant Operations was unaware of the grout issue. The facility's cleaning practices and adherence to sanitation policies were inadequate.
A facility failed to meet professional standards for three residents due to improper medication administration. A resident received heart and blood pressure medications without vital sign checks, another was given prostate medication without food, and a third received insulin without proper priming. These actions were contrary to physician orders and facility policies.
A facility exceeded the acceptable medication error rate during a medication pass observation. A resident received heart medications without vital sign checks, another was given prostate medication without food, and a third received insulin without proper priming of the device. These actions were contrary to physician orders and facility policies.
A resident with Parkinson's disease experienced difficulty moving around in a manual wheelchair and requested an assessment for a power wheelchair, which was not provided. The Restorative Nursing Assistant communicated the request to the Physical Therapy department, but no referral was made, and the Occupational Therapy department did not conduct the assessment. The Director of Nursing Services noted that the request should have been communicated to a licensed nurse for follow-up.
A resident with Parkinson's disease requested an assessment for a power wheelchair due to difficulties with a manual wheelchair. Despite the resident's ability to make healthcare decisions and communicate effectively, the request was not fulfilled. The RNA mentioned the request to a staff member, but the OT confirmed no referral was received, and the DON indicated the RNA should have communicated the request to a licensed nurse.
The facility failed to maintain accurate medical records for two residents. One resident's Restorative Nurses Aide-Weekly Notes had incorrect session dates, while another resident's chart contained a Physician Progress Note for a different resident. These errors were confirmed by staff and violated the facility's documentation principles.
A facility failed to follow its infection control policy for a resident with an indwelling Foley catheter under Enhanced Barrier Precaution (EBP). Two CNAs transferred the resident without wearing gowns, contrary to the facility's policy and CDC guidelines, which require gowns and gloves for high-contact activities. The CNAs were unaware of the EBP status and did not check the door sign before entering the room.
A resident, fully dependent on assistance for all ADLs, sustained a head injury when their head hit the bed's headboard during repositioning by a CNA. The resident's MDS assessment and care plan indicated a need for extensive assistance, highlighting a failure in maintaining a safe environment and providing adequate supervision.
The facility failed to store and prepare food in accordance with professional standards for food service safety. Ice machines in two satellite kitchens had discoloration and residue, kitchen appliances and countertops had dirt and grime buildup, bulk sugar was contaminated, and toolboxes used for clean utensils were dirty. These failures posed risks of contamination, microorganism growth, and pest attraction.
The facility failed to ensure that residents' disposable care equipment (DCE) such as basins, urinals, and bedpans were stored in a clean and sanitary manner. Observations revealed multiple instances of undated and unlabeled DCE in various rooms, with items improperly stored. Interviews with staff indicated inconsistencies in the facility's practices and a lack of adherence to the policy requiring labeling and dating of DCE.
The facility failed to follow the menu for lunch when pureed cheesecake was served with a #16 scoop (1/4 cup) instead of the indicated #12 scoop (1/3 cup), potentially affecting the nutritional status of 10 residents. Interviews revealed that staff were trained to use the correct scoop size as per the menu and Portion Control Menu Planner.
The facility failed to ensure that two residents were treated with dignity during meal times, as a CNA was observed standing while feeding them, contrary to the facility's policy requiring CNAs to sit at eye level with residents. Both residents required maximum assistance when eating and have conditions such as Alzheimer's Disease and Dementia.
The facility failed to update a resident's ADL care plan based on his needs, despite a significant decline in ADLs and a history of falls. The care plan lacked interventions to maintain or improve his ADLs after discontinuation of rehabilitation therapy, potentially not meeting the resident's needs.
The facility failed to re-evaluate a resident for the Restorative Nursing Program after discontinuation of physical and occupational therapy, despite the resident's significant decline in ADL functions and multiple falls. The nursing staff did not communicate the need for the resident to be placed on the program, contrary to the facility's policy.
A resident experienced inadequate pain management due to the facility's failure to update the care plan and follow up on physician's progress notes. Despite the resident's complaints of severe pain, the current pain management was ineffective, and necessary diagnostic imaging was not ordered. The facility's policy required care plans to be updated based on ongoing assessments, but this was not done for the resident.
An opened Acidophilus Probiotic bottle requiring refrigeration was found stored at room temperature in a medication cart. The RN confirmed it was not in use and the Pharmacist stated it was unusable once stored at room temperature. Facility policy mandates proper storage according to manufacturer's recommendations.
