Healthcare Centre of Fresno

Inspectors wroteBased on interview and record review, the facility failed to ensure the Individual Narcotic Record (INR) for Controlled Drugs (medications that are highly regulated by the government because of the significant risk of abuse and dependence they pose) were maintained accurately for five of six sampled residents (Resident 26, Resident 74, Resident 139, Resident 158 and Resident 159) when:1. The Licensed Nurse (LN)s transferred controlled medications for Resident 26 and Resident 158 from one medication cart to another, and the INR was not accurately completed by two required witnesses as indicated on the INR. This failure had the potential for Resident 26 and Resident 158 controlled medications to be diverted (illegal transfer or use of prescription medication) and Resident 26 and Resident 158's pain not to be met.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards and ensure for five of eight sampled residents (Resident 18, Resident 86, Resident 92, Resident 119 and Resident 131) were free from significant medication errors, when Resident 86, Resident 119 and Resident 131's insulin (insulin lispro/ insulin aspart: fast-acting with a quick onset of 5-15 minutes injectable medication that lowers blood glucose (BG- sugar)) and Resident 18 and Resident 92's insulin (regular insulin: short-acting with a slower onset of 30-60 minutes injectable medication) were administered more than an hour before meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, homelike environment for two of nine sampled residents (Resident 11 and Resident 69) when:1. Resident 11's bedside table had the plastic strip pulled away from the edge of the table with jagged rough edges on the bedside table.2. Resident 69's overhead bed light did not have a string attached that allowed Resident 69 to turn the light on and off. These failures had the potential to create a non-homelike environment for Resident 11 and Resident 69 and placed Resident 11 and Resident 69 at risk of injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 13 sampled residents (Resident 5 and Resident 125) when:1. License Nurses (LN)s did not develop a detailed and person-centered care plan for Resident 5's pain. 2. LNs did not develop a care plan for Resident 125 indicating family preferences to not having the bedside table within reach due to safety concerns. These failures created the risk of inadequate care, potentially compromising Resident 5 and Resident125's safety and negatively affecting the overall quality of care and services provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage, supervision, and control of smoking materials for one of five sampled residents (Resident 37) when Resident 37 had a box of cigarettes with cigarettes inside placed on top of Resident 37's nightstand, accessible without staff knowledge or supervision. This failure had the potential to result in significant safety hazards, including unsupervised smoking, burn injuries, accidental fires, flash fires if smoking materials were used near oxygen equipment, and access to cigarettes by other residents. During a concurrent observation and interview on 5/5/2026 at 9:59 a.m. with Resident 37 in Resident 37's room, Resident 37 was observed lying in bed with a box of cigarettes with cigarettes inside, placed on top of Resident 37's nightstand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received food that was palatable, attractive and appetizing for three of five sampled residents (resident 43, resident 126, and resident 130) when the facility ran out of polenta (coarsely ground cornmeal (yellow or white) that is boiled in water or broth until it becomes a thick, creamy porridge), during the lunch meal service and it was replaced with mashed potatoes. The temperature of the potatoes had not been taken, and the potatoes had a water-like consistency with water visibly pooling in the corner of the pan. The potatoes were placed on the tray line and served to residents. This failure had the potential for resident choking, weight loss, and malnutrition due to residents not eating unpalatable mashed potatoes.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate residents' preferences and allergies and to follow the meal ticket (list of food dislikes, allergies, and texture of food), for one of eight sampled residents (Resident 69), when Resident 69 was allergic to orange juice and was served orange juice for her lunch time meal. This failure had the potential for undesired side effects including weight loss, rash, hives, and anaphylaxis shock (a severe, rapidly progressing, and potentially life-threatening systemic allergic reaction that affects multiple body systems simultaneously, such as the skin, breathing, and blood pressure).

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for two of nine sampled residents (Resident 6 and Resident 83), when Resident 6 and Resident 83's copy of the Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for Resident 6 and Resident 83's decisions regarding lifesaving treatment options and end of life wishes to not be honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program to help prevent the development and transmission of infections for four of 14 sampled residents (Resident 58, Resident 17, Resident 31, and Resident 59) when:1. Resident 58's foley catheter drainage tubing (a tube that is inserted into the urinary bladder to collect urine into a bag) was touching the floor and Resident 58's urine drainage bag (a bag that collects urine from a urinary catheter) was on the floor.2. The connector end of the feeding bag tubing for Resident 17 was left open to air and did not have a tube cover cap.3. The appropriate Personal Protective Equipment (PPE) was not worn during care for Resident 31 who was on contact precaution.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 14 residents (Resident 69 and Resident 93) had the ability to call for staff assistance through the call system (a communication system which relays the call directly to a staff member or to a centralized staff work area) when:1. Resident 69's call system was not working.2. Resident 93 was unable to reach her call button to access the call system while in their bed. These failures had the potential for Resident 69 and Resident 93 to not receive assistance or help from staff when needed and put Resident 69 and Resident 93 at risk of injury, harm and not having their needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to document changes in resident health status according to professional standards of practice and the facility's policy and procedure titled Licensed Nurse Weekly Progress Notes, for one of three sampled residents (Resident 1) when the facility nursing staff did not accurately assess, document and monitor Resident 1's skin changes that included multiple bruising to bilateral (both) upper thighs, knees, buttocks and right ankle. This failure placed Resident 1 at risk for further injury, potential for falls, increased pain and further skin breakdown.

