Inspection citations
4’23
5’24
20’25
19’26
48 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Apr 24, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Apr 24, 2026 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Apr 24, 2026 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Apr 24, 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 |
| Apr 24, 2026 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Apr 24, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Apr 24, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Apr 24, 2026 | 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 |
| Apr 24, 2026 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 24, 2026 | E · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Apr 24, 2026 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 24, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Apr 24, 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 |
| Apr 24, 2026 | E · 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 |
| Apr 24, 2026 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Apr 24, 2026 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Apr 24, 2026 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 24, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 1, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Aug 27, 2025 | D · potential | Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source | Complaint |
| Feb 7, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 7, 2025 | E · potential | 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. | Routine |
| Feb 7, 2025 | E · potential | 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. | Routine |
| Feb 7, 2025 | D · potential | 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. | Routine |
| Feb 7, 2025 | 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 |
| Feb 7, 2025 | 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 |
| Feb 7, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 7, 2025 | D · potential | Provide appropriate foot care. | Routine |
| Feb 7, 2025 | G · harm | 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. | Routine |
| Feb 7, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Feb 7, 2025 | D · potential | Post nurse staffing information every day. | Routine |
| Feb 7, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Feb 7, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Feb 7, 2025 | 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 |
| Feb 7, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Feb 7, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 7, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 7, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 7, 2025 | E · potential | Put firmly secured handrails on each side of hallways. | Routine |
| Nov 26, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Nov 26, 2024 | 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. | Complaint |
| Oct 4, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Oct 4, 2024 | F · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Complaint |
| Mar 15, 2024 | G · harm | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Nov 30, 2023 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Nov 30, 2023 | D · potential | 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. | Routine |
| Nov 30, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Nov 30, 2023 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | 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
Pacific Gardens Nursing and Rehabilitation Center
577 S. Peach Ave., Fresno, CA 93727 · (559) 251-8463
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056207
- Certified beds
- 188
- Legal owner
- Juniper Springs Healthcare INC
- Part of
- The Ensign Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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