The home failed to provide appropriate care to help a resident maintain or improve movement and mobility. Cited February 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 688 — 42 CFR §483.25(c) — S/S: G
Nursing home report
PACIFIC GARDENS NURSING AND REHABILITATION CENTER
FRESNO, CA · Medicare-certified · 188 beds
Needs attention
For-profitChain member
3 of 5 overall
Pacific Gardens Nursing and Rehabilitation Center in Fresno has a 3-star overall rating, with weak health inspection and staffing scores (2 stars each) but a 5-star quality rating. It has $30,654 in recent fines, a recent federal penalty, and reported nurse staffing of 4.11 hours per resident per day, just above the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
4.1116 hrs/resident/day
Quality measures
Last inspection: August 27, 2025Penalties, last 24 months: $30,654recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.1116.
Staffing detail
- Registered nurses
- 0.68
- Licensed practical nurses
- 0.69
- Nurse aides
- 2.74
- Weekend nursing
- 3.77
Hours per resident per day.
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
6.1%4.1%Improving
Residents with a fall causing major injury
0.9%2.7%Worsening
Residents with pressure ulcers (bedsores)
5.4%3%Improving
Residents with a urinary tract infection
0%0.9%Worsening
Residents who lost too much weight
5.1%5.9%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
6.2%4.9%Improving
Residents whose ability to walk got worse
11.4%10.9%Improving
Long-stay residents on antianxiety or sleep medication
8.8%6.8%Improving
Short-stay residents newly given an antipsychotic
0.9%1.4%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
8.7%6.6%Improving
Residents with depressive symptoms
4.8%3%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—99.2%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—91.1%—
Short-stay residents given the pneumonia vaccine
95%91.5%Worsening
What the inspectors found
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited March 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited October 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to make sure it had a pest control program to prevent or deal with mice, insects, and other pests. Cited October 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 925 — 42 CFR §483.90 — S/S: F
The home failed to honor residents’ choices about treatment, research participation, and advance care instructions. Cited February 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 578 — 42 CFR §483.10 — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $30,654 was recorded.
- INSPECTION
Health inspection found 19 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $30,654 in total fines.
- $30,654
Federal fine
Feb 7, 2025
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of COVENANT CARE · 19 homes · 3.1 stars avg
- Occupancy
- 154 residents on an average day (82% of 188 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 55 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.