Inspection citations
12’23
1’24
6’25
15’26
34 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 2, 2026 | E · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Jul 2, 2026 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jul 2, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jul 2, 2026 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jul 2, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jul 2, 2026 | 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 |
| Jul 2, 2026 | F · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jul 2, 2026 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Jul 2, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 2, 2026 | F · potential | Dispose of garbage and refuse properly. | Routine |
| Jul 2, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jul 2, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 2, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Jan 9, 2026 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| Jan 9, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 22, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 2, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 2, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Mar 17, 2025 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 30, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jan 30, 2025 | 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 |
| Jul 8, 2024 | D · potential | Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Complaint |
| Feb 17, 2023 | E · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Feb 17, 2023 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Feb 17, 2023 | 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 |
| Feb 17, 2023 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Feb 17, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Feb 17, 2023 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Feb 17, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 17, 2023 | F · 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 |
| Feb 17, 2023 | E · 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 |
| Feb 17, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 17, 2023 | D · potential | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Routine |
| Feb 17, 2023 | D · 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 |
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
Oakwood Gardens Care Center
3510 East Shields, Fresno, CA 93726 · (559) 222-4807
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055204
- Certified beds
- 103
- Legal owner
- Lily Holdings, LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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