PACIFIC GARDENS NURSING AND REHABILITATION CENTER
PACIFIC GARDENS NURSING AND REHABILITATION CENTER is a 188-bed nursing home in FRESNO, California. CMS has certified it for Medicare and Medicaid since 1970-07-06. It averages 164.1 residents a day.
What harm was found in the violations cited at PACIFIC GARDENS NURSING AND REHABILITATION CENTER?
CMS lists 48 health-inspection deficiencies for PACIFIC GARDENS NURSING AND REHABILITATION CENTER, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-04-24.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-04-24 | F0658, F0755, F0757, F0759, F0761, F0803 | Ensure services provided by the nursing facility meet professional standards of quality. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure medication error rates are not 5 percent or greater. / 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. / Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E |
| 2026-04-24 | F0552, F0554, F0605, F0656, F0677, F0692, F0700, F0760, F0805, F0806, F0812, F0880 | Ensure that residents are fully informed and understand their health status, care and treatments. / Allow residents to self-administer drugs if determined clinically appropriate. / Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide enough food/fluids to maintain a resident's health. / Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. / Ensure that residents are free from significant medication errors. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. | D |
| 2026-04-01 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D |
| 2025-08-27 | F0621 | Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source | D |
| 2025-02-07 | F0688 | 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. | G |
| 2025-02-07 | F0578, F0584, F0761, F0802, F0812, F0880, F0924 | 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. / 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. / 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. / Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Put firmly secured handrails on each side of hallways. | E |
| 2025-02-07 | F0550, F0625, F0656, F0657, F0658, F0687, F0689, F0732, F0757, F0760, F0842 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide appropriate foot care. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Post nurse staffing information every day. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure that residents are free from significant medication errors. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2024-11-26 | F0658, F0726 | Ensure services provided by the nursing facility meet professional standards of quality. / 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. | D |
| 2024-10-04 | F0812, F0925 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F |
| 2024-03-15 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2023-11-30 | F0695 | Provide safe and appropriate respiratory care for a resident when needed. | E |
| 2023-11-30 | F0554, F0584, F0692 | Allow residents to self-administer drugs if determined clinically appropriate. / 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. / Provide enough food/fluids to maintain a resident's health. | D |
Why was PACIFIC GARDENS NURSING AND REHABILITATION CENTER fined?
| Date | Type | Amount |
|---|---|---|
| 2025-02-07 | Fine | $30,654 |
How is PACIFIC GARDENS NURSING AND REHABILITATION CENTER staffed relative to the CA average?
| Measure | This facility | CA average |
|---|---|---|
| Total nurse staffing hours per resident per day | 4.05653 | 4.51570 |
| Total nursing staff turnover (%) | 35.9 | 36.7 |
| Average number of residents per day | 164.1 | 87.9 |
Who owns PACIFIC GARDENS NURSING AND REHABILITATION CENTER, and what chain is it in?
PACIFIC GARDENS NURSING AND REHABILITATION CENTER is registered with CMS as For profit - Limited Liability company, operates under the legal business name COVENANT CARE CALIFORNIA, LLC and belongs to the COVENANT CARE chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | COVENANT CARE CALIFORNIA, LLC, COVENANT CARE, LLC | since 07/17/2008 |
| 5% OR GREATER INDIRECT OWNERSHIP INTEREST | CENTRE CAPITAL INVESTORS V, LP, CENTRE COVENANT PURCHASER (B), LLC, CENTRE COVENANT PURCHASER (Q), LLC, CENTRE COVENANT PURCHASER (S), LLC, CENTRE V SECONDARY FUND, L.P., COVENANT HOLDCO, LLC, COVENANT SUBCO, LLC, STATE TREASURER OF MICH CUSTODIAN OF PUBLIC SCHOOL EMPL RTMNT SYSTEMS, STOCKWELL FUND II LP, EVANS, MARY, LEVIN, ROBERT, SIMS, CHRISTINE, TOROK, ANDREW | since 07/17/2008 |
| 5% OR GREATER SECURITY INTEREST | MIDCAP FUNDING IV TRUST | since 02/20/2014 |
| CORPORATE OFFICER | ASHLEY, DAVA, CARNEY, KEVIN, EVANS, MARY, HASSELL, LANCE, LEVIN, ROBERT, SIMS, CHRISTINE, TOROK, ANDREW | since 05/17/2018 |
| OPERATIONAL/MANAGERIAL CONTROL | ASHLEY, DAVA, EVANS, MARY, HASSELL, LANCE, LEVIN, ROBERT, SIMS, CHRISTINE, SPARKS, CAROL | since 03/26/2018 |
Were you or a family member harmed at PACIFIC GARDENS NURSING AND REHABILITATION CENTER?