The facility failed to maintain kitchen equipment in safe operating condition when a water hose connection site under a food preparation table was found leaking. Despite a work order indicating the need for a new part, a miscommunication led to the part not being ordered, violating the facility's policies for equipment maintenance and sanitation.
Failure to Follow Physician’s Wound Care Orders for Ear Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s wound care orders for a resident with a non-healing ulcer on the left ear. During an observation in the resident’s room, an RN performed a dressing change using normal saline, gauze, a Vaseline packet, and a non-adherent dressing, stating that the wound was cleaned with saline, patted dry, petroleum was applied to the gauze, and then covered with a dry dressing. The resident’s monthly physician orders, however, directed staff to cleanse the non-healing ulcer on the left ear auricle with mild soap and water, pat dry, apply Vaseline, and cover with a dry dressing daily and as needed for soilage or dislodgement. Further record review of the resident’s nursing progress notes showed that on one documented occasion the wound was cleaned with normal saline, patted dry, and an antibiotic cream was applied before covering with a dressing, despite there being no physician order for antibiotic cream. An LVN confirmed there was no order for the antibiotic cream and acknowledged that the physician’s order specifying mild soap and water was not followed. In interviews, the supervising RN stated the wound should have been cleaned with mild soap and water per the order, and the DON stated that physician’s orders should be followed and that providing wound care according to those orders prevented infections, complications, and worsening of the wound. The facility’s medication and treatment administration policy indicated that treatments will be administered as prescribed.
Failure to Maintain Clean, Covered Ear Wound Resulting in Maggot Infestation
Penalty
Summary
The facility failed to ensure a resident’s left ear wound was kept clean and covered as ordered, resulting in the wound being found with maggots. The resident had a history of squamous cell carcinoma of the left postauricular skin, hypertension, and stroke. A physician’s order dated 2/22/26 directed staff to cleanse the non-healing ulcer on the left ear with mild soap and water, pat dry, apply Vaseline, and cover with a dry dressing daily and as needed for soilage or dislodgement. The Treatment Administration Record for March indicated the wound was to be cleaned and dressed daily, and an LVN stated wound care was done every day. However, during observation, a bandage with gauze was seen hanging off the back of the resident’s left ear rather than being securely in place. On one evening, a CNA observed a tiny white worm moving by the resident’s left neck while providing ADLs and reported it to the nurse. Nursing progress notes for that date documented maggots on the resident’s left back ear wound, and an LVN later described seeing “a lot of tiny maggots” behind the ear. A supervising RN reported there were about 50 maggots, each about half a grain of rice in size, crawling out of the wound. The supervising RN and the LVN both stated that if the wound had been properly cleaned and securely covered, flies would not have been able to access the wound and there should have been no maggots. Staff also noted the resident preferred to lie on the left side, which caused the dressing to become dislodged, and the DON confirmed there should be no maggots in the wound and that a properly secured dressing would have prevented fly access. When asked, the DON stated the facility did not have a wound care policy.
Lack of Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident because it did not employ or obtain the services of a licensed pharmacist. During an interview, the Supervising Registered Nurse stated that no pharmacist had been reviewing residents’ medications monthly since October 2025. The Skilled Nursing Facility Administrator stated that the facility did not have a pharmacist in November 2025, December 2025, or January 2026. Review of the facility’s Pharmaceutical Services policy dated 9/25/25 showed that pharmaceutical services include consultative and other services furnished by pharmacists to assist in the development, coordination, supervision, and review of pharmaceutical services within the SNF.
Failure to Complete Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews for four sampled residents. Resident 3 had diagnoses of vascular dementia, hyperlipidemia, and diabetes mellitus; Resident 7 had diagnoses of dementia, hypertension, and hyperlipidemia; Resident 21 had diagnoses of left knee pain and non-rheumatic aortic valve stenosis; and Resident 50 had diagnoses of dementia, diabetes mellitus, and hypertension. Record review and staff interviews showed that Resident 21 had no documented drug regimen review since admission, and the most recent drug regimen review for Residents 3, 7, and 50 was completed on 10/24/25 by the former pharmacist. During interviews, staff stated the facility had not had a pharmacist since October 2025 and that no drug regimen reviews were completed for several months. The Supervising Registered Nurse stated there was no pharmacist completing the reviews after October 2025, and there was no developed structure to complete drug regimen reviews when the pharmacist stopped reviewing medications. The Quality Registered Nurse and the Skilled Nursing Facility Administrator also stated that pharmacy reports were not completed during November 2025, December 2025, and January 2026. The facility policy titled Drug Regimen Review required a pharmacist to review each resident's drug regimen at least monthly and prepare appropriate reports, including review of the medical chart and reporting medication-related irregularities.
