Pacific Gardens Nursing and Rehabilitation Center
577 S. Peach Ave., Fresno, CA 93727 · Fresno County · 188 certified beds · avg 164 residents/day · certified since Jul 6, 1970
Part of chain: COVENANT CARE (12 facilities, chain avg rating 2.8★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$30,654
Fines, last 3 years
3.94
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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 · Feb 7, 2025 · F-0688
The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Why it matters: Without this care, residents can develop stiff, contracted joints and lose the ability to move on their own.
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: Mar 11, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 15, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Apr 1, 2024 (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 |
|---|---|---|
| Apr 24, 2026 | 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 24, 2026 | 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. |
| Apr 24, 2026 | E · Potential for harm, repeated | 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. |
| Apr 24, 2026 | 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. |
| Apr 24, 2026 | 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. |
| Apr 24, 2026 | 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. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 24, 2026 | 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. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 24, 2026 | 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 24, 2026 | D · Potential for harm, one-off | 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 24, 2026 | D · Potential for harm, one-off | 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. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Apr 24, 2026 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Apr 24, 2026 | D · Potential for harm, one-off | 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 24, 2026 | 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. |
| Apr 1, 2026 | 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 |
| Aug 27, 2025 | D · Potential for harm, one-off | The facility did not treat all residents equally in transfers, discharges, and services — treatment differed based on how a resident paid, such as Medicaid versus private pay. · from a complaint |
| Feb 7, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Feb 7, 2025 | 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. |
| Feb 7, 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. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Feb 7, 2025 | 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. |
| Feb 7, 2025 | 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. |
| Feb 7, 2025 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. |
| Feb 7, 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. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Feb 7, 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. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 7, 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. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Feb 7, 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. |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Feb 7, 2025 | 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 7, 2025 | D · Potential for harm, one-off | 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. |
| Feb 7, 2025 | 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. |
| Nov 26, 2024 | 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 |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Oct 4, 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 |
| Oct 4, 2024 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Mar 15, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Nov 30, 2023 | 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. |
| Nov 30, 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. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (19 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | E |
| 2024 | 5 | 1 | G ▲ |
| 2025 | 20 | 1 | G ▲ |
| 2026 | 19 | 0 | E |
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 $30,654.
| Date | Type | Amount / length |
|---|---|---|
| Feb 7, 2025 | Fine | $30,654 |
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) | 3.94 | 4.31 | 3.95 | bottom 37% in California; top 42% in the U.S. |
| Registered Nurse hours | 0.66 | 0.61 | 0.69 | top 27% in California; top 41% in the U.S. |
| Weekend total nurse staffing | 3.63 | 3.90 | 3.50 | bottom 42% in California; top 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.61 | 0.51 | 0.48 | top 21% in California; top 22% in the U.S. |
| Total nursing staff turnover (%) | 35.9 | 36.7 | 45.8 | top 49% in California; top 26% in the U.S. |
| RN turnover (%) | 39.3 | 38.1 | 42.9 | bottom 47% in California; top 46% 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 4.06, RN 0.68, weekend 3.74. Staffing rating: 4/5.
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: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Centre Capital Investors V, LP | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (b), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (q), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Centre Covenant Purchaser (s), LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Centre V Secondary Fund, L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Covenant Care California, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 07/17/2008 |
| Covenant Care, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 07/17/2008 |
| Covenant Holdco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Covenant Subco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Evans, Mary | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Levin, Robert | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Sims, Christine | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| State Treasurer of Mich Custodian of Public School Empl RTMNT Systems | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Stockwell Fund II LP | Organization | 5% or Greater Indirect Ownership Interest | — | 12/19/2008 |
| Torok, Andrew | Individual | 5% or Greater Indirect Ownership Interest | — | 07/17/2008 |
| Ashley, Dava | Individual | Corporate Officer | NOT APPLICABLE | 05/17/2018 |
| Ashley, Dava | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/26/2018 |
| Carney, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2013 |
| Evans, Mary | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2013 |
| Evans, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/14/2006 |
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 do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "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 |
|---|---|---|---|---|---|
| Evergreen Care Center | 0.2 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| Orchard Post Acute | 0.7 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Stonehaven Senior Living | 0.9 mi | Fresno, CA | —/5 | ||
| Sierra Vista Healthcare | 1.8 mi | Fresno, CA | ★★★☆☆ | 3/5 | |
| California Home for the Aged | 2.8 mi | Fresno, CA | ★★★★★ | 5/5 | |
| Grace Healthcare Center | 2.9 mi | Fresno, CA | ★☆☆☆☆ | 1/5 | |
| Healthcare Centre of Fresno | 3.9 mi | Fresno, CA | ★★☆☆☆ | 2/5 | |
| Oakwood Gardens Care Center | 4.0 mi | Fresno, CA | ★★★★★ | 4/5 | |
| Covenant Post Acute | 4.0 mi | Fresno, CA | ★★★☆☆ | 2/5 | |
| Keystone Post-Acute | 4.3 mi | Fresno, CA | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 056207.