Inspection Reports for
Vintage Gardens Assisted Living Community
540 S Peach Ave, Fresno, CA 93727, CA, 93727
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection report documents a deficiency related to the facility's failure to follow its policy on admission, transfer, discharge, and bed-holds, specifically regarding denial of admission based on payment source.
Findings
The facility failed to admit a veteran resident for rehabilitation services due to payment source issues, contrary to its policy of providing equal access regardless of payment source. Interviews and record reviews confirmed the denial was based on Medicare billing requirements, which led to a missed admission opportunity.
Deficiencies (1)
F 0621: The facility failed to treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source. Resident 1 was denied admission for rehabilitation services based on payment source, contrary to facility policy.
Report Facts
Days of rehabilitation services referral: 20
Date of operation: Jul 11, 2025
Date of discharge: Aug 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding referral and admission denial of Resident 1. | |
| Business Office Manager | Interviewed regarding payment source verification and admission denial. | |
| Admission Services Manager | Interviewed regarding referral review and admission process. | |
| Director of Nursing | Interviewed regarding admission policies and clinical service provision. | |
| Administrator | Interviewed regarding admission decision and miscommunication. |
Inspection Report
Routine
Deficiencies: 18
Date: Feb 7, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, advance directive documentation, safe environment maintenance, care planning, medication management, infection control, food safety, and maintenance of facility equipment and infrastructure.
Deficiencies (18)
F 0550: Facility failed to ensure dignity for two residents by not covering their foley catheter drainage bags with dignity bags, violating privacy and self-esteem rights.
F 0578: Facility failed to inform and provide written information on how to formulate an advance directive for four residents, potentially preventing their wishes from being followed.
F 0584: Facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, including cold room temperatures, broken beds, and poor TV reception.
F 0625: Facility failed to notify residents or their representatives in writing about the bed hold policy upon hospital transfer for two residents, risking confusion and loss of bed availability.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans for seven residents, including lack of plans for foley catheter care, vision needs, anticoagulant monitoring, oxygen therapy, and contracture prevention.
F 0657: Facility failed to revise a care plan for one resident to reflect healing of a stage two pressure ulcer, risking unclear communication among healthcare team.
F 0658: Facility failed to meet professional standards of practice by administering oxygen at incorrect flow rates and failing to label oxygen tubing with change dates for two residents, risking oxygen toxicity and infection.
F 0687: Facility failed to provide appropriate foot care for one resident whose toenails were long, jagged, and sharp, risking discomfort, infection, and injury.
F 0688: Facility failed to provide required treatment and services to one resident to maintain range of motion, resulting in contracture development due to lack of restorative nursing assistant services after physical therapy discharge.
F 0757: Facility failed to provide a drug regimen free from unnecessary drugs for one resident who received mirtazapine without documented attempts at gradual dose reduction.
F 0760: Facility failed to ensure potassium chloride medication was administered according to manufacturer's instructions, risking poor absorption and side effects for one resident.
F 0761: Facility failed to properly store and label medications and supplies, including unlabeled inhalers, improper refrigerator temperatures affecting medications for three residents, risking ineffective or spoiled medications.
F 0802: Facility cook staff failed to accurately measure milk and margarine when preparing pureed rice for 12 residents, risking inconsistent nutrient content and potential weight changes.
F 0812: Facility failed to maintain safe and sanitary food preparation and storage practices including unlabeled thawing meat, dust on ceiling fan in food storage, and dietary aide failing to wash hands after touching face.
F 0842: Facility failed to maintain accurate and complete medical records for one resident when the Physician Orders for Life-Sustaining Treatment (POLST) was incomplete, risking resident's end-of-life wishes not being honored.
F 0880: Facility failed to maintain an effective infection prevention and control program for six residents, including improper storage of nebulizer mouthpiece, catheter bag and tubing on floor, urinal on bedside table with food, failure to follow enhanced barrier precautions, and storage of personal items in care areas.
F 0890: Facility failed to properly store and label opened syringes with clean syringes, risking infection and injury.
F 0924: Facility failed to ensure corridors were equipped with firmly secured handrails on each side, with broken and loose handrails observed, increasing fall risk.
