Keystone Post-Acute
3672 North First Street, Fresno, CA 93726 · Fresno County · 65 certified beds · avg 61 residents/day · certified since Feb 25, 1971
Part of chain: EDURO HEALTHCARE (34 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Nov 15, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 28, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 5, 2022 · F-0656
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 30, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 5, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 22, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (48)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 8, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 5, 2026 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| May 30, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 30, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 30, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 30, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 30, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 30, 2025 | D · Potential for harm, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 30, 2025 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 21, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Apr 26, 2024 | F · Potential for harm, facility-wide | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 26, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Apr 26, 2024 | F · Potential for harm, facility-wide | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 26, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 26, 2024 | E · Potential for harm, repeated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
| Apr 26, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Apr 26, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 26, 2024 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Apr 26, 2024 | D · Potential for harm, one-off | The facility did not have firmly secured handrails on both sides of its hallways. |
| Nov 15, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 5, 2022 | ▲ G · Actual harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 5, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 5, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 5, 2022 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Aug 5, 2022 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 5, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 5, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (16 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 11 | 2 | G ▲ |
| 2023 | 2 | 1 | G ▲ |
| 2024 | 20 | 0 | F |
| 2025 | 13 | 0 | F |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $42,764, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Nov 15, 2023 | Fine | $42,764 |
| Nov 15, 2023 | Payment Denial | 13 days from Dec 15, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.62 | 4.31 | 3.95 | bottom 16% in California; bottom 43% in the U.S. |
| Registered Nurse hours | 0.22 | 0.61 | 0.69 | bottom 2% in California; bottom 3% in the U.S. |
| Weekend total nurse staffing | 3.24 | 3.90 | 3.50 | bottom 13% in California; bottom 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.51 | 0.48 | bottom 3% in California; bottom 6% in the U.S. |
| Total nursing staff turnover (%) | 47.1 | 36.7 | 45.8 | bottom 20% in California; bottom 44% in the U.S. |
| RN turnover (%) | 42.9 | 38.1 | 42.9 | bottom 39% in California; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.93, RN 0.23, weekend 3.51. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Eduro Healthcare LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 06/01/2019 |
| Fresno Nursing and Rehab Center LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/01/2019 |
| Bewsey, Michael | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2019 |
| Carter, Braeden | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/01/2024 |
| Fresno Nursing and Rehab Center LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2019 |
| Monroe, Dustin | Individual | Corporate Officer | NOT APPLICABLE | 07/19/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Oakwood Gardens Care Center | 0.3 mi | Fresno, CA | ★★★★★ | 4/5 | |
| Covenant Post Acute | 0.3 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Community Subacute and Transitional Care Center | 0.7 mi | Fresno, CA | ★★★★★ | 5/5 | |
| The Terraces at San Joaquin Gardens Village | 2.4 mi | Fresno, CA | ★★★★★ | 3/5 | |
| North Point Healthcare & Wellness Centre LP | 2.7 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Healthcare Centre of Fresno | 3.1 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Orchard Post Acute | 3.6 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Morning Star Post Acute | 4.0 mi | Clovis, CA | ★★★☆☆ | 2/5 | |
| Horizon Health & Subacute Center | 4.0 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Fresno Postacute Care | 4.1 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| Evergreen Care Center | 4.1 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| Sierra Vista Healthcare | 4.2 mi | Fresno, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 056266.