Home / California / Fresno
3672 North First Street, Fresno, CA 93726 · Fresno County · (559) 227-5383
65 certified beds, about 61 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1971
CMS Care Compare ratings, data as of September 1, 2026 · CCN 056266 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 17, 2026, inspectors cited 9 health deficiencies (the California average is 15.6, the national average 9.2).
Of 46 health citations since October 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $42,764 in the last three years; the largest was $42,764, and the latest is dated November 15, 2023.
Nurses and nurse aides worked 3.93 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.23 of those hours.
47.1% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to Eduro Healthcare, an affiliated group of 34 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.
Inspectors wroteBased on interviews and record reviews the facility failed to meet the minimum requirement of a registered nurse (RN) on duty for eight consecutive hours per day, seven days per week when a RN was not on duty for a the minimum eight consecutive hours for 12 days in May 2026, 24 days in June 2026, and 17 days in July 2026. This failure had the potential to result in residents not receiving services required to be provided by a RN.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to eradicate and contain the presence of pests when:1. Cockroaches were observed in the kitchen on 7/14/26 and 7/15/26. This failure had the potential to place 64 out of 65 residents receiving food from the kitchen at risk for cross-contamination when cockroaches were observed in the kitchen, and throughout the facility, since 10/23/25. 2. A fly was observed on 7/14/26 in the shared room of Resident 34 and Resident 38 and Resident 34 was holding a fly swatter. Resident 22 was observed with a fly swatter in her container for personal items on her bedside table which was positioned over her bed, and a fly was observed in the hallway between the kitchen and dining room on 7/15 /26. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for one of six sampled residents (Resident 32) when Resident 32's shared bathroom had a hole in the bathroom ceiling exposing white, cotton-like, dusty substance inside. This failure placed Resident 32 in an unclean, unsafe, unsanitary and non-homelike environment which could affect Resident 32's well-being.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for three of 12 sampled residents (Resident 2, Resident 25 and Resident 38) when:1. Resident 2 had edema (swelling caused by excess fluid trapped in your body's tissues) to the lower left extremity and no weekly progress skin assessment, change in condition and care plans were done. This failure had the potential to place Resident 2's at risk for increased edema and hospitalization.2. The physician and Resident Responsible Party (RP) were not notified when Resident 25 declined related to having their nails trimmed. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care and treatment, in accordance with professional standards of practice for one of six sampled residents (Resident 25) when Resident 25 had long, overgrown and jagged fingernails. This failure had the potential to result in Resident 25 cutting his skin with his long fingernails, leading to poor wound healing, infection, and hospitalization.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management was provided consistent with professional standards of practice and comprehensive person-centered care plan for one of six sampled residents (Resident 38) when Licensed Nurses did not address Resident 38's frequent complaints of pain after her pain medication frequency was changed. This failure resulted in Resident 38's frequent complaints of pain going unrelieved and had the potential for Resident 38's needs to be unmet and her physical well-being to go unsupported.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served safely when the ice machine was observed with yellow, brown and black colored residue under the ice grate (a compartment within the ice machine that determines the size of the ice cubes that are produced). This failure resulted in the facility ice machine not being in a clean safe operating condition which can lead to the growth of microorganisms and result in foodborne illness for 64 out of 65 residents receiving ice at the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for one of six sampled residents (Resident 38) when Resident 38 was not placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant bacteria that requires gown and glove use during high contact resident care activities) for her two surgical incision wounds and ileostomy (an opening on the belly that connects the last part of the small intestine to the outside of the belly)This failure placed Resident 38 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable working environment for kitchen staff when temperature readings exceeded 85 degrees Fahrenheit ( F -measurement of temperature) in the kitchen. This failure resulted in kitchen staff visible sweating during plating of meals in the kitchen which could increase the risk of unsafe and unsanitary handling of resident food.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from accidents for one of three sampled residents (Resident 1) when Resident 1 was not assessed for safe transfer, seating, and supervision needs prior to being transferred and Resident 1 was left unattended in wheelchair despite documented weakness and limited mobility on 4/17/26This failure resulted in Resident 1 experiencing an unwitnessed fall from a wheelchair on 4/21/26 onto the floor. After the fall Resident 1 experienced facial abrasions and busing and was sent to the general acute care hospital (GACH) for evaluation.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accept one of four resident's (Resident 1) back after hospitalization when Resident 1 required the services provided by the skilled nursing facility (SNF) and was sent to the hospital for an urgent transfer due to a critically low hemoglobin (protein in red blood cells that carries oxygen from the lungs to the rest of the body) level of 4.5 (normal hemoglobin levels for men range from 13.5-17.5). After being stabilized at the hospital, Resident 1 was denied readmission to the SNF.This failure resulted in Resident 1 not being readmitted to the skilled nursing facility.