Report Facts
Deficiencies cited: 19
Residents with pureed diet: 12
Temperature: 30
Temperature: 48
Temperature: 60
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in infection control and catheter bag finding for Resident 37 |
| LVN 3 | Licensed Vocational Nurse | Named in medication and oxygen administration findings |
| DON | Director of Nursing | Named in multiple findings including dignity, medication, infection control, and care planning |
| SSD | Social Services Director | Named in advance directive and bed hold policy findings |
| IP | Infection Preventionist | Named in infection control findings |
| COOK 1 | Cook | Named in food preparation and measurement findings |
| DM | Dietary Manager | Named in food safety and sanitation findings |
| RNA 1 | Restorative Nursing Assistant | Named in restorative care program findings |
| PT 1 | Physical Therapist | Named in restorative care program findings |
Inspection Report
Deficiencies: 2
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality and nursing care, specifically focusing on documentation and assessment practices by licensed nursing staff.
Findings
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) performed necessary resident assessments and accurately documented care for Resident 1 while the resident was admitted to a hospital. This resulted in falsified clinical records and potential risk to resident safety and care quality.
Deficiencies (2)
F 0658: The facility failed to provide services meeting professional standards when LVN 1 documented vital signs, pain assessment, feeding tube assessment, enteral feeding intake, and non-pharmacological pain interventions for Resident 1 while the resident was hospitalized from 12/25/21 to 12/30/21. This led to inaccurate clinical records and potential negative impact on resident care.
F 0726: The facility failed to ensure licensed nurses performed resident assessments and documented accurately when LVN 1 documented care and assessments for Resident 1 during hospitalization from 12/25/21 to 12/30/21. This resulted in inaccurate clinical records and risk to other residents' care.
Report Facts
Residents Affected: 1
Dates of improper documentation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in findings for falsifying documentation and failure to perform resident assessments. |
| ADON | Assistant Director of Nursing | Provided interview statements confirming documentation issues and facility policies. |
| DON | Director of Nursing | Provided interview statements regarding the impact of documentation errors on resident safety. |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and pest control regulations in the kitchen and pantry areas.
Findings
The facility failed to maintain sanitary conditions in the kitchen and pantry, including accumulation of debris, buildup of substances, and presence of dead cockroaches. The pest control program was ineffective as multiple dead cockroaches were found in various kitchen areas, posing a risk of foodborne illness to residents.
Deficiencies (2)
F 0812: The facility failed to ensure sanitary conditions in the kitchen, including buildup of debris behind the stove, soiled items and debris on pantry floors, peeled vinyl baseboard molding, black substance buildup on pantry storage counter, and presence of dead cockroaches in multiple locations.
F 0925: The facility failed to maintain an effective pest control program as evidenced by multiple dead cockroaches found in the kitchen floor beneath the food preparation area, three-compartment sink, and behind hallway ice machines.
Report Facts
Date of survey: Oct 4, 2024
Date of pest control service: Aug 7, 2024
Date of pest control service: Aug 28, 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
The inspection was conducted following a complaint filed by a Medical Social Worker regarding a facility-acquired pressure ulcer in Resident 1. The complaint alleged failure to provide appropriate pressure ulcer care and prevention.
Complaint Details
The complaint was filed on 1/29/24 by the Medical Social Worker to the local Ombudsman and California Department of Public Health regarding Resident 1's facility-acquired pressure ulcer. The complaint was substantiated by findings that the facility failed to implement required skin assessments and care plans.
Findings
The facility failed to implement the nursing care plan for Resident 1, who was at moderate risk for pressure ulcers, resulting in the development of a preventable Stage 3 pressure ulcer on the sacrum. Skin assessments were not performed as required from 1/6/24 to 1/19/24, and communication among staff about the ulcer was inadequate.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. Resident 1, assessed at moderate risk, did not receive daily and weekly skin assessments from 1/6/24 to 1/19/24, resulting in a Stage 3 pressure ulcer on the sacrum.