Inspectors wroteBased on observation, interview and record review the facility failed to meet professional standards of practice and follow the policy and procedure titled, Referrals to Outside Services, Resident Rights and NP04 Comprehensive Person-Centered Care Planning for two of five sampled residents (Residents 2 and Resident 3) when: 1. Licensed Nurse (LN) did not develop a care plan when Resident 2 refused all showers from 1/26/26-2/19/26. This failure had the potential to result in Resident 2 developing wounds and infections.2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received necessary services for activities of daily living to maintain personal and oral hygiene for three of four sampled residents (Resident 1, Resident 2, Resident 3), when the facility staff did not provide oral care or grooming to Resident 1, Resident 2 and Resident 3 daily. These failures resulted in Resident 1, Resident 2 and Resident 3 to feel unclean and placed residents at risk for loss of dignity and potential tooth decay, oral, respiratory and skin infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the policy and procedures Medication Storage, Disposal of Medications and Medication Related Supplies and have a secure medication destruction bin (MDB- a bin for unused medications that are set to be destroyed) for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when the medication destruction bins' lids were not sealed. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices.

Inspectors wroteBased on observation, interview and record review the facility failed to store drugs in a safe manner for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when seven pills (Five in Medication room [ROOM NUMBER] and two in Medication room [ROOM NUMBER]) were found on the floor without packaging or labels. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the meal served on 1/7/25 reflected the menu items for 49 of 54 residents on the first floor (Resident 122, 73, 66, 34, 109, 88, 110, 69, 7, 84, 79, 3, 31, 96, 70, 61, 130, 131, 126, 37, 59, 105, 72, 111, 113, 108, 114, 64, 103, 65, 6, 8, 24, 39, 13, 60, 92, 23, 133, 20, 14, 15, 112, 86, 119, 48, 78, 101, 42) when residents received an alternate food for lunch on 1/7/25 due to the kitchen ran out of spinach bake. The facility failed to ensure the food served to the majority of residents on the first floor reflected the menu items served to other residents. The facility did not ensure sufficient food was cooked to serve the main menu items to all residents. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident requests, preferences for 141 of 141 sampled residents, when the lunch meal on 1/7/25 was served 30 to 45 minutes after the scheduled mealtime and the dinner meal on 1/10/25 was served 50 minutes after the scheduled mealtime. These failures had the potential to trigger resident feelings of anger and frustration which could diminish a resident's ability to eat resulting in a resident not meeting hydration and nutritional needs which could lead to unexpected weight loss or delay the timely recovery of clinical illness or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP-a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Residents 94 and 63) when: 1. Licensed nurses (LNs) did not implement CP for Resident 94's foley catheter (a thin, flexible tube that is inserted into your bladder to drain urine) to monitor signs and symptoms of infectious disease process. This failure had the potential for Resident 94 to develop an infection and placed an increased risk on Resident 94's health and safety. 2. Resident 63 did not have a comprehensive care plan for his diagnosis of Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the policy and procedure (P&P) to ensure the Care Plans (CP) were reviewed and revised for five of 23 sampled residents (Resident 45, 67, 74, 76, and 392) when: 1. The CP for Resident 45 was not reviewed and revised after Resident 45 had a fall and was sent to the acute care hospital. This failure placed Resident 45 at an increased risk for additional falls. 2. Resident 67's care plan was not updated and revised when his pressure ulcer (a wound which develops as a result of prolonged pressure to one area) progressed to a stage III (a deep skin wound where the full thickness of the skin is damaged, exposing the fatty layer underneath, but not reaching the muscle or bone) wound. This failure had the potential to result in Resident 67 to not receive the wound care needed. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of quality were met in accordance with the comprehensive care plan and facility policies and procedures for four of nine sampled residents (Residents 74, 67, 55 and 392) when: 1. Resident 67's change of condition and Nutritional Assessment for a facility acquired pressure ulcer (a wound which develops as a result of prolonged pressure to one area), Stage 2 pressure ulcer to right thigh and Stage 3 pressure ulcer to left buttock were not assessed. This failure had the potential for Resident 67's wounds to worsen which could result in more serious health condition. 2. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food was palatable and served at an appetizing temperature when 5 of 32 sampled residents (Resident 3, 67, 74, 96 and 112) complained of the food being served cold, undercooked and without flavor. This failure had the potential for Residents 3, 67, 74, 96 and 112 not eating their meal and placed their nutritional status at risk which could potentially lead to weight loss.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, staff and the public when: 1. Five of 23 residents' rooms on the first floor were observed with non functioning vertical blinds (window coverings made of long, vertical slats that are attached to a headrail and can be opened and closed by sliding along a track). These failures had the potential of violating residents rights to their privacy. 2. A hole measuring approximately 2.5 X 2.5 inches on the wall with exposed wiring. This failure had the potential to place residents and other staff in an unsafe environment which had the potential to lead to electrocutions and pest infestation. