Pacific Gardens Nursing and Rehabilitation Center
577 S. Peach Ave. · Fresno, CA · 93727 · 5592518463
188 certified beds For profit - Limited Liability company Chain: Covenant Care
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.11 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.68 | 0.55–0.75 |
| Weekend hours / resident-day | 3.77 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $30,654 |
Inspection citations (39 in the current record)
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Potential for harm · D April 1, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 3, 2026 · Resident Assessment and Care Planning
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Potential for harm · D August 27, 2025 · found via complaint
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Corrected October 1, 2025 · Resident Rights
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Actual harm · G February 7, 2025
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.
Corrected March 11, 2025 · Quality of Life and Care
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Potential for harm · D February 7, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 11, 2025 · Resident Rights
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Potential for harm · E February 7, 2025
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.
Corrected March 11, 2025 · Resident Rights
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Potential for harm · E February 7, 2025
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.
Corrected March 11, 2025 · Resident Rights
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Potential for harm · D February 7, 2025
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.
Corrected March 11, 2025 · Resident Rights
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Potential for harm · D February 7, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 7, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 7, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected March 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 7, 2025
Provide appropriate foot care.
Corrected March 11, 2025 · Quality of Life and Care
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Potential for harm · D February 7, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 11, 2025 · Quality of Life and Care
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Potential for harm · D February 7, 2025
Post nurse staffing information every day.
Corrected March 11, 2025 · Nursing and Physician Services
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Potential for harm · D February 7, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected March 11, 2025 · Pharmacy Service
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Potential for harm · D February 7, 2025
Ensure that residents are free from significant medication errors.
Corrected March 11, 2025 · Pharmacy Service
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Potential for harm · E February 7, 2025
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.
Corrected March 11, 2025 · Pharmacy Service
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Potential for harm · E February 7, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected March 11, 2025 · Nutrition and Dietary
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Potential for harm · E February 7, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 11, 2025 · Nutrition and Dietary
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Potential for harm · D February 7, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected March 11, 2025 · Resident Assessment and Care Planning
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Potential for harm · E February 7, 2025
Provide and implement an infection prevention and control program.
Corrected March 11, 2025 · Infection Control
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Potential for harm · E February 7, 2025
Put firmly secured handrails on each side of hallways.
Corrected March 11, 2025 · Environmental
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Potential for harm · D November 26, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 29, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 26, 2024 · found via complaint
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.
Corrected December 29, 2024 · Nursing and Physician Services
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Potential for harm · F October 4, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 1, 2024 · Nutrition and Dietary
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Potential for harm · F October 4, 2024 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected November 1, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 7, 2025 | Fine | $30,654 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056207 · certified since July 6, 1970. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.