Report Facts
Wound Measurements - Pressure Ulcer: 36.4
Wound Length: 8.5
Wound Width: 5.9
Braden Scale Score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Assigned nurse who assessed Resident 1 and provided nursing care; unable to find documentation of pressure ulcer on admission |
| CNA 1 | Certified Nurse Aide | Assigned CNA who discovered the pressure ulcer on 1/19/24 and reported it to RN 1 |
| ADON 1 | Nursing Supervisor/Assistant Director of Nursing | Reviewed care plan documentation and stated failure to implement skin assessments |
| ADON 2 | Assistant Director of Nursing | Reviewed CNA task descriptions and stated failure to implement skin integrity care plan |
| DON | Director of Nursing | Stated that nursing care plan interventions to prevent skin breakdown should have been implemented and were not |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to medication self-administration, environmental safety and maintenance, nutrition assistance, and respiratory care.
Findings
The facility was found deficient in assessing a resident prior to allowing self-administration of medication, maintaining a safe and comfortable environment with building components in good repair, providing required assistance with meals to a resident, and ensuring oxygen therapy was administered according to physician orders.
Deficiencies (4)
F 0554: The facility failed to assess Resident #114 prior to allowing self-administration of medication as required by policy.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment for Residents #97 and #114 due to a sliding glass door gap and lack of cold water in a resident's bathroom.
F 0692: The facility failed to ensure Resident #72 received required assistance with eating during observed meals.
F 0695: The facility failed to ensure Resident #10 had a physician's order for oxygen and failed to administer oxygen at the ordered flow rate for Residents #106 and #208.
Report Facts
Residents sampled for medication self-administration: 28
Residents reviewed for environment: 3
Residents reviewed for nutrition: 4
Residents reviewed for respiratory care: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN #8 | Licensed Vocational Nurse | Acknowledged giving Resident #114 a tube of diclofenac sodium without assessment. |
| Assistant Director of Nursing #11 | Assistant Director of Nursing | Stated expectations regarding medication self-administration assessment, safe environment, meal assistance, and oxygen therapy compliance. |
| Executive Director | Executive Director | Acknowledged expectations for medication self-administration assessment, environment maintenance, meal assistance, and oxygen therapy compliance. |
| Certified Nursing Assistant #17 | Certified Nursing Assistant | Stated Resident #114 was not allowed to self-administer medications. |
| Director of Maintenance | Director of Maintenance | Acknowledged not noticing the sliding glass door gap or cold water issue in Resident #114's room. |
| Environmental Services Supervisor | Environmental Services Supervisor | Acknowledged not noticing the sliding glass door gap. |
| Certified Nursing Assistant #13 | Certified Nursing Assistant | Stated Resident #72 did not require assistance with eating. |
| Registered Dietician | Registered Dietician | Was not aware Resident #72 required assistance with eating. |
| LVN #2 | Licensed Vocational Nurse | Acknowledged Resident #72 required assistance with eating and confirmed Resident #106's oxygen flow rate. |
| CNA #14 | Certified Nursing Assistant | Stated Resident #72 did not require assistance with eating. |
| CNA #15 | Certified Nursing Assistant | Stated Resident #72 required feeding assistance. |
| CNA #17 | Certified Nursing Assistant | Stated Resident #72 required help with meal setup. |
| RN #1 | Registered Nurse | Observed and adjusted Resident #208's oxygen flow rate. |
| LVN #10 | Licensed Vocational Nurse | Stated Resident #10 did not have a physician's order for oxygen until 11/28/2023. |
| Assistant Director of Nursing #9 | Assistant Director of Nursing | Acknowledged obtaining oxygen order for Resident #10 on 11/28/2023. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide a prescribed medication to a resident as ordered by a physician.
Complaint Details
The complaint investigation found that the medication was not administered for four days because it was not available from the pharmacy. The nurse did not notify the physician or take further action. The Director of Nursing confirmed that medication omissions should have been documented and reported to the physician.
Findings
The facility failed to administer chlordiazepoxide-clidinium as ordered for Resident 1 for four days due to medication unavailability and lack of notification to the physician. This failure had the potential to cause weight loss due to abdominal pain and decreased appetite.