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for two of three sampled residents (Residents 69 and 191) when Residents 69 and Resident 191's urinary catheter (flexible tube inserted into bladder to drain urine) bag were uncovered and visible to other residents and visitors to see and not in accordance with facility's policy and procedure. This failure resulted in the violation of Residents 69 and 191's right to privacy and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the right to self-administer medication for one of seven sampled residents (Resident 92), when Resident 92 had not been assessed for her ability to keep her albuterol (a medication which makes it easier to breathe) inhaler at bedside and self-administer it as needed. This failure violated Resident 92's right to self-administer her own medication and had the potential to cause her to experience breathing difficulties as a result of not having her inhaler nearby.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Significant Change of Condition Assessment (an assessment which captures a major decline or improvement in a resident's condition) in the Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment for one of five sampled residents (Resident 67) when Resident 67 developed a facility acquired Stage 3 pressure ulcer (a wound which develops as a result of prolonged pressure to one area) to left buttock and did not have a significant change of condition assessment in accordance with facility's policy and procedure. This failure placed Resident 67 at risk for further decline in health including worsening of her wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR- The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a admission level screening and if necessary a level ll evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of six sampled residents (Resident 17) when Resident 17 was re-admitted to the facility on [DATE] and an updated PASRR was not completed. This failure had the potential for Resident 17 not to receive the necessary and appropriate psychiatric treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete personal hygiene and follow the policy and procedure (P&P) Grooming Care of the Fingernails and Toenails for one of one sampled residents (Resident 94), when staff did not cut Resident 94's fingernails on his contractured (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of movement of a joint or body part) right and left hands. This failure resulted in Resident 94 to have long fingernails that were growing into his hand with the potential to cause pain and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care and follow the policy and procedure (P&P) Grooming Care of the Fingernails and Toenails for one of seven sampled residents (Resident 40), when staff did not cut Resident 40's toenails. This failure resulted in Resident 40 having thick and long toenails and placed resident 40 at risk for an infection and pain when ambulating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 92) was provided food that accommodated her allergies and preferences, when Resident 92 had a listed dislike and allergy for lactose (sugar present in milk) products and was served milk on 1/7/25. This failure had the potential to cause Resident 92 to experience distress and an allergic reaction if she drank the milk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a mechanical soft diet (a diet that involves only foods that are physically soft with the goal of reducing or eliminating the need to chew the food) according to the physician order for one of 32 sampled residents (Resident 83) when, Resident 83 did not receive mechanical soft diet per physician's order and was served whole kernel corn with her meal. This failure placed resident 83 at risk for choking and aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident).

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate and complete medical records in accordance with facility's policy and procedure (P&P) and professional standards of practices for one of five sampled residents (Resident 137) when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete. Sections C for POLST form which included -artificially administered nutrition, physician signature, physician license, physician phone number, and date was incomplete. This failure had the potential for Resident 137's decisions regarding treatment options and end-of-life wishes to not be honored.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 55) when Resident 55's oxygen nasal cannula (O2 NC- tube that directs oxygen into the nose) tubing and nebulizer mask (a mask used to inhale liquid medication in the form of a mist to treat lung conditions) were laying on the residents nightstand not in a protective bag. This failure had the potential to result in Resident 55's O2 NC tubing and nebulizer mask getting bacteria and potentially resulting in a respiratory infection (an illness that inflames the respiratory system, which includes the throat, nose, airways, and lungs).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when facility had knowledge of Resident 1's preference to sit outside, had a history of falls, and required assistance with personal care. Facility staff did not provide supervision while Resident 1 was outside and were unaware Resident 1 left the facility's premises on 10/1/24 unsupervised. These failures resulted in Resident wandering unsafely in the streets around the facility and suffering an avoidable auto versus pedestrian accident. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of quality for one of nine sampled residents (Resident 1) when, Licensed Vocational Nurses (LVN)s did not administer oxygen (O2- a colorless, odorless and tasteless gas essential for life) per physician's order for Resident 1 and physician ordered parameters for O2 administration were not followed. LVNs did not document the administration of O2 treatment for Resident 1 in Treatment Administration Record (TAR). This failure had the potential for Resident 1 to receive inadequate amount of O2 which could affect her health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free form involuntary seclusion not required to treat the resident's medical symptoms for two of three sampled residents (Resident 1 and Resident 2), when Licensed Vocational Nurse (LVN) 1 closed the door to Resident 1 and Resident 2's room while the needs of both residents (Resident 1 and Resident 2) were not met. This failure resulted in isolation for Resident 1 and Resident 2 and their basic care needs were unmet. Resident 1 expressed feeling sad, unheard and angry when she did not receive the assistance to leave her room to a quiet area of choice and was instead left in her room with Resident 2, while Resident 2 was yelling with closed door.