Unsafe Storage of Discarded Medications
Penalty
Summary
The facility failed to safely store medications when discarded medications designated for disposal were found accessible in unlocked soiled utility rooms in Building 1A and Building 5A. In Building 1A, a blue waste container with a white top was observed in the medication room holding non-controlled resident medications that were no longer in use and were to be disposed of; staff stated that once full, it would be placed in a larger bin in the soiled utility room across the hall for pickup and disposal. In Building 5A, staff stated that discontinued and expired uncontrolled medications in blue and black containers were bagged and walked across the hallway to the soiled utility room, where they were placed in designated bins for later pickup by Environmental Services and transport for destruction. During observation, bins labeled for pharmaceutical waste were found in the unlocked soiled utility room in Building 1A, and one container of discarded medications was observed tied in a clear plastic bag in the bottom of a gray bin labeled RCRA ONLY in Building 5A's soiled utility room. Staff interviews confirmed that the soiled utility room was not locked and that all facility staff members could access the hallway leading to it. The facility policy stated that discontinued drug and biological containers would be stored in a separate location identified solely for this purpose in the medication room, and the list of authorized personnel included licensed nurses and pharmacy staff.
Failure to Use Gowns During Enhanced Barrier Precautions
Penalty
Summary
The facility did not ensure an effective infection prevention and control program when nursing staff failed to use gowns as required for Enhanced Barrier Precautions (EBP) while providing care to three residents with indwelling urinary catheters. During an observation, CNA 1 and LVN 1 assisted Resident 10 with a transfer from bed to wheelchair, moved the catheter bag, and moved the resident’s blanket, but neither staff member wore a gown. Resident 10’s care plan identified an indwelling urinary catheter, and the door to the room displayed an EBP sign. During another observation, SRN 1, RN 1, and CNA 2 were in Resident 14’s room providing care while the resident reported difficulty breathing. The staff checked vital signs and SRN 1 provided a breathing treatment, but none of the staff wore gowns. Resident 14’s care plan identified an indwelling urinary catheter, and the room door also displayed an EBP sign. In a third observation, CNA 3 was in Resident 21’s room grooming the resident’s hair and changing linens without wearing a gown. Resident 21’s room had an EBP sign, and the care plan identified an indwelling urinary catheter. The Infection Preventionist stated EBP was implemented for residents with multidrug-resistant organisms, indwelling devices, or wounds requiring dressings, and that gowns and gloves were needed for high-contact activities such as dressing, transferring, hygiene, and changing linens. The facility policy also identified these activities as requiring gown and glove use.
Discharge Notification and Medication Reconciliation Not Completed
Penalty
Summary
The facility failed to ensure proper discharge notification and documentation for Resident 113, who was admitted with diagnoses including a compression fracture and hypertension. The physician orders dated 1/5/26 indicated the resident may discharge to an RCFE due to goals met, but the chart contained no documentation that the State Long Term Care Ombudsman was notified of the discharge. During interviews, the QRN stated the ombudsman was not notified when residents were discharged to an RCFE, and the SCC confirmed the facility did not send discharge notification to the ombudsman and did not have policies and procedures for the ombudsman notification process. The facility also failed to perform and document a discharge medication reconciliation for Resident 113. During record review and interview, the QRN stated medication reconciliation was not performed or documented as part of the discharge process to the RCFE, and there were no physician orders for discharge medications in the resident's record. The NRS ED stated that upon discharge, the resident's current medications should be reconciled with the medications needed at discharge and that the physician should document discharge medication orders. The MD Director stated the nurse should call the physician about medication changes for discharge, but a complete medication list was not usually reviewed during the call, and the medication reconciliation and discharge medication list were not performed for this discharge.
