Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Community Subacute And Transitional Care Center during CMS and state inspections, most recent first.
The facility failed to follow professional standards for food service safety by not adhering to diet orders for three residents and lacking an air gap under the food preparation sink. The Dietary Aide used incorrect portion sizes, potentially affecting residents' weight, while the absence of an air gap posed a risk of food contamination. These issues were confirmed by the Dietary Manager and Building Maintenance Supervisor, respectively.
A facility failed to ensure resident privacy and dignity in three incidents. A nurse administered medication and checked blood pressure without closing privacy curtains or doors, affecting two residents. Another resident's privacy curtain was tied in a knot, preventing its use. Staff interviews confirmed these actions did not respect residents' rights to privacy.
The facility failed to maintain complete and accurate medical records for three residents, as their POLST forms were incomplete and lacked essential information such as preparation and completion dates. This deficiency was identified during interviews and record reviews with staff, including the DON and nurses. The incomplete forms could potentially lead to the residents' healthcare treatment preferences not being honored.
A resident's MDS assessment failed to accurately reflect their use of antipsychotic medication, Olanzapine, despite being prescribed for unspecified psychosis. The MDS Coordinator acknowledged the oversight, and both the DON and administrator emphasized the need for accurate MDS assessments. The facility's policies and job descriptions also highlighted the importance of accurate and timely MDS completion.
A medication cart in the Transitional Unit contained a resident's Fluticasone Propionate without an open date and beyond use date, contrary to facility policy and professional guidelines. The LVN stated the facility followed the pharmacy's expiration date, while the DON confirmed the medication was used daily. Facility policy required labeling with the date opened, which was not adhered to, posing a risk of administering expired medication.
A resident's call light was repeatedly found out of reach, wrapped around a television arm, and on the floor, making it inaccessible. Despite staff acknowledging the importance of having the call light within reach, it remained inaccessible, potentially delaying care. The resident had serious medical conditions, and the facility's policy required accessible call systems, which was not followed.
Deficiencies in Food Service Safety and Compliance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by two main deficiencies. Firstly, the cook did not follow the diet orders for three residents, resulting in incorrect portion sizes being served. During a lunch service, the Dietary Aide used a 1/2 cup serving scoop instead of the required 1/4 cup scoop for residents with small portion diet orders. This error was observed by the Dietary Manager, who confirmed that the wrong scoop was used, potentially leading to undesired weight gain for the residents. The facility's policy and procedure, as well as the job description for the Dietary Aide, emphasize the importance of following standard recipes and diet orders accurately. Secondly, the facility's kitchen was found to lack an air gap under the food preparation sink, which is necessary to prevent sewage backup and contamination of food. This was confirmed during an observation and interview with the Building Maintenance Supervisor, who acknowledged the absence of an air gap. The FDA Food Code requires an air gap to prevent backflow and contamination, highlighting the facility's failure to comply with these safety standards. These deficiencies pose a risk of exposing residents to contaminated food and not adhering to prescribed dietary needs.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by three specific incidents involving residents. In the first incident, a registered nurse (RN) administered medication to a resident without providing privacy, as the privacy curtain and door were not closed, allowing staff and other residents to see inside the room. The resident had no cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. In the second incident, the same RN checked another resident's blood pressure without closing the privacy curtain or door, again failing to provide privacy. This resident had a moderate cognitive deficit, with a BIMS score of 9 out of 15. The RN acknowledged the oversight and the importance of respecting residents' rights to privacy. The third incident involved a resident's privacy curtain being tied in a knot, preventing it from being used to provide privacy. Staff interviews revealed that the curtain should not have been tied, and it was unclear who was responsible for this. The Director of Nursing suggested the resident might have tied the curtain themselves, but staff generally agreed that the curtain should have been untied to ensure privacy and dignity for the resident.
Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards for three residents. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 6, 41, and 55 were found to be incomplete. The forms lacked essential information such as the preparation and completion dates, which are necessary for the forms to be considered valid and accurate. This deficiency was identified during a series of interviews and record reviews conducted with various staff members, including the Director of Staff Development, Licensed Vocational Nurses, Registered Nurse, and the Director of Nursing. The incomplete POLST forms were not readily available as part of the current medical records for Residents 6 and 55, which could potentially lead to their healthcare treatment preferences not being honored. Resident 6 was admitted with diagnoses including end-stage renal disease and heart failure, while Resident 55 was readmitted with a history of transient ischemic attack and schizophrenia. The facility's policy and procedure, as well as professional standards by the Centers for Medicare and Medicaid Services, emphasize the importance of complete, dated, and authenticated medical records, which the facility failed to uphold in these instances.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the use of antipsychotic medication. Resident 6, who was admitted with diagnoses including unspecified psychosis and end-stage renal disease, was receiving Olanzapine, an antipsychotic medication, as per the Order Summary Report. However, the MDS assessment did not reflect this medication use, as confirmed by the Minimum Data Set Coordinator (MDSC) during a review. The MDSC acknowledged that the resident's use of antipsychotic medication was not coded in the annual MDS assessment, which was an oversight. Interviews with the Director of Nursing (DON) and the administrator revealed that there was an expectation for MDS assessments to be accurate and for MDS nurses to ensure the accuracy of their assessments. The facility's job description for the RN MDS Coordinator and the policy and procedure for MDS Assessment and Care Planning both emphasized the importance of accurate and timely completion of MDS assessments. This inaccuracy in coding had the potential to result in unmet care needs for Resident 6.
Medication Labeling Deficiency in Transitional Unit
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy. During an observation and interview, it was found that a medication cart in the Transitional Unit contained a medication for a resident, Fluticasone Propionate, which lacked an open date and beyond use date (BUD). The Licensed Vocational Nurse (LVN) stated that the facility followed the expiration date provided by the pharmacy, which led to the medication not being labeled with the necessary dates. The Director of Nursing (DON) confirmed that the pharmacy labels the medication and that the medication was administered daily, suggesting it would be used before the expiration date. However, the facility's policy and procedure required that multi-dose vials be labeled with the date opened to ensure product integrity. The policy also stated that no expired medication should be administered, and a 'date opened' sticker should be placed on the medication. The manufacturer's guidelines for Fluticasone Propionate also indicated that a 'pouch opened' and 'use by' date should be written on the label, which was not done in this case.
Inaccessible Call System for Resident
Penalty
Summary
The facility failed to provide an accessible call system for one of its residents, identified as Resident 43. During multiple observations, it was noted that Resident 43's call light was out of reach, wrapped around the television arm behind the bed, and at one point, the call button was found on the floor. Interviews with staff, including Licensed Vocational Nurses (LVN) and Certified Nursing Assistants (CNA), revealed that the call light should always be within reach of the resident. Despite this, the call light was consistently found to be inaccessible to Resident 43, who had a history of serious medical conditions including nontraumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease, epilepsy, and schizophrenia. Interviews with the Director of Nursing (DON) and the Administrator (ADM) further highlighted the deficiency. The DON acknowledged that call lights should be placed next to residents to ensure accessibility, while the ADM suggested that Resident 43 might have moved the call light himself, although it was acknowledged that the call light should be as close to the resident as possible. The facility's policy and procedure on call systems emphasized the importance of providing each resident with a means to call for assistance, yet this was not adhered to in the case of Resident 43, leading to a potential delay in care during emergencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Gardens Care Center | 0.6 mi | — | 2 | 0 |
| Covenant Post Acute | 0.6 mi | — | 5 | 0 |
| Keystone Post-acute | 0.7 mi | — | 1 | 0 |
| Healthcare Centre Of Fresno | 2.5 mi | — | 3 | 0 |
| The Terraces At San Joaquin Gardens Village | 2.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.