Inspectors wroteBased on observation, interview and record review the facility failed to prepare and distribute food in accordance with professional standards for food service safety when one three-compartment sink in the kitchen did not contain air gaps (unobstructed vertical space between the water outlet and the flood level of a fixture) to prevent backflow of sewage (waste) water on 5/27/25 for 58 of 59 residents who consumed food prepared in the kitchen. This failure placed residents at risk for foodborne illness (illness caused by consuming contaminated food or drink) and food contamination.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services met the needs of two out of three sampled resident's (Resident 54 and Resident 166) when three controlled medication (medication with a high potential for physical and mental dependence) entries for Resident 54 and four controlled medication entries for Resident 166 did not have received by dates in the controlled drug disposition log. This failure resulted in inadequate record keeping of controlled medication which had the potential to lead to inaccurate controlled medication inventory, delayed medication destruction, diversion (when healthcare providers obtain or use prescription medicines illegally) of controlled medications and delayed identification of controlled medication diversion.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for three of 15 residents (Residents 3, 16, and 31) when Residents 3, 16 and 31 failed to receive insulin (a short-acting insulin [a hormone that lowers the levels of sugar in the blood] used to treat diabetes [a disorder characterized by difficulty in blood sugar control and poor wound healing]) prior to eating their meal per physician's orders and manufacturer's recommendations. This failure had the potential to place the Residents 3, 16, and 31 at risk of not receiving the desired amount of insulin which could result in hypoglycemia (low blood glucose [b/s - a simple sugar] the body's primary source of energy from food) and potentially lead to negative medical outcomes.
Inspectors wroteBased on observations, interview, and record review, the facility failed to properly label medication in the medication room and in two of three medication carts when: 1. Resident 25's inhaler was stored in the medication room and not labeled. 2. Resident 11's, Resident 19's and Resident 28's eye drops, as well as Resident 167's liquid morphine sulfate (controlled medication used to treat pain) was stored in medication cart A and not labeled. 3. Resident 39's and Resident 216's eye drops was stored in medication cart B and not labeled. These failures had the potential to result in misidentification of a medication, for Residents 25, 11, 19, 28, 167, 39 and 216 and had the potential for needed medication to not be available for resident use.
Inspectors wroteBased on observation, interview and record review the facility failed to promote quality of life for two of 11 sampled residents (Resident 59 and Resident 30) when Resident 59 did not receive a shower on 5/8, 5/12, 5/15, 5/19, and 5/26 and Resident 30 did not receive a shower on 5/9, 5/13, 5/16, and 5/20. This failure resulted in nine missed opportunities for personal hygiene care and resulted in Resident 59 to feel dirty, neglected and isolated and Resident 30 to feel dirty and gross.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of eleven sampled residents (Resident 38) was provided the opportunity to participate in his care process when the facility did not attempt to contact Resident 38's family or friends to act as a representative or decision maker on or throughout admission and did not involve Resident 38's, family, friends or a patient care representative prior to obtaining informed consents. This failure had the potential to result in Resident 38's wishes and preferences not being upheld by the acting facility representative which had the potential to lead to decreased autonomy (ability to make own decisions and control own actions) or participation in his care planning process.
Inspectors wroteBased on observation, interview and record review, facility failed to ensure one of 11 sampled residents (Resident 16) was provided with safe, clean, comfortable furniture that is in good working condition when the over-the-bed table had an approximate 2-inch by 1.5-inch chip out of the corner of the table with exposed sharp edges and a visible area that would be considered a porous surface leaving the area a potential for injury and unable to be cleaned. This failure had a potential to result in Resident 16 sustaining serious injuries, including skin tears and infection.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive individualized care plan was developed and implemented for one of 15 residents (Resident 57) when Resident 57 ' s care plan was not developed and implemented for monitoring and care of his central venous catheter port (a thin tube that goes into a vein in your arm or chest and ends at the right side of your heart and is attached to a device [port] under the skin) and surgical incision wound. This failure had the potential to put Resident 50 at increased risk for wound infection, pain, discomfort and medical complications of his indwelling central line due to improper care and monitoring of his device and surgical incision wound.
