California ›Fresno

Pacific Gardens Nursing and Rehabilitation Center

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577 S. Peach Ave., Fresno, CA 93727 (opens Google Maps) · Fresno County · (559) 251-8463· 188 certified beds · avg 164 residents/day · certified since Jul 6, 1970 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

Part of chain: COVENANT CARE (12 facilities, chain avg rating 2.8★)

2/5
Health inspection rating (on-site)
inspected Apr 24, 2026
2
Serious findings on record
most recent Feb 7, 2025
$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)

New to these records? How to read an inspection report →

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5 · how star ratings work →

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 quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Mar 11, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 1, 2024 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 48 inspection findings. Open the full record below to read every finding.

  1. E · Potential for more than minimal harm, pattern

    The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. F-0658

  2. E · Potential for more than minimal harm, pattern

    The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. F-0755

  3. E · Potential for more than minimal harm, pattern

    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. F-0757

View all 48 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Apr 24, 2026E · Potential for more than minimal harm, patternThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Apr 24, 2026E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Apr 24, 2026E · Potential for more than minimal harm, patternThe 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. · F-0757
Apr 24, 2026E · Potential for more than minimal harm, patternThe 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. · F-0759
Apr 24, 2026E · Potential for more than minimal harm, patternThe 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. · F-0761
Apr 24, 2026E · Potential for more than minimal harm, patternThe 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. · F-0803
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0554
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0605
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0677
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0700
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0805
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Apr 24, 2026D · Potential for more than minimal harm, isolatedThe 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. · F-0880
Apr 1, 2026D · Potential for more than minimal harm, isolatedThe 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 · F-0658
Aug 27, 2025D · Potential for more than minimal harm, isolatedThe 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 · F-0621
Feb 7, 2025▲ G · Actual harm, isolatedThe 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. · F-0688
Feb 7, 2025E · Potential for more than minimal harm, patternThe 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. · F-0578
Feb 7, 2025E · Potential for more than minimal harm, patternThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Feb 7, 2025E · Potential for more than minimal harm, patternThe 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. · F-0761
Feb 7, 2025E · Potential for more than minimal harm, patternThe facility did not have enough support staff to safely and effectively run its food and nutrition service. · F-0802
Feb 7, 2025E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Feb 7, 2025E · Potential for more than minimal harm, patternThe 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. · F-0880
Feb 7, 2025E · Potential for more than minimal harm, patternThe facility did not have firmly secured handrails on both sides of its hallways. · F-0924
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0550
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0625
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0656
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0657
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0687
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0732
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe 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. · F-0757
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760
Feb 7, 2025D · Potential for more than minimal harm, isolatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842
Nov 26, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0658
Nov 26, 2024D · Potential for more than minimal harm, isolatedThe 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 · F-0726
Oct 4, 2024F · Potential for more than minimal harm, widespreadThe 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 · F-0812
Oct 4, 2024F · Potential for more than minimal harm, widespreadThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925
Mar 15, 2024▲ G · Actual harm, isolatedThe 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 · F-0686
Nov 30, 2023E · Potential for more than minimal harm, patternThe 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. · F-0695
Nov 30, 2023D · Potential for more than minimal harm, isolatedThe 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. · F-0554
Nov 30, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Nov 30, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (19 → 18).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 4
Serious citations (G–L): 0
2024
All citations: 5
Serious citations (G–L): 1
2025
All citations: 20
Serious citations (G–L): 1
2026
All citations: 19
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
202340E
202451G ▲
2025201G ▲
2026190E

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)

How to file a complaint about care →

1 fine totaling $30,654.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Feb 7, 2025Fine$30,654

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.94
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: 0.66
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.63
California average: 3.90
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.944.313.95bottom 37% in California; top 42% in the U.S.
Registered Nurse hours0.660.610.69top 27% in California; top 41% in the U.S.
Weekend total nurse staffing3.633.903.50bottom 42% in California; top 36% in the U.S.
Weekend RN hours (not acuity-adjusted)0.610.510.48top 21% in California; top 22% in the U.S.
Total nursing staff turnover (%)35.936.745.8top 49% in California; top 26% in the U.S.
RN turnover (%)39.338.142.9bottom 47% in California; top 46% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.06 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Pacific Gardens Nursing and Rehabilitation Center. CMS inspection and staffing records do not tell us what this home will charge you.

