Pacific Gardens Nursing And Rehabilitation Center
Fresno, Fresno County, California · CCN 056207 · For-profit (LLC) · part of Covenant Care (12 facilities, chain average 2.8 stars)
CMS rates Pacific Gardens Nursing And Rehabilitation Center 3 of 5 overall as of August 2026. 188 certified beds, 164 residents a day on average. 48 citations on record from the current inspection cycles, 2 involving actual harm; 1 fine totalling $30,654.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / 5 of 5 |
Staffing
| Total nurse staffing | 4.05653 hours per resident per day |
|---|---|
| Registered nurses | 0.67958 hours per resident per day |
| Weekend total | 3.74225 hours per resident per day |
| Nursing staff turnover | 35.9% (registered nurses 39.3%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-24 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · tag F0803 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · tag F0700 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-24 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-05-15 |
| 2026-04-01 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-03 |
| 2025-08-27 complaint survey |
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source Resident Rights Deficiencies · tag F0621 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has plan of correction 2025-10-01 |
| 2025-02-07 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · tag F0688 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · tag F0578 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Nutrition and Dietary Deficiencies · tag F0802 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Put firmly secured handrails on each side of hallways. Environmental Deficiencies · tag F0924 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2025-02-07 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-11 |
| 2024-11-26 complaint survey |
Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-29 |
| 2024-11-26 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-29 |
| 2024-10-04 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-11-01 |
| 2024-10-04 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-11-01 |
| 2024-03-15 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-04-01 |
| 2023-11-30 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-12-28 |
| 2023-11-30 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-11-30 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
| 2023-11-30 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-28 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-02-07 | Fine | $30,654 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Covenant Care California, LLC Organization | 5% or greater direct ownership interest | — | 2008-07-17 |
| Covenant Care, LLC Organization | 5% or greater direct ownership interest | — | 2008-07-17 |
| Centre Capital Investors V, Lp Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Centre Covenant Purchaser (B), LLC Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Centre Covenant Purchaser (Q), LLC Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Centre Covenant Purchaser (S), LLC Organization | 5% or greater indirect ownership interest | — | 2008-12-19 |
| Centre V Secondary Fund, L.P. Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Covenant Holdco, LLC Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Covenant Subco, LLC Organization | 5% or greater indirect ownership interest | — | 2008-07-17 |
| State Treasurer Of Mich Custodian Of Public School Empl Rtmnt Systems Organization | 5% or greater indirect ownership interest | — | 2008-12-19 |
| Stockwell Fund II Lp Organization | 5% or greater indirect ownership interest | — | 2008-12-19 |
| Midcap Funding IV Trust Organization | 5% or greater security interest | — | 2014-02-20 |
| Evans, Mary Individual | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Levin, Robert Individual | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Sims, Christine Individual | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Torok, Andrew Individual | 5% or greater indirect ownership interest | — | 2008-07-17 |
| Ashley, Dava Individual | corporate officer | — | 2018-05-17 |
| Carney, Kevin Individual | corporate officer | — | 2013-11-01 |
| Evans, Mary Individual | corporate officer | — | 2013-11-01 |
| Hassell, Lance Individual | corporate officer | — | 2018-05-17 |
| Levin, Robert Individual | corporate officer | — | 2013-11-01 |
| Sims, Christine Individual | corporate officer | — | 2013-11-01 |
| Torok, Andrew Individual | corporate officer | — | 2013-11-01 |
| Ashley, Dava Individual | operational/managerial control | — | 2018-03-26 |
| Evans, Mary Individual | operational/managerial control | — | 2006-04-14 |
| Hassell, Lance Individual | operational/managerial control | — | 2018-05-17 |
| Levin, Robert Individual | operational/managerial control | — | 2006-04-14 |
| Sims, Christine Individual | operational/managerial control | — | 2006-04-14 |
| Sparks, Carol Individual | operational/managerial control | — | 2006-04-17 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Pacific Gardens Nursing And Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Fresno County.