Inspectors wroteBased on observation, interview and record review the facility failed to follow professional standards for one of 11 sampled residents (Resident 216) when Resident 216 did not have his urinary catheter(a hollow tube inserted into the bladder to drain and collect urine) changed per physician order, the physician was not notified that the catheter was not changed and Resident 216 had signs that included mucus and sediment in the catheter tubing, amber-colored foul-smelling urine. This failure resulted in a missed urinary catheter change, and the lack of notification regarding Resident 216 ' s catheter tubing had the potential of delayed diagnosis and treatment of a urinary tract infection, increasing risk of worsening infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eleven sampled residents (Resident 38) was effectively and efficiently cared for by the administrator to maintain Resident 38's highest practicable physical, mental, and psychosocial well-being when the Administrator (ADM) was the acting decision maker for Resident 38. This failure had the potential to result in Resident 38 to not maintain his highest well-being, wishes and preferences not being upheld which had the potential to lead to decreased autonomy (ability to make own decisions and control own actions) or participation in his care planning process.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for two of 26 sampled residents (Resident 57 and Resident 216) when: 1. When Resident 57 was not placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) for his central venous catheter port (a thin tube that goes into a vein in your arm or chest and ends at the right side of your heart and is attached to a device [port] under the skin) incision wound. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 46) had access to a call light when Call light cord was found strung over the head of the bed and the call light was tucked between the mattress and the bed frame. This failure resulted in Resident 46 not being able to directly call for assistance and had the potential to place Resident 46 at risk for accidents and injuries.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and an accident-free environment for one of two sampled residents (Resident 1), when Resident 1 eloped (a resident who departs from a facility unsupervised and undetected) on 3/10/25 from the facility through the front entrance door and was found on 3/14/25 when resident returned back to her apartment. This failure resulted in Resident 1 eloping from the facility on 3/10/25, which placed Resident 1 at risk for harm, injury and/or death.
Inspectors wroteBased on interview and record review, the facility failed to revise and implement a comprehensive person-centered care plan for two of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were involved in a resident to resident verbal altercation on 9/20/24, the Interdisciplinary Team (IDT-a group of health care professionals with various areas of expertise who work together to establish goals for residents) met on 9/23/24 and implemented Social Services Director (SSD) and Activities Director (AD) daily visits from 9/23/24 to 9/25/24 and Resident 1 and Resident 2's care plans were not updated to reflect these interventions. Resident 1 and Resident were not seen by the SSD and the AD on 9/24/24 and 9/25/24. [...]
Inspectors wroteBased on interview and record review, the facility failed to maintain complete, accurately documented and readily accessible medical records in accordance with accepted professional standards and practices for three of six sampled residents (Resident 1, Resident 2, and Resident 4) when: 1. Resident 1 had care plan interventions for 15 Minute Checks (staff member is checking on resident every 15 minutes) documentation from 9/20/24 to 9/23/24 (72 hours) and facility staff was unable to locate 15 Minute Checks documentation for 9/20/24 to 9/21/24. 2. Resident 2 ' s care plan had goals documented for Resident 1. 3. Resident 4 had care plan intervention for 15 Minute Checks documentation from 9/15/24 to 9/18/24 (72 hours) and facility staff was unable to locate 15 Minute Checks documentation for 9/17/24 and 9/18/24. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment for six of 61 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when an unknown visitor entered the building on two occasions, and on the second occasion, entered three resident rooms and stole a cellular telephone from Resident 1. This failure resulted in Resident 1 and Resident 2 experiencing fear and a theft of a cellular telephone from Resident 1.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when large pantry storage room temperatures were 96 degrees Fahrenheit (F- a unit used for measuring temperature) in the large pantry where dry goods (sugar, flour, oatmeal, cream of wheat, canned fruit, pancake mix, cornbread mix, chicken and beef flavored base, bottled lemon juice, packaged Jello, cooking oil, and packaged condiments) were stored. This failure had the potential for the dry goods to spoil and cause food-borne illness (stomach illness acquired from ingesting contaminated food) for residents that ate from the kitchen.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 16 of 16 Residents (Residents 6, 8, 25, 27, 29, 32, 35, 37, 38, 41, 43 44, 45, 48, 53, 270) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard [raised] or lowered position) and bed assist rails (a bed rail used to assist the resident with repositioning or getting in and out of bed) prior to installation, had consent (form signed by resident or family explaining the risks of bed rail use), used appropriate alternatives, and followed the manufacturers' recommendations and specifications for installing and maintaining bed rails prior to the use of the bed (side) rails when: 1. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse was designated as the Director of Nursing (DON) on a full time basis when the facility did not have a designated DON from 3/13/24 to 4/16/24. This failure resulted in the lack of guidance, direction and leadership to all nursing staff, and had the potential to impact the quality of care, quality of life and medical treatment and services for all facility residents.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ten out of .residents (Residents 37, 17, 7, 50, 41, 34, 16, 11, 26, 2) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. Resident 37 was administered fluoxetine (an antidepressant medication) and did not implement adequate behavior monitoring and side effect monitoring for the use of fluoxetine. 2. Resident 17 was administered buspirone and trazodone (antidepressant medications) and did not implement resident specific non-pharmacological (behavioral) interventions and adequate behavior monitoring for the use of buspirone and trazodone. 3. [...]
