Cycle 1
Health 2025-02-07 · Fire 2025-02-07
20 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fresno, CA
Pacific Gardens Nursing And Rehabilitation Center
2-star overall rating with 2-star inspections with $30,654 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
577 S. Peach Ave., Fresno, CA
(559) 251-8463
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
188
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Covenant Care
Operator or chain grouping
Approved since
1970-07-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
0.38
Licensed practical nurse staffing
Aide hours / resident day
1.93
Nurse aide staffing
Weekend hours
2.74
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.5%
1.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
98.2%
1 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
6.8%
3.7 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
13.7%
4.5 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
14.2%
6.7 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
11.0%
0.6 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
10.9%
5.3 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.7%
0.1 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
94.0%
1.2 pts worse
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
93.2%
2.1 pts worse
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
23.2%
1.6 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-02-15 · Fire 2019-02-15
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-13
F · Potential for more than minimal harm
2025-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-14
C · Minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-30
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-12-30
D · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-30
D · Potential for more than minimal harm
2019-02-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-02-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-02-15
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2019-04-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
F621 · Resident Rights Deficiencies
Health
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Corrected 2025-10-01
G · Actual harm
2025-02-07
F688 · Quality of Life and Care Deficiencies
Health
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 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F578 · Resident Rights Deficiencies
Health
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 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F584 · Resident Rights Deficiencies
Health
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 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F761 · Pharmacy Service Deficiencies
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 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-07
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F625 · Resident Rights Deficiencies
Health
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 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-11
D · Potential for more than minimal harm
2024-11-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-29
D · Potential for more than minimal harm
2024-11-26
F726 · Nursing and Physician Services Deficiencies
Health
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 2024-12-29
F · Potential for more than minimal harm
2024-10-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-11-01
G · Actual harm
2024-03-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-01
E · Potential for more than minimal harm
2023-11-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F584 · Resident Rights Deficiencies
Health
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 2023-12-28
D · Potential for more than minimal harm
2023-11-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-15
E · Potential for more than minimal harm
2019-02-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-03-14
E · Potential for more than minimal harm
2019-02-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-03-14
E · Potential for more than minimal harm
2019-02-15
F761 · Pharmacy Service Deficiencies
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 2019-03-14
E · Potential for more than minimal harm
2019-02-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-03-14
E · Potential for more than minimal harm
2019-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-14
D · Potential for more than minimal harm
2019-02-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-03-14
D · Potential for more than minimal harm
2019-02-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-03-14
D · Potential for more than minimal harm
2019-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-14
D · Potential for more than minimal harm
2019-02-15
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2019-03-14
Penalties and ownership
What sits behind the stars
$30,654
2025-02-07
Fine
Fine · fine $30,654
Fine
Ownership
Ashley, Dava
Operational/Managerial Control · Individual
Ashley, Dava
Corporate Officer · Individual
Carney, Kevin
Corporate Officer · Individual
Centre Capital Investors V, LP
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (B), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (Q), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre Covenant Purchaser (S), LLC
5% Or Greater Indirect Ownership Interest · Organization
Centre V Secondary Fund, L.p.
5% Or Greater Indirect Ownership Interest · Organization
Covenant Care California, LLC
5% Or Greater Direct Ownership Interest · Organization
Covenant Care, LLC
5% Or Greater Direct Ownership Interest · Organization
Covenant Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Covenant Subco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Evans, Mary
5% Or Greater Indirect Ownership Interest · Individual
Evans, Mary
Operational/Managerial Control · Individual
Evans, Mary
Corporate Officer · Individual
Hassell, Lance
Operational/Managerial Control · Individual
Hassell, Lance
Corporate Officer · Individual
Levin, Robert
5% Or Greater Indirect Ownership Interest · Individual
Levin, Robert
Operational/Managerial Control · Individual
Levin, Robert
Corporate Officer · Individual
Midcap Funding Iv Trust
5% Or Greater Security Interest · Organization
Sims, Christine
5% Or Greater Indirect Ownership Interest · Individual
Sims, Christine
Operational/Managerial Control · Individual
Sims, Christine
Corporate Officer · Individual
Sparks, Carol
Operational/Managerial Control · Individual
State Treasurer Of Mich Custodian Of Public School Empl Rtmnt Systems
5% Or Greater Indirect Ownership Interest · Organization
Stockwell Fund Ii LP
5% Or Greater Indirect Ownership Interest · Organization
Torok, Andrew
5% Or Greater Indirect Ownership Interest · Individual
Torok, Andrew
Corporate Officer · Individual
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2-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
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3-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
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