Oakwood Gardens Care Center
3510 East Shields, Fresno, CA 93726
Oakwood Gardens Care Center is a nursing home in Fresno, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (559) 222-4807
- Last standard health inspection
- July 2, 2026 (4 months ago)
- Certified beds
- 103
- Residents per day, on average
- 94.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Lily Holdings, LLC
- Chain
- Pacs Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the California average (34 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
13 citations
Health inspection on July 2, 2026
CMS lists this as a standard inspection.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 8, 2026.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0812 2 times since 2023.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on September 8, 2026.
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on September 8, 2026.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0658 2 times since 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0759 3 times since 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0761 2 times since 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 8, 2026.
CMS has cited this home for F0880 2 times since 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on September 8, 2026.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on September 8, 2026.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on September 8, 2026.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on September 8, 2026.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on September 8, 2026.
11 citations
Fire safety inspection on July 2, 2026
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for K0345 2 times since 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for K0920 3 times since 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for K0353 3 times since 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for K0363 2 times since 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for K0919 3 times since 2023.
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on July 16, 2026.
Citation E0013. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on July 17, 2026.
Citation E0029. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop a communication plan.
CMS lists it as corrected on July 16, 2026.
Citation E0036. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on July 16, 2026.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 16, 2026.
CMS has cited this home for E0039 2 times since 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 16, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
2 citations
Health inspection on January 9, 2026
CMS lists this as a complaint inspection.
Citation F0573. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
CMS lists it as corrected on January 28, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 28, 2026.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on April 22, 2025
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 29, 2025.
2 citations
Health inspection on April 2, 2025
CMS lists this as a complaint inspection.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 3, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 3, 2025.
1 citation
Health inspection on March 17, 2025
CMS lists this as a complaint inspection.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 3, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
2 citations
Health inspection on January 30, 2025
CMS lists this as a standard inspection.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 24, 2025.
Citation F0911. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
CMS lists it as corrected on February 24, 2025.
CMS has cited this home for F0911 2 times since 2023.
13 citations
Fire safety inspection on January 30, 2025
CMS lists this as a standard inspection.
Citation K0347. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on February 12, 2025.
CMS has cited this home for K0347 2 times since 2023.
Citation E0007. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on February 12, 2025.
Citation E0023. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on February 12, 2025.
Citation E0024. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Establish policies and procedures for volunteers.
CMS lists it as corrected on February 12, 2025.
Citation E0026. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on February 12, 2025.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 12, 2025.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on February 12, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 12, 2025.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 12, 2025.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 1, 2025.
CMS has cited this home for K0918 2 times since 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on February 5, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 4, 2025.
Citation E0018. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on February 12, 2025.
CMS update of August 29, 2024
Ownership
CMS lists this home under a new chain.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
1 citation
Health inspection on July 8, 2024
CMS lists this as a complaint inspection.
Citation F0620. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
CMS lists it as corrected on September 5, 2024.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
12 citations
Health inspection on February 17, 2023
CMS lists this as a standard inspection.
Citation F0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on March 18, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on March 18, 2023.
Citation F0552. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on March 18, 2023.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on March 18, 2023.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 18, 2023.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on March 18, 2023.
Citation F0801. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS lists it as corrected on March 18, 2023.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on March 18, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 18, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on March 18, 2023.
Citation F0836. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
CMS lists it as corrected on March 18, 2023.
Citation F0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
CMS lists it as corrected on March 18, 2023.
13 citations
Fire safety inspection on February 17, 2023
CMS lists this as a standard inspection.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on March 20, 2023.
Citation E0039. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on March 20, 2023.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on March 20, 2023.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on March 20, 2023.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on March 20, 2023.
Citation K0347. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on March 20, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 20, 2023.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on March 20, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on March 20, 2023.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on March 20, 2023.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on March 20, 2023.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 20, 2023.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on March 20, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- HUDSON RIVER OPCO LLC5% or greater direct ownership interest · 100% · since 11/05/2021
- BAY BRIDGE CAPITAL PARTNERS, LLC5% or greater indirect ownership interest · 100% · since 11/05/2021
Questions
When was Oakwood Gardens Care Center last inspected?
CMS lists July 2, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Oakwood Gardens Care Center have?
CMS lists 34 health citations since February 17, 2023. CMS also calls these deficiencies.
Has Oakwood Gardens Care Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Oakwood Gardens Care Center?
Its CMS overall star rating is 4 of 5.
Is Oakwood Gardens Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.