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Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Centre Capital Investors V, LPOrganization5% or Greater Indirect Ownership Interest—07/17/2008
Centre Covenant Purchaser (b), LLCOrganization5% or Greater Indirect Ownership Interest—07/17/2008
Centre Covenant Purchaser (q), LLCOrganization5% or Greater Indirect Ownership Interest—07/17/2008
Centre Covenant Purchaser (s), LLCOrganization5% or Greater Indirect Ownership Interest—12/19/2008
Centre V Secondary Fund, L.P.Organization5% or Greater Indirect Ownership Interest—07/17/2008
Covenant Care California, LLCOrganization5% or Greater Direct Ownership Interest—07/17/2008
Covenant Care, LLCOrganization5% or Greater Direct Ownership Interest—07/17/2008
Covenant Holdco, LLCOrganization5% or Greater Indirect Ownership Interest—07/17/2008
Covenant Subco, LLCOrganization5% or Greater Indirect Ownership Interest—07/17/2008
Evans, MaryIndividual5% or Greater Indirect Ownership Interest—07/17/2008
Levin, RobertIndividual5% or Greater Indirect Ownership Interest—07/17/2008
Sims, ChristineIndividual5% or Greater Indirect Ownership Interest—07/17/2008
State Treasurer of Mich Custodian of Public School Empl RTMNT SystemsOrganization5% or Greater Indirect Ownership Interest—12/19/2008
Stockwell Fund II LPOrganization5% or Greater Indirect Ownership Interest—12/19/2008
Torok, AndrewIndividual5% or Greater Indirect Ownership Interest—07/17/2008
Ashley, DavaIndividualCorporate OfficerNOT APPLICABLE05/17/2018
Ashley, DavaIndividualOperational/Managerial ControlNOT APPLICABLE03/26/2018
Carney, KevinIndividualCorporate OfficerNOT APPLICABLE11/01/2013
Evans, MaryIndividualCorporate OfficerNOT APPLICABLE11/01/2013
Evans, MaryIndividualOperational/Managerial ControlNOT APPLICABLE04/14/2006

Showing 20 of 29 parties CMS has on file for this facility; 9 are not displayed. The full list is in the CMS Ownership dataset.

Other facilities in the same chain

CMS lists this facility under the chain Covenant Care — 12 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking. Showing 8 of the 11 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

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?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the California midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 36% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 29 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 29 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Evergreen Care Center0.2 miFresno, CA★★★☆☆3/5
Orchard Post Acute0.7 miFresno, CA★★★☆☆2/5
Stonehaven Senior Living0.9 miFresno, CA—/5
Sierra Vista Healthcare1.8 miFresno, CA★★★☆☆3/5
California Home for the Aged2.8 miFresno, CA★★★★★5/5
Grace Healthcare Center2.9 miFresno, CA★☆☆☆☆1/5
Healthcare Centre of Fresno3.9 miFresno, CA★★☆☆☆2/5
Oakwood Gardens Care Center4.0 miFresno, CA★★★★★4/5
Covenant Post Acute4.0 miFresno, CA★★★☆☆2/5
Keystone Post-Acute4.3 miFresno, CA★★☆☆☆2/5
Community Subacute and Transitional Care Center4.3 miFresno, CA★★★★★5/5
Fresno Postacute Care4.5 miFresno, CA★★★☆☆3/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Fresno, CA — 31 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Fresno →

Facility data as of CMS processing date 2026-08-01. CCN 056207.

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