Urinary Catheter Drainage Bag Left on Floor
Penalty
Summary
The facility failed to ensure appropriate treatment and services to prevent urinary tract infections for one resident with an indwelling urinary catheter when the catheter drainage bag was observed resting directly on the floor. During an observation in the resident’s room, the resident was lying in bed with the urinary catheter bag on the floor. RN 2 confirmed the bag was on the floor and acknowledged it posed an infection risk. The Infection Preventionist confirmed the bag should not be on the floor and stated it should be hanging above the floor. Two RN nurse instructors also confirmed the bag should not be on the floor, and one stated that this was not what they teach. The facility did not have a specific policy for urinary catheter maintenance and stated it follows the Lippincott Nursing Procedure Manual, which states not to place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI.
QAPI Program Did Not Address Absence of Pharmacist
Penalty
Summary
The facility failed to implement an effective QAPI program when it did not use the QAPI process to address the known absence of a licensed pharmacist since October 2025. During an interview, the SNF Admin stated the facility did not have a pharmacist in November 2025, December 2025, and January 2026. The SCC stated QAPI meetings occur at least quarterly and as needed, and that the last QAPI meeting was on 10/30/25. The SCC also stated there were no specific issues discussed regarding pharmacy services, no plan was created for pharmacy services during that meeting, and communication between leadership and headquarters regarding the termination of pharmacy services with the contracted pharmacy company was not discussed with other members in QAPI during the last meeting. A review of the facility's QAPI plan dated 2/2025 showed the stated purpose of QAPI was to take a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all caregivers in practical and creative problem solving.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Sara lift without the required second staff member. The resident, who had left hemiplegia and contracture of the left hand due to a stroke, was assessed as having very limited functional ability and required a two-person assist for all transfers. Despite this, the CNA performed the transfer alone, which was confirmed during interviews with the resident and the CNA. The resident reported feeling unsafe during the transfer and noted that only one person often assisted, even though two were required. Further review of the resident's clinical records, assessments, and care plan confirmed the need for a two-person assist due to the resident's physical limitations, including being tall, heavy, and non-ambulatory with no functionality on the left side. Both the physical and occupational therapists stated that a two-person assist was necessary for safety. Facility training records showed that the CNA had attended training on the proper use of mechanical lifts, and facility policy required adherence to manufacturer recommendations and assessment of the resident's condition to determine the appropriate level of assistance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident (R3) after a fall occurred on 3/14/25. The interdisciplinary team (IDT) did not create a new intervention following the incident, despite the resident being assessed as a high risk for falls with a score of 21 on the fall risk assessment. The IDT decided to continue with the existing plan of care without adding new interventions, which was contrary to the facility's policy that requires new approaches to be implemented based on IDT findings. The resident, who was severely cognitively impaired and had a history of two falls with injuries, was found on the floor in their room on 3/14/25. Despite this, the IDT note and care plan review indicated no new interventions were added to address the fall risk. The facility's policy on Fall Prevention and Intervention Program mandates that new interventions should be developed for residents assessed as high risk, but this was not adhered to in R3's case.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain food storage and preparation areas in accordance with professional standards for food service safety. During an observation in the main kitchen, it was noted that the fryer had a significant build-up of yellow grease on its wheels and in the compartment underneath. Additionally, the compartment housing the gas lines contained a black grease build-up. The tile floor in front of the cooking line was missing grout, and there was a black build-up of food and grease between the tiles. The floor under the center island of the cooking line also had a build-up of black grime and old food. The Dietary Director acknowledged these issues, stating that the fryer should be cleaned more frequently and that the cabinet next to the stove should be included in the cleaning schedule. The facility's cleaning practices were found to be inadequate, as the main kitchen floor was only deep cleaned once a quarter, which the Dietary Director admitted should occur more often. The Director of Plant Operations was unaware of the grout issue and stated that a contract request for a complete rehaul of the tile flooring had been filed, but it was a lengthy process. The facility's policy and procedure for sanitation required that kitchen and serving areas be kept clean and maintained in good repair, which was not adhered to. The U.S. Food and Drug Administration's Food Code also mandates that nonfood-contact surfaces be kept free of dust, dirt, food residue, and other debris to prevent the accumulation of pathogenic microorganisms, which was not followed in this case.