NursingHomeGrade

PACIFIC GARDENS NURSING AND REHABILITATION CENTER

577 S. PEACH AVE., FRESNO, CA 93727

D
Facility Assessment 1 federal violation at this facility remains unresolved. Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles.

At or above the 2024 benchmark — elevated deficiency count.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
 0.57 — At or above the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 39
Outstanding 1
Actual harm or worse (G–L) 2
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★★★ (5/5)
Staffing: ★☆☆☆☆ (1/5)
NursingHomeGrade Score
 36/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

2 actual harm issues found among 39 total deficiencies. 38 corrected. — 1 still outstanding

Most recent inspection (February 7, 2025)

D Potential harm — isolated F0621 Status: Outstanding — Plan Filed

Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source

Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected October 1, 2025

E Potential harm — pattern F0924 Status: Corrected

Put firmly secured handrails on each side of hallways.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0732 Status: Corrected

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0802 Status: Corrected

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0757 Status: Corrected

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0761 Status: Corrected

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0687 Status: Corrected

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

G Actual harm — isolated F0688 Status: Corrected

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0657 Status: Corrected

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0842 Status: Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0578 Status: Corrected

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

E Potential harm — pattern F0584 Status: Corrected

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0625 Status: Corrected

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

Inspection cycle 2 (October 4, 2024)

F Potential harm — widespread F0925 Status: Corrected

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

D Potential harm — isolated F0726 Status: Corrected

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 29, 2024

F Potential harm — widespread F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 1, 2024

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

E Potential harm — pattern F0695 Status: Corrected

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 29, 2024

D Potential harm — isolated F0554 Status: Corrected

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

D Potential harm — isolated F0584 Status: Corrected

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 28, 2023

Inspection cycle 3 (February 15, 2019)

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

E Potential harm — pattern F0806 Status: Corrected

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

D Potential harm — isolated F0807 Status: Corrected

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

E Potential harm — pattern F0761 Status: Corrected

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

G Actual harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 1, 2024

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 15, 2023

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

E Potential harm — pattern F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

D Potential harm — isolated F0657 Status: Corrected

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

E Potential harm — pattern F0558 Status: Corrected

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

D Potential harm — isolated F0582 Status: Corrected

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 14, 2019

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