Inspection citations
20’23
29’24
1’25
24’26
74 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 5, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 24, 2026 | F · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Complaint |
| Jul 24, 2026 | F · potential | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Complaint |
| Jul 10, 2026 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jul 10, 2026 | E · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jul 10, 2026 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 27, 2026 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| May 27, 2026 | E · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Mar 20, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Mar 20, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Mar 20, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Mar 20, 2026 | D · potential | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Routine |
| Mar 20, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Mar 20, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Mar 20, 2026 | D · potential | 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. | Routine |
| Mar 20, 2026 | D · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Mar 20, 2026 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Mar 20, 2026 | D · potential | 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. | Routine |
| Mar 20, 2026 | F · potential | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Routine |
| Mar 20, 2026 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 20, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Mar 20, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Mar 20, 2026 | F · potential | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Mar 20, 2026 | E · potential | Have policies on smoking. | Routine |
| Sep 5, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 23, 2024 | D · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Complaint |
| Oct 2, 2024 | F · potential | Protect each resident from the wrongful use of the resident's belongings or money. | Complaint |
| Oct 2, 2024 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Oct 2, 2024 | F · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Oct 2, 2024 | E · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Complaint |
| Oct 2, 2024 | E · potential | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Complaint |
| Oct 2, 2024 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Oct 2, 2024 | E · potential | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Complaint |
| Oct 2, 2024 | E · potential | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | Complaint |
| Oct 2, 2024 | D · potential | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Complaint |
| Sep 13, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Sep 13, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Sep 13, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Sep 13, 2024 | D · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Sep 13, 2024 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Sep 13, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Sep 13, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Sep 13, 2024 | D · potential | 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. | Routine |
| Sep 13, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Sep 13, 2024 | E · potential | 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. | Routine |
| Sep 13, 2024 | F · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Sep 13, 2024 | F · potential | 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. | Routine |
| Sep 13, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Sep 13, 2024 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Sep 13, 2024 | D · potential | Keep all essential equipment working safely. | Routine |
| Sep 13, 2024 | C · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Sep 13, 2024 | F · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| May 16, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 4, 2024 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| Jun 16, 2023 | E · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Jun 16, 2023 | E · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Jun 16, 2023 | E · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Jun 16, 2023 | F · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jun 16, 2023 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 16, 2023 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 16, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jun 16, 2023 | E · potential | 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. | Routine |
| Jun 16, 2023 | D · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Routine |
| Jun 16, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 16, 2023 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jun 16, 2023 | E · potential | 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. | Routine |
| Jun 16, 2023 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Jun 16, 2023 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Jun 16, 2023 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Jun 16, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 16, 2023 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Jun 16, 2023 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 16, 2023 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jun 16, 2023 | D · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Grace Healthcare Center
2939 S. Peach Avenue, Fresno, CA 93725 · (559) 233-6248
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555352
- Certified beds
- 101
- Legal owner
- R. Fellen, INC.
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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