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of quality for three residents due to improper medication administration. For Resident 77, medications including Diltiazem, Lisinopril, and Metoprolol were administered without checking the resident's blood pressure and heart rate as required by the physician's orders. The Licensed Vocational Nurse (LVN) did not take the necessary vital signs before administering these medications, which was confirmed during a medication pass observation and subsequent interviews with the Director of Nursing Services (DON). Resident 51 was administered Alfuzosin, a medication for benign prostate hypertrophy, without food, contrary to the physician's orders that specified it should be taken with food. This was observed during a medication pass with a Registered Nurse (RN), and the facility's policy indicated that medications ordered in relation to meals should be administered during or up to 30 minutes after meal time. For Resident 47, Novolog insulin was administered using an ASPART insulin flexpen without priming the device as per the manufacturer's instructions. The LVN did not ensure a drop of insulin appeared at the needle tip before administration, which is necessary to avoid injecting air and ensure proper dosing. The DON confirmed that the insulin flexpen should be primed with two units before administration, as outlined in the manufacturer's instructions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass observation, resulting in a cumulative error rate of 15.15%. This was observed in the cases of three residents. For Resident 77, medications including Diltiazem, Lisinopril, and Metoprolol were administered without checking the resident's blood pressure and heart rate, despite physician orders requiring these checks before administration. The facility's policy also mandates that vital signs be taken when medication administration is conditioned upon them. Resident 51 was administered Alfuzosin, a prostate medication, without food, contrary to the physician's order that specified it should be taken with food. The facility's policy states that medications ordered in relation to meals should be administered during or up to 30 minutes after meal time. This oversight was noted during a medication pass observation with a registered nurse. For Resident 47, Novolog insulin was administered using an ASPART insulin flexpen without priming the device, as required by the manufacturer's instructions. The insulin pen should be primed to ensure proper dosing and avoid injecting air. The Director of Nursing confirmed that the insulin flexpen needs to be primed before administration, aligning with the manufacturer's guidelines.
Failure to Provide Power Wheelchair Assessment for Resident
Penalty
Summary
The facility failed to enhance the quality of life for Resident 68 by not providing a qualification assessment for a power wheelchair, which was requested by the resident. Resident 68, who was admitted with a diagnosis of Parkinson's disease, expressed difficulty in maneuvering around the puzzle table in the common area using a manual wheelchair. Despite requesting an assessment for a power wheelchair, the resident did not receive one, as confirmed by the absence of a referral form and assessment documentation in the clinical record. Interviews with facility staff revealed that the Restorative Nursing Assistant (RNA) was aware of the resident's request and communicated it to a staff member in the Physical Therapy department, but the request was not followed through. The Occupational Therapist (OT) confirmed that the Occupational Therapy department was responsible for conducting such assessments upon receiving a referral from the nursing department, but no referral was made for Resident 68. The Director of Nursing Services (DON) indicated that the RNA should have communicated the request to a licensed nurse for follow-up, which did not occur, leading to the deficiency.
Failure to Conduct Power Wheelchair Assessment for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain the highest practicable physical and psychosocial well-being for a resident diagnosed with Parkinson's disease. The resident, who was capable of making healthcare decisions and communicating effectively, requested an assessment for a power wheelchair due to difficulties maneuvering a manual wheelchair. Despite the resident's repeated requests, no assessment was conducted, and there was no referral form for the assessment found in the resident's clinical record. Interviews with staff revealed that the resident had requested the assessment approximately one month prior, but the request was not properly communicated to the appropriate department. The Restorative Nursing Assistant (RNA) mentioned discussing the request with a staff member in the Physical Therapy department, but the Occupational Therapist (OT) confirmed that no referral was received. The Director of Nursing Services (DON) indicated that the RNA should have communicated the request to a licensed nurse for follow-up, highlighting a breakdown in communication and procedure within the facility.
Inaccurate and Disorganized Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and systematically organized medical records for two residents. For one resident, the Restorative Nurses Aide-Weekly Notes contained incorrect session dates, with dates from January and November 2025 mistakenly recorded for February 2025. This error was confirmed by the Restorative Nursing Assistant during an interview and record review. The facility's policy on documentation principles, which requires records to be complete, accurately documented, and systematically organized, was not adhered to in this instance. For another resident, a Physician Progress Note belonging to a different resident was found in their medical chart. This was confirmed by a Quality Registered Nurse during a concurrent interview and record review. The facility's policy on documentation principles was again not followed, as the records were not accurately documented or systematically organized. These deficiencies had the potential to result in inaccurate clinical records for the residents involved.