Deficiencies (1)
F 0684: The facility failed to provide chlordiazepoxide-clidinium as ordered for Resident 1, missing doses for four days, which could cause weight loss due to abdominal pain and decreased appetite.
Report Facts
Days medication not administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Validated medication was not administered and stated the pharmacy did not send the medication. | |
| Director of Nursing (DON) | Stated medication omissions should have been documented and physician notified. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to properly administer medication to a resident.
Complaint Details
The complaint was substantiated as the facility did not follow proper medication administration procedures, specifically the 'five rights' of medication administration, leading to unsafe practice.
Findings
The facility failed to administer Gabapentin to Resident 7 according to policy, as the medication was left at the bedside without observing the resident consume it. This posed a risk of medication misplacement, potential overdose, or missed doses.
Deficiencies (1)
F 0755: The facility failed to administer Gabapentin to Resident 7 according to policy by not observing the resident consume the medication, leaving it at the bedside. This practice risked medication misplacement, overdose, or missed doses.
Report Facts
Medication dose: 300
Medication capsules: 3
Date of medication order: Aug 12, 2022
Date of medication administration: Dec 16, 2022
Time of medication administration: 1300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Documented medication administration but did not observe resident consume medication | |
| Director of Nursing (DON) | Stated LVN 1 did not follow the five rights of medication administration |
Inspection Report
Routine
Census: 111
Deficiencies: 9
Date: Feb 15, 2019
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements and resident care standards at Pacific Gardens Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents' call light accessibility, incomplete advance beneficiary notices, inadequate care planning for hearing impairments and fluid restrictions, improper pressure ulcer prevention, medication storage and labeling issues, failure to honor resident food preferences, inadequate hydration provision, and lapses in infection control practices.
Deficiencies (9)
F 0558: Facility failed to provide reasonable accommodations for four residents by not ensuring call lights were within reach, risking delayed assistance.
F 0582: Facility failed to complete Advance Beneficiary Notice for one resident, resulting in lack of notification about potential service costs.
F 0656: Facility failed to implement comprehensive care plans for hearing impairments for two residents, risking unmet needs and misplacement of hearing aids.
F 0657: Facility failed to timely revise care plans for fluid restriction and anticoagulant use for two residents, risking hydration issues and bleeding complications.
F 0686: Facility failed to prevent pressure ulcer development for one resident by not repositioning every two hours as required.
F 0761: Facility failed to properly store medications securely and at correct temperatures, risking unauthorized access and medication ineffectiveness.
F 0806: Facility failed to honor food preferences for two residents, serving disliked foods and risking decreased intake and weight loss.
F 0807: Facility failed to provide adequate hydration during lunch for one resident on fluid restriction, risking dehydration.
F 0880: Facility failed to maintain infection control by improper handling of urinals and failure to clean blood pressure cuffs between residents, risking cross contamination.
Report Facts
Residents sampled: 111
Residents affected: 4
Fluid restriction amount: 2000
Fluid intake at lunch: 360
Temperature readings above 77F: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 8 | Licensed Vocational Nurse | Did not clean blood pressure cuff between residents |
| LVN 5 | Licensed Vocational Nurse | Left medications unattended on medication cart |
| LVN 7 | Licensed Vocational Nurse | Left medication cart unlocked |
| RN 1 | Registered Nurse | Stated call lights should be accessible to residents |
| DON | Director of Nursing | Provided multiple statements on care plan and hydration deficiencies |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control and care plan issues |
| CNA 8 | Certified Nursing Assistant | Noted food preference errors for Resident 35 |
| DA 1 | Dietary Aide | Described meal preparation process and food preference importance |
Report
August 27, 2025
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August 11, 2025
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August 11, 2025
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April 8, 2025
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April 3, 2025
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February 7, 2025
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November 26, 2024
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October 11, 2024
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October 10, 2024
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October 4, 2024
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September 27, 2024
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July 5, 2024
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March 15, 2024
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November 30, 2023
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August 9, 2023
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August 9, 2023
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May 11, 2023
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February 7, 2023
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July 11, 2022
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March 28, 2022
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December 30, 2021
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October 22, 2021
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May 20, 2021
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May 20, 2021
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February 15, 2019
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