Inspectors wroteBased on observation, interview, record review, the facility failed to ensure food and ice were stored in accordance with professional standards for food service safety for all residents eating and drinking at the facility when: 1. The ice machine was not sanitized according to the manufacturer's directions 2. The dishes in dish machine were not sanitized according to the manufacturer's directions and the facility policy and procedure These failures had the potential to result in the growth of microorganisms and could lead to foodborne illnesses for the 63 residents eating food and drinking in the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician obtained Informed Consents (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medications (medication capable of affecting mind, emotions, and behavior) was completed for four of ten sampled residents (Residents 2, 34, 41, and 50) when: 1. Resident 2 received Olanzapine (an antipsychotic medication that can treat several mental health conditions like schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition that affects your moods) without an informed consent. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 10 of 16 sampled residents (Residents 1, 7, 26, 29, 35, 39, 45, 48, 53, and 271) when: 1. Residents 1, 7, 26 and 271's shared bathroom had blackened floor tiles with dirt on the floor, a loose doorknob with the doorknob plate hanging on the doorknob, missing paint and chipped areas on the lower bathroom door frame, and scattered black areas measuring one-half to two inches on the bathroom ceiling and a hole on the bathroom ceiling measuring two and one-half by two inches. Residents 1,7,26 and 271 2. Resident 29 and 53's joint bathroom had a discolored bathroom ceiling with bubbling and peeling paint. 3. Resident 35's wall guard protector (devices installed into walls made to stop beds and equipment from touching walls) was found to have peeling paint, and a large hole. 4. [...]
Inspectors wroteBased on 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 four of 62 sampled residents (Resident 11, Resident 41, Resident 44, and Resident 45) ) when: 1. Resident 45 did not have an individualized care plan developed and implemented for unintentional severe weight loss until 41 days after admission. This failure placed Resident 45 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. 2. Resident 11 did not have a person-centered CP to address his dental needs. This failure resulted in resident 11's dental and nutrition needs to go unmet. 3. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for three of seven sampled residents (Residents 11, 41, and 44) when: 1. Licensed Nurses (LNs) did not have physician orders for oxygen therapy (treatment intended to relieve or heal a disorder) administration for Resident 41 and Resident 44. 2. Oxygen tubing was not labeled with date/time and stored in a protective covering (such as a bag) when not in use to prevent contamination for Residents 11, 41, and 44. These failures resulted in residents receiving unnecessary oxygen treatment and the potential for infection from contaminated oxygen tubing.
Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff with the appropriate competencies and skill sets to provide nursing services and ensure residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being when: 1. One of seven Licensed Vocational Nurses (LVN)s did not receive a blood glucometer (a small portable device used to check sugar levels in the blood) competency skills check off after being hired. This failure had the potential to place residents at risk of being exposed to the spread of infections. 2. Four of seven LVNs did not complete their required mandatory annual competency trainings. 3. One of five Certified Nursing Assistants (CNA)s did not receive a competency skills check off after being hired. 4. Two of five CNAs did not complete their required mandatory annual competency trainings. [...]
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 eight sampled residents (Residents 23 and 31) when Resident 23 and 31's copy of 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 23 and 31'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 ensure a safe, and sanitary environment to help prevent diseases and infections when: 1. One of four residents sampled (Resident 32's) oxygen (O2) nasal cannula (NC-a tube that directs oxygen into the nose) was found on the floor and part of the tube was laying on top of a garbage can. 2. Three of four oxygen concentrators (a medical device that gives you extra oxygen) and filters sampled, were visibly soiled with dust and debris, and not cleaned according to manufacturer's recommendation. 3. One of one (central) nurses' station countertop was peeling, cracked and/or missing veneer (a thin decorative covering of fine wood applied to a coarser wood or other material) which exposed the porous, non-wipe-able countertop. 4. [...]
Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective training program for new and existing Licensed Nurses (LN's), Certified Nursing Assistants (CNAs), and ancillary (additional) support staff for demonstrated competency consistent with their expected roles in the areas of abuse, neglect and exploitation (the action of using someone or something unfairly for your own benefit) training, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) training, communication training, resident rights training, infection control training, and falls training, for six of 13 direct care staff. This failure had the potential to place residents at risk for care not provided in a safe and competent manner.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled Residents (Resident 45) reviewed for nutrition care when Resident 45 experienced a severe unplanned weight loss of 22 pounds (lbs-measurement of weight) or 11.2 % of admitting weight in 41 days from 3/6/24 to 4/16/24 when the Nutrition Assessment was not completed in a timely manner. As a result of these failures, Resident 45's compromised nutritional status was not addressed timely by the Registered Dietitian which could lead to further medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility and negatively affect the diagnoses for Resident 45 and the reasons for admission to the facility.
Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five residents (Resident 16) was offered or administered the pneumonia (infection that affects one or both lung) vaccine (a substance injected into the body to protect it against diseases). This failure placed Resident 16 at risk to develop pneumonia.
Inspectors wroteBased on observation, interview, record review), the facility failed to ensure physical environmental maintenance were maintained when: 1. There were multiple areas of the floor throughout the kitchen that had missing sections of epoxy (a type of synthetic resin floor system that is laid on top of concrete substrates as a form of protection and decoration). resulting in a build-up of food particles. This failure had the potential to result in the growth of pathogenic (an organism which can cause diseases in a host [person)] organisms and create an environment for pest harborage for the 62 residents eating food in the facility. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three hallways, handrail was firmly secured to the wall. This failure had the potential to result in injury to residents, visitors, and staff.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 7) was free from accidents, when Resident 7, who was identified as being at-risk for falls with a history of multiple falls in the facility, fell and was injured when left unattended in her unlocked wheelchair on 8/31/23. This failure resulted in Resident 7 being sent to the general acute care hospital (GACH) for evaluation. Resident 7 was diagnosed with an odontoid fracture (break of the second bone in the neck) and was hospitalized from [DATE] to 9/8/23.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan that provides direction for individualized care of the resident) for one of three sampled residents (Resident 1) when a fall intervention was not implemented for Resident 1. This failure resulted in an unwitnessed fall for Resident 1 on 8/23/23.
24 fire safety citations on file: 10 on July 17, 2026, 8 on May 30, 2025, 6 on April 26, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| November 15, 2023 | Fine | $42,764 |
| November 15, 2023 | Payment Denial | 13 days from December 15, 2023 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.93 | 4.52 | 3.86 |
| Registered nurses | 0.23 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.51 | 4.09 | 3.42 |
| Nurse aides | 2.47 | ||
| Licensed practical nurses | 1.22 | ||
| Nursing staff turnover (share who left in a year) | 47.1% | 36.7% | 45.8% |
| Registered nurse turnover | 42.9% | 38.1% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.16 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.09 on weekdays and 3.51 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.03 in April to June 2025 to 3.93 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.93 | 0.23 | 4.09 | 3.51 | 0.3% | 0 of 90 | 61 |
| Oct to Dec 2025 | 3.85 | 0.28 | 4.03 | 3.39 | 0.0% | 0 of 92 | 61 |
| Jul to Sep 2025 | 3.94 | 0.30 | 4.08 | 3.59 | 0.9% | 0 of 92 | 60 |
| Apr to Jun 2025 | 4.03 | 0.40 | 4.28 | 3.42 | 3.6% | 0 of 91 | 61 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 5.7 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.1 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.9 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.2 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 10.2 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.8 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 6.0 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.0 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 16.3 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Keystone Post-Acute's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (41.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
41.9% this home
No different from the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 123 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 131 eligible stays.
6.1% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 100 eligible stays.
44.7% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 47 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 76 residents counted.
0.0% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 76 residents counted.
75.0% this home
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 24 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: FRESNO NURSING AND REHAB CENTER LLC. CMS links this home to Eduro Healthcare, a group of 34 nursing homes averaging 2.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Fresno Nursing and Rehab Center LLC | 5% or greater direct ownership interest | Organization | 100% | 06/01/2019 |
| Eduro Healthcare LLC | 5% or greater indirect ownership interest | Organization | 100% | 06/01/2019 |
| Carter, Braeden | W-2 managing employee | Individual | 02/01/2024 | |
| Bewsey, Michael | Corporate officer | Individual | 06/01/2019 | |
| Monroe, Dustin | Corporate officer | Individual | 07/19/2022 | |
| Fresno Nursing and Rehab Center LLC | Operational/managerial control | Organization | 06/01/2019 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.