Infection Control Policy Violation for Resident with Foley Catheter
Penalty
Summary
The facility failed to adhere to its infection control policy for a resident with an indwelling Foley catheter who was under Enhanced Barrier Precaution (EBP). During an observation, two Certified Nursing Assistants (CNAs) were seen transferring the resident from a wheelchair to a bed without wearing gowns, which is required for high-contact care activities under EBP. The CNAs admitted to not being aware of the resident's EBP status and not checking the door sign before entering the room. The resident, who was admitted with diagnoses including Alzheimer's Disease, pneumonitis, chronic kidney disease, and urinary retention, was confirmed to have an indwelling Foley catheter. The facility's policy and the CDC guidelines both indicate that gowns and gloves should be worn during high-contact activities, such as transferring residents with urinary catheters, to prevent the spread of infections. The Director of Nursing confirmed that staff are expected to wear gowns in such situations to break the chain of infection.
Resident Injury Due to Inadequate Supervision During Repositioning
Penalty
Summary
The facility failed to maintain a safe environment free from accidents and hazards for a resident who was fully dependent on assistance for all Activities of Daily Living (ADLs). The resident, diagnosed with vascular dementia, unspecified osteoarthritis, and a history of repeated falls, sustained a head injury while being repositioned by a Certified Nursing Assistant (CNA). The incident occurred when the resident's head hit the headboard of the bed, resulting in a 3 x 4 cm abrasion on the posterior head, accompanied by a bump and bleeding. The Minimum Data Set (MDS) assessment indicated that the resident was completely dependent on assistance for repositioning, requiring the support of one or more helpers. The care plan also highlighted the resident's decreased functional mobility and need for extensive to total assistance with ADLs. Despite these assessments, the incident occurred, suggesting inadequate supervision or improper handling during repositioning. The facility's policy on accident prevention emphasized maintaining an environment free of hazards and providing adequate supervision, which was not adhered to in this case.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. The ice machines in the satellite kitchens of buildings one and five had a buildup of yellow and purple discoloration on their water tubes, which had the potential to contaminate the water and ice used for residents' beverages and ice baths. The Director of Dietetics (DD) and the Chief of Plant Operations (CPO) acknowledged that the ice machine tubing should be replaced if discolored and that food-contact surfaces should not have any buildup or discoloration. The facility's policy indicated that ice machines should be cleaned according to the manufacturer's guidelines, which were not followed in this case. Additionally, the Food and Drug Administration's Food Code requires routine cleaning of ice makers to prevent microorganism accumulation, which was not adhered to by the facility. The facility's failure to maintain clean ice machines posed a risk of contamination to the residents' food and beverages. The facility's policy and procedure for cleaning and sanitizing ice machines were not followed, leading to the potential contamination of the ice used for residents' beverages and ice baths. The facility's policy and procedure for food storage and sanitation were also not followed, as evidenced by the buildup of dirt and grime under kitchen appliances and countertops, crumbs found behind an ice machine and on the bottom shelf of a reach-in freezer, and the contamination of bulk sugar with a black substance. The Director of Dietetics (DD) acknowledged that the area under kitchen equipment was hard to clean and that the freezer shelves were supposed to be wiped out daily. The facility's policy indicated that all utensils, counters, shelves, and equipment should be kept clean and maintained in good repair, which was not adhered to in this case. The Food and Drug Administration's Food Code requires nonfood contact surfaces to be kept free of an accumulation of dust, dirt, food residue, and other debris, which was not followed by the facility. The facility's failure to maintain clean kitchen appliances and countertops posed a risk of microorganism growth and pest attraction. The facility's policy and procedure for food storage were not followed, as evidenced by the contamination of bulk sugar with a black substance. The Director of Dietetics (DD) acknowledged that contaminated food items should be discarded immediately upon discovery and that the bulk food bin should be washed and sanitized before refilling. The facility's policy indicated that food should be protected from contamination by storing it in a clean, dry location, which was not adhered to in this case. The Food and Drug Administration's Food Code requires food to be protected from contamination, which was not followed by the facility. The facility's failure to maintain clean food storage areas posed a risk of food contamination. The facility's policy and procedure for sanitation were not followed, as evidenced by the buildup of dust, grime, and food residue in toolboxes used to store clean utensils. The Director of Dietetics (DD) acknowledged that the tool cabinet drawers should have been kept clean with daily cleanings and that the tool cabinets may not have been food-safe equipment. The facility's policy indicated that all utensils, counters, shelves, and equipment should be kept clean and maintained in good repair, which was not adhered to in this case. The Food and Drug Administration's Food Code requires nonfood contact surfaces to be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and facilitate maintenance, which was not followed by the facility. The facility's failure to maintain clean toolboxes for storing clean utensils posed a risk of microorganism growth and pest attraction.