Inspectors wroteBased on observation interview and record review the facility failed to ensure an environment free of accident hazards for one of three sampled residents (Resident 1), when on 7/12/24 Resident 1 removed the window screw, opened the window, and jumped from the facility's second story. Certified Nursing Assistant (CNA) 1 noted a change in Resident 1's demeanor and heard Resident 1 stating she is done and did not report to licensed staff. This failure resulted in Resident 1 sustaining a fracture (broken bone) of multiple ribs on the right side, laceration (bleeding or tearing) of the liver, fracture of the right femur (bone of the thigh articulating at the hip and the knee), and right pneumothorax (when air builds up in the space between the chest wall and lung and puts pressure on the lung causing it to collapse).

Inspectors wroteBased on observation interview and record review the facility failed to provide a safe environment for 28 of 134 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27 and Resident 28) when 15 resident rooms were observed to have loose window screws that were used to secure the windows in place from opening more than three inches (unit of measure) on the second and third floors of the facility. This failure placed residents in an unsafe environment which could potentially lead to an avoidable resident injury.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for 181 out of 181 residents, when on 7/9/2024 the dish washing station was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink on the floor where dirty dishes were placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. The walls of the dishwashing area had roaches nesting in the corners. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide needed care according to professional standards of practice for one of three sampled Residents (Resident 1) when Resident 1 did not receive pain medication according to physician ' s order for three days. This failure had the potential to result in inadequate pain management for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of five sampled residents (Resident 1) when Resident 1 fell out of bed during provision of care by Certified Nurse Assistant (CNA) without assistance from another staff member in accordance with the Comprehensive Assessment and needs of the resident. This failure resulted in Resident 1 having an avoidable fall, sustaining injuries of a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and experienced pain.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of practice when one of nine sampled residents (Resident 1) had dry, cracked peeling skin to his left foot and there was no documented weekly skin assessment that included documentation of Resident 1's feet appearance by the licensed nurses since 9/9/23. This failure had the potential for Resident 1's left foot treatment status and progress to worsen.

Inspectors wroteBased on observations, interviews, record review, and facility document review, the facility failed to serve palatable food for 2 of 2 sampled test trays. This deficient practice had the potential to affect 122 of 122 residents who received meals from the kitchen.

Inspectors wroteBased on observations, interviews, record review, and facility policy reviews, the facility failed to ensure 1 (Resident #31) of 2 sampled residents reviewed for assistance with activities of daily living (ADLs) were treated with dignity during mealtimes. Specifically, facility staff placed a meal tray in front of Resident #31, left the room, and continued to deliver trays to other residents before returning to feed Resident #31. In addition, Resident #31's roommates were served and consumed their meals before Resident #31 received their meal tray.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident # 31) of 2 sampled residents reviewed for assistance with activities of daily living (ADLs) had a care plan that addressed the level of assistance the resident required for ADLs.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure 1 (Resident #62) of 4 sampled residents reviewed for smoking did not use an electronic cigarette device (e-cigarette; vape product) in their room. In addition, staff failed to ensure Resident #62's Smoking and Safety assessment reflected the resident's use of vape products, despite staff's knowledge the resident vaped.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure nursing staff followed a physician's order for water flushes for 1 (Resident #102) of 1 resident in the facility with a gastrostomy tube (a surgically placed device used to administer supplemental feeding, hydration, or medication directly to the stomach). Specifically, Resident #102 was ordered to receive a 200 milliliters (mL) water flush every four hours (q4h), but during 2 of 4 observations, the resident only received 150 mL q4h.

Inspectors wroteBased on observations, interviews, record review, and facility document and policy review, the facility failed to serve meals according to the planned menu. Specifically, planned menu items were not provided to all residents who received food from the kitchen for 2 of the 6 meals observed during the recertification survey.