8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fresno, CA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3510 East Shields, Fresno, CA
(559) 222-4807
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
103
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.28
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
12,307
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.26% · Performance 22.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.35% · Performance 8.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.30
Performance 46.09% · Measure score 4.30 · Achievement 4.30 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.87
Baseline 3.74 hours · Performance 3.33 hours · Measure score 0.87 · Achievement 0.87 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 256 · Observed rate 10.55% · Lower 95% interval 8.09% |
| Discharge to community | 43.28% |
50.57%
7.3 pts worse
|
Worse than the National Rate · Eligible stays 296 · Observed rate 36.49% · Lower 95% interval 37.94% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 185 · Denominator 185 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 185 |
| Discharge self-care score | 48.94% |
53.69%
4.8 pts worse
|
Numerator 46 · Denominator 94 |
| Discharge mobility score | 35.11% |
50.94%
15.8 pts worse
|
Numerator 33 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.16% |
2.29%
0.1 pts better
|
Numerator 4 · Denominator 185 · Adjusted rate 1.71% |
| Healthcare-associated infections requiring hospitalization | 8.4% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 187 · Observed rate 9.63% · Lower 95% interval 5.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 157 |
| Staff flu vaccination coverage | 91.33% |
42%
49.3 pts better
|
Numerator 158 · Denominator 173 |
| Discharge function score | 48.94% |
56.45%
7.5 pts worse
|
Numerator 46 · Denominator 94 |
| Transfer of health information to provider | 98.25% |
95.95%
2.3 pts better
|
Numerator 56 · Denominator 57 |
| Transfer of health information to patient | 89.89% |
96.28%
6.4 pts worse
|
Numerator 80 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 3.16% |
25.2%
22 pts worse
|
Numerator 3 · Denominator 95 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
98.5%
1.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
1.6%
0.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
6.8%
5.1 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 5.2% · 4Q avg 1.7% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
4.1%
2.2 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.1% · Q3 3.6% · Q4 8.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.6% |
13.7%
8.1 pts better
|
19.6%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.8% · Q3 5.4% · Q4 7.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
14.2%
10.2 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.7% · Q3 4.9% · Q4 2.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.3% |
11.0%
0.3 pts worse
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
10.7%
0.6 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 12.2% · Q3 1.9% · Q4 8.5% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
10.9%
5.7 pts worse
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 25.7% · Q3 15.0% · Q4 12.0% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.7%
3.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 1.0% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
94.0%
4.8 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.4% |
11.2%
9.2 pts worse
|
12.0%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 20.6% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.1% |
93.2%
8.1 pts worse
|
79.7%
5.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
23.2%
1.1 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 26.2% · Expected 25.8% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-02-12
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-02-12
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-02-12
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-12
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-12
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-01
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-02-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-04
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-02-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-20
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-20
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-20
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-20
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-20
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-03-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-20
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-20
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-08-31
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-08-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-08-31
Inspection history
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-03
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-03
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-24
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2025-02-24
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2024-09-05
Health
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 2023-03-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-18
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-03-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-18
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-18
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-03-18
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-18
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-18
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-18
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-03-18
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2023-03-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-11-24
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2020-11-24
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-11-24
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-11-24
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-11-24
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2020-11-24
Health
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected 2020-11-24
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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3-star overall rating with 2-star inspections with $174,074 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Fresno, CA
2-star overall rating with 2-star inspections with $42,764 in total fines with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Fresno, CA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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