Failure to Maintain Clean and Sanitary Disposable Care Equipment
Penalty
Summary
The facility failed to ensure that residents' disposable care equipment (DCE) such as basins, urinals, and bedpans were stored in a clean and sanitary manner, as observed in multiple bathrooms in building five. During an observation, multiple instances of undated and unlabeled DCE were found, including basins stacked together with unknown residue inside, urinals placed on top of linen hampers, and bedpans stored improperly. Specific rooms were noted to have these deficiencies, with items found on the floor, on shower chairs, and on top of hampers, all undated and unlabeled. Interviews with various staff members, including registered nurses (RNs) and certified nursing assistants (CNAs), revealed inconsistencies in the facility's practices regarding the care and disposal of DCE. Staff members provided conflicting information about the frequency of DCE replacement and the requirement for labeling and dating. The Infection Control Registered Nurse (ICRN) and other staff members indicated that the facility did not have a consistent policy for labeling and dating DCE, and there was no clear procedure for ensuring the cleanliness and proper storage of these items. A review of the facility's policy and procedure indicated that disposable items should be labeled with the projected discard date and the resident's name, which was not being followed.
Failure to Follow Menu Portion Sizes for Pureed Dessert
Penalty
Summary
The facility failed to follow the menu for lunch on March 18, 2024, when pureed cheesecake was served with a #16 scoop (1/4 cup) instead of the indicated #12 scoop (1/3 cup). This discrepancy was observed in Building Five Satellite Kitchen, where a Food Service Tech I prepared the dessert for residents in Skilled Nursing Building 5A. The facility's lunch menu and Portion Control Menu Planner (PCMP) both specified that the #12 scoop should be used, but the staff used the #16 scoop instead. This resulted in residents receiving less dessert than prescribed, potentially affecting the nutritional status of the 10 residents assigned to receive pureed dessert from the kitchen. Interviews with the Director of Dietetics (DD) on March 19 and March 20, 2024, revealed that staff were trained to use the PCMP as their color guide for selecting scoop utensils and were expected to use the scoop size indicated on the menu. The facility's policy and procedure titled 'Food & Nutrition Services - Diet Manual & Menu Guidelines,' dated October 31, 2023, also stated that menus must meet nutritional needs and be followed as prepared in advance. Despite these guidelines, the staff's failure to use the correct scoop size led to the deficiency observed by the surveyors.
Failure to Ensure Residents' Dignity During Meal Times
Penalty
Summary
The facility failed to ensure that two residents, Resident 34 and Resident 49, were treated with dignity during meal times. Certified Nursing Assistant (CNA) 1 was observed standing while feeding both residents, which is against the facility's policy that requires CNAs to sit at eye level with residents to ensure their dignity. This was observed during dining meal observations in the residents' rooms. CNA 1 admitted that she typically sits while feeding residents to maintain their dignity, and both Registered Nurse (RN) 1 and Supervising Registered Nurse (SRN) 2 confirmed that CNAs should be sitting while assisting residents with meals to prevent them from feeling rushed or hovered over. The facility had previously conducted in-services about this requirement. Resident 49, who has Alzheimer's Disease and requires maximum assistance when eating, and Resident 34, who has Dementia and also requires maximum assistance when eating, were both affected by this failure. The facility's policies on the RNA - CNA Dining Program and Residents Rights emphasize the importance of providing a conducive environment for meeting residents' nutritional needs and respecting their personal rights. However, these policies were not followed, leading to a potential violation of the residents' dignity during meal times.
Failure to Update ADL Care Plan for Resident
Penalty
Summary
The facility failed to ensure that Resident 10's activities of daily living (ADL) care plan was revised and updated based on his needs. Resident 10, who has a history of falls and was admitted with diagnoses including Atherosclerosis Heart Disease and Chronic Kidney Disease, experienced a significant change of condition (SCOC) due to a decline in ADLs. Despite documented fall incidents and a decline in ADL functions, the care plan did not include interventions to maintain or improve his ADLs after the discontinuation of rehabilitation therapy. This was observed during interviews and record reviews, where it was noted that Resident 10 required extensive assistance for transfers and was unable to ambulate at the time. The Minimum Data Set (MDS) Registered Nurse and other staff confirmed that Resident 10 had a significant decline in ADLs and required more assistance than previously documented. Despite being placed on physical and occupational therapy, Resident 10 was unable to tolerate these therapies and expressed a desire to walk again. The care plan, reviewed on multiple occasions, lacked documentation of interventions to prevent further decline in range of motion and mobility. This failure had the potential to not meet Resident 10's ADL needs, as the care plan did not reflect his current condition and needs.
