Fresno Postacute Care

In the surveyor’s words

From the most serious findings on record at Fresno Postacute Care, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 15, 2025

  Based on interview and record review, the facility failed to ensure residents were free from neglect when Certified Nursing Assistant (CNA) 9 intentionally did not provide incontinent care (provided for those who cannot control their bowels and/or bladder) for three of five residents (Resident 1, Resident 2, and Resident 3) on 12/21/24 between the hours of 11 p.m. and 7:30 a.m. on 12/22/24. CNA 9 expressly limited incontinent care to one change for Resident 1 and Resident 2 and did not provide care for the entire shift for Resident 3. These failures resulted in withholding of required services and neglecting the needs of Residents 1, 2, and 3. […]

• No harm, potential for more than minimal, widespreadF727Mar 25, 2026

  Based on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis when the facility had no full time DON.This failure had the potential to not to meet the critical needs of high acuity residents (individuals requiring intensive, specialized care, constant monitoring, and frequent medical interventions due to severe or complex health conditions) causing serious injury, harm and impairment.During an interview on 3/19/26 at 2:00 p.m. with the Administrator (ADM), the ADM stated he's been the administrator of the facility for eight days. The ADM stated the facility does not have a DON or an interim (in the meantime, temporary or acting) DON. […]

• No harm, potential for more than minimal, widespreadF658Aug 16, 2024

  Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of eight sampled residents (Resident 8, 38, 2 and 57) when: 1. Registered Nurse (RN) 2 did not follow medication administration direction when she gave medication to Resident 8 without giving food. This failure had the potential to put Resident 8 at risk for stomach upset. 2. A small medication cup with one tablet was left on top of Resident 38's bedside table accessible to other residents. This failure had the potential for Resident 38 to not receive a prescribed medication and for other residents to have access to the medication. 3. Resident 2 and Resident 57's physician order for bed rails was not followed. […]

• No harm, potential for more than minimal, widespreadF803Aug 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed for the lunch meal on August 12, 2024 when: 1. Incorrect portion sizes were used on the therapeutic diets: a. 1/2 cup (4 ounces) of sweet potato fries were served instead of 1/4 cup (2 ounces) to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, and 13) who were on a Consistent Carbohydrate (CCHO) diet (a diet that provides a consistent amount of carbohydrates at each meal and from day to day to help keep blood sugar levels stable); and b. […]

• No harm, potential for more than minimal, widespreadF880Aug 16, 2024

  Based on 0bservation, interview, and record review the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for two of seven residents (Resident 61 and Resident 238) when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene (process of washing or disinfecting hands to prevent the spread of germs) after leaving the shared room of Resident 61 and Resident 238, while carrying a bag of soiled (dirty or contaminated) linen. […]