Oakwood Gardens Care Center

Name: Oakwood Gardens Care Center
Address: 3510 EAST SHIELDS, Fresno, CA, 93726, US
Telephone: 5592224807

3510 East Shields, Fresno, CA 93726 · Fresno County · 103 certified beds · avg 97 residents/day · certified since Jan 1, 1967

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.85

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

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.

All citations in the current public record (28)

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
Jan 9, 2026	D · Potential for harm, one-off	The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint
Jan 9, 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
Apr 22, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 2, 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. · from a complaint
Apr 2, 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. · from a complaint
Mar 17, 2025	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 30, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jan 30, 2025	B · Minimal risk, repeated	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Jul 8, 2024	D · Potential for harm, one-off	The facility required residents to give up Medicare or Medicaid benefits or pay privately as a condition of moving in, or failed to tell residents which types of care it does not provide. Both practices are against the rules. · from a complaint
Feb 17, 2023	F · Potential for harm, facility-wide	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.
Feb 17, 2023	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.
Feb 17, 2023	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.
Feb 17, 2023	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Feb 17, 2023	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.
Feb 17, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 17, 2023	E · Potential for harm, repeated	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Feb 17, 2023	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Feb 17, 2023	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.
Feb 17, 2023	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Feb 17, 2023	D · Potential for harm, one-off	The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards.
Feb 17, 2023	D · Potential for harm, one-off	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Mar 5, 2020	E · Potential for harm, repeated	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.
Mar 5, 2020	E · Potential for harm, repeated	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Mar 5, 2020	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Mar 5, 2020	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Mar 5, 2020	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Mar 5, 2020	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 5, 2020	B · Minimal risk, repeated	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (12 → 2).

Year	Citations	Worst severity that year
2020	7	E
2023	12	F
2024	1	D
2025	6	E
2026	2	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)

No fines or payment denials in the published 3-year window.

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)	3.85	4.31	3.95	bottom 30% in California; top 46% in the U.S.
Registered Nurse hours	0.29	0.61	0.69	bottom 10% in California; bottom 8% in the U.S.
Weekend total nurse staffing	3.58	3.90	3.50	bottom 37% in California; top 38% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.27	0.51	0.48	bottom 27% in California; bottom 26% in the U.S.
Total nursing staff turnover (%)	51.7	36.7	45.8	bottom 11% in California; bottom 32% in the U.S.
RN turnover (%)	0.0	38.1	42.9	top 1% in California; top 1% 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 4.01, RN 0.30, weekend 3.73. Staffing rating: 3/5.

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: 5/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bay Bridge Capital Partners, LLC	Organization	5% or Greater Indirect Ownership Interest	100%	11/05/2021
Hudson River Opco LLC	Organization	5% or Greater Direct Ownership Interest	100%	11/05/2021
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Grossman, Stephen	Individual	Contracted Managing Employee	NOT APPLICABLE	06/01/2002
Hobbs, Brett	Individual	W-2 Managing Employee	NOT APPLICABLE	12/01/2022
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"If I ask for a copy of my family member's records, how quickly will I get them and what does it cost?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"How many residents share each room, and what options are there for more privacy?"
"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
Covenant Post Acute	0.0 mi	Fresno, CA	★★★☆☆	2/5
Keystone Post-Acute	0.3 mi	Fresno, CA	★★☆☆☆	2/5
Community Subacute and Transitional Care Center	0.6 mi	Fresno, CA	★★★★★	5/5
The Terraces at San Joaquin Gardens Village	2.7 mi	Fresno, CA	★★★★★	3/5
Healthcare Centre of Fresno	2.8 mi	Fresno, CA	★★☆☆☆	2/5
North Point Healthcare & Wellness Centre LP	3.0 mi	Fresno, CA	★★★★★	5/5
Orchard Post Acute	3.4 mi	Fresno, CA	★★★☆☆	2/5
Fresno Postacute Care	3.9 mi	Fresno, CA	★★★☆☆	3/5
Sierra Vista Healthcare	3.9 mi	Fresno, CA	★★★☆☆	3/5
Evergreen Care Center	3.9 mi	Fresno, CA	★★★☆☆	3/5
Pacific Gardens Nursing and Rehabilitation Center	4.0 mi	Fresno, CA	★★★☆☆	2/5
Morning Star Post Acute	4.2 mi	Clovis, CA	★★★☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Fresno →

Facility data as of CMS processing date 2026-08-01. CCN 055204.

The Care File

Visit checklist — Oakwood Gardens Care Center

3510 East Shields, Fresno, CA 93726 · 5592224807

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "If I ask for a copy of my family member's records, how quickly will I get them and what does it cost?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "How many residents share each room, and what options are there for more privacy?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055204 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)