Failure to Re-evaluate Resident for Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that Resident 10 was re-evaluated to maintain or improve his activities of daily living (ADL). Resident 10, who has a history of falls and was admitted with diagnoses including Atherosclerosis Heart Disease and Chronic Kidney Disease, experienced a significant decline in ADL functions. Despite being alert and able to make decisions, as indicated by a BIMS score of 30, Resident 10 required extensive assistance for transfers and maximum assistance for bed mobility following a significant change of condition due to weakness and falls. The resident had multiple fall incidents and was placed on physical and occupational therapy, which was later discontinued without a subsequent re-evaluation for the facility's Restorative Nursing Program to maintain his functional levels of independence gained through therapy. During interviews, it was revealed that the nursing staff did not communicate the need for Resident 10 to be placed on the Restorative Nursing Program after his therapy was discontinued. The Chief Restorative Care and the MDS Registered Nurse confirmed that Resident 10 was not re-evaluated and was not placed on the restorative nursing program, despite the facility's policy indicating that residents who no longer require specialized rehabilitation therapy services should be referred to the Restorative Nursing Program. This oversight had the potential to prevent Resident 10 from receiving appropriate treatment and services to prevent further decline in range of motion and mobility.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to ensure adequate pain management for Resident 88, who was observed lying in bed and complaining of severe pain in his right arm and hernia pain. Despite the resident's complaints, the physician's progress notes were not followed up on, and the comprehensive care plan was not updated to reflect the new pain sites. The resident had been receiving Diclofenac gel and Acetaminophen, which were not effectively managing his pain, and there was no evidence of a physician's order for further diagnostic imaging as noted in the progress notes. Licensed Vocational Nurse (LVN) 1 was unaware of the resident's hernia pain and stated that the current pain management was ineffective. The physician confirmed the resident's complaints and diagnosed lateral epicondylitis, ordering Diclofenac gel but no imaging. The Supervising Registered Nurse (SRN) and Director of Nursing (DON) acknowledged that the care plan should have been updated based on the physician's notes and that licensed nurses should review progress notes daily to make necessary updates. The Treatment Administration Record (TAR) indicated that staff assessed the resident's pain as zero every shift, which contradicted the resident's reported pain level of 5/10. The facility's policy required comprehensive care plans to be updated based on ongoing assessments, but this was not done for Resident 88. The failure to update the care plan and follow up on the physician's recommendations resulted in inadequate pain management for the resident.
Improper Storage of Probiotic Medication
Penalty
Summary
The facility failed to ensure an opened probiotic medication bottle was stored at an appropriate temperature in one of eight medication carts. During a medication storage inspection, an opened Acidophilus Probiotic bottle, which required refrigeration after opening, was found inside the medication cart. The Registered Nurse (RN) stated that the medication was never used and there were no residents with an order for it. The RN was unable to determine when the medication was last administered, and the bottle still contained 30 capsules out of 100. The Pharmacist confirmed that the medication should have been refrigerated and was unusable once stored at room temperature. The facility's policy indicated that medications should be stored according to the manufacturer's recommendations to maintain their integrity and shelf life.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when a water hose connection site under a food preparation table was found leaking. During an observation in the Main Kitchen, water was seen leaking from the hose connection under the stainless-steel countertop in the food preparation area. A work order dated 8/17/23 indicated that the water spigot under the prep sink was leaking and required a new part to fix the issue. However, the Director of Dietetics stated that there was a miscommunication, and the necessary part was not ordered. The facility's policies and procedures for maintaining equipment in good working order and keeping equipment clean and in good repair were not followed.
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What surveyors actually found near you
We read the 325 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.
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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) |
|---|---|---|---|---|
| Fresno Postacute Care | 2.9 mi | ★★★★★ | 16 | 0 |
| Foundation Skilled Nursing | 3.9 mi | ★★★★★ | 37 | 0 |
| Healthcare Centre Of Fresno | 3.9 mi | ★★★★★ | 25 | 0 |
| Sierra Vista Healthcare | 5.2 mi | ★★★★★ | 18 | 0 |
| Community Subacute And Transitional Care Center | 6.2 mi | ★★★★★ | 12 | 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.