Report
TheVardellReport
Pacific Gardens Nursing and Rehabilitation Center
Skilled nursing facility and nursing facility
577 S. Peach Ave.
Fresno, CA 93727
Report
← Pacific Gardens Nursing and Rehabilitation Center, free profile
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The Vardell Report.Pacific Gardens Nursing and Rehabilitation Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Fresno, CA
- Record Period
- 2023–2026
- Source Documents
- 10
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 8 inspections from November 2023 to April 2026, state surveyors documented 48 findings at Pacific Gardens Nursing and Rehabilitation Center; 48 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 8
- 2023–2026, standard and complaint
- Findings
- 48
- Deficiencies cited by state inspectors
- Corrected
- 48
- Of 48 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 4 | 0 |
| 2024 | 3 | 5 | 1 |
| 2025 | 2 | 20 | 1 |
| 2026 | 2 | 19 | 0 |
What the Record Shows
- 48 of 48 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $30,654, its payment not published.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, April 24, 2026, recorded 18 findings (most serious: Level E).
What to Ask About
- Professional Standards, Cited in Four Inspections
- Kitchen and Food Safety, Cited in Three Inspections
- Residents Taking Their Own Medication, Cited in Two Inspections
- A Clean, Homelike Setting, Cited in Two Inspections
- Care Plans, Cited in Two Inspections
- Nutrition and Hydration, Cited in Two Inspections
- Citation F757, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- Pacific Gardens Nursing and Rehabilitation Center
- Address
- 577 S. Peach Ave., Fresno, CA 93727
- CMS Certification Number
- 056207
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 188
- Ownership
- For profit - Limited Liability company
- Record Window
- November 30, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Standard health inspection
18 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F803Ensure 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.Level ENo actual harm, potential for moreCorrected May 15, 2026
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F700Try 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.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected May 15, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 15, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 3, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F621Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment sourceLevel DNo actual harm, potential for moreCorrected Oct 1, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
19 findings
- F688Provide 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.Level GActual harmCorrected Mar 11, 2025
- F578Honor 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.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F924Put firmly secured handrails on each side of hallways.Level ENo actual harm, potential for moreCorrected Mar 11, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F625Notify 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.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 11, 2025
Enforcement Action
Civil money penalty, $30,654 imposed February 7, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 7, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 29, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Dec 29, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 1, 2024
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Nov 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
4 findings
- F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Dec 28, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
- F584Honor 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.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Dec 28, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Professional Standards, Cited in Four Inspections
Inspectors cited F658 in November 2024, February 2025, April 2026 and April 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F658 across all 8 inspections, oldest to newest - 2
Kitchen and Food Safety, Cited in Three Inspections
Inspectors cited F812 in October 2024, February 2025 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F812 across all 8 inspections, oldest to newest - 3
Residents Taking Their Own Medication, Cited in Two Inspections
Inspectors cited F554 in November 2023 and April 2026. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F554 across all 8 inspections, oldest to newest - 4
A Clean, Homelike Setting, Cited in Two Inspections
Inspectors cited F584 in November 2023 and February 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F584 across all 8 inspections, oldest to newest - 5
Care Plans, Cited in Two Inspections
Inspectors cited F656 in February 2025 and April 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F656 across all 8 inspections, oldest to newest - 6
Nutrition and Hydration, Cited in Two Inspections
Inspectors cited F692 in November 2023 and April 2026. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F692 across all 8 inspections, oldest to newest - 7
Citation F757, Cited in Two Inspections
Inspectors cited F757 in February 2025 and April 2026. The agency describes it this way: Ensure each resident’s drug regimen must be free from unnecessary drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F757 across all 8 inspections, oldest to newest - 8
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in February 2025 and April 2026. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F760 across all 8 inspections, oldest to newest - 9
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in February 2025 and April 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F761 across all 8 inspections, oldest to newest - 10
Infection Control, Cited in Two Inspections
Inspectors cited F880 in February 2025 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242425252626F880 across all 8 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in four inspections, most seriously at level E.
- 02
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
- 03
How do you decide whether a resident may keep and take their own medications?
Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.
- 04
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
- 05
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D.
- 06
How are weight and fluid intake tracked, and what happens when a resident starts losing weight?
Nutrition and Hydration: cited in two inspections, most seriously at level D.
- 07
What changed after F757 was cited, and how do you check it now?
Citation F757: cited in two inspections, most seriously at level E.
- 08
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 09
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
- 10
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 12
What led to the 2025 fine, and has it been paid?
A $30,654 civil money penalty was imposed February 7, 2025. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Nov 30, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Mar 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Nov 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Feb 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Apr 1, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Apr 24, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 056207
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowNovember 30, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before November 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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