Fresno Postacute Care: Kitchen Chaos, Cockroaches - CA
Inspectors watched a dietary aide use a four-ounce scoop to serve sweet potato fries to 20 residents on diabetic diets when their meal tickets required quarter-cup portions. The same aide served small portions of ground roast beef to eight residents who were supposed to get regular portions, and gave regular cups to a seizure patient whose medical orders required a sippy cup.
"The kitchen does not have enough sippy cups to go on residents' meal trays," one dietary aide told inspectors.
Resident 3, who has seizure precautions, was supposed to receive a sippy cup with every meal according to his physician's orders. Instead, kitchen staff put two regular cups with no handles on his tray. His nurse confirmed he needed cups with handles for safety.
The dietary aide responsible for calling out special dietary needs from meal tickets simply wasn't doing it. During lunch service on August 12, inspectors watched as the aide failed to announce when residents needed diabetic or kidney-friendly meals.
Two residents on kidney diets received sweet potato fries when their menu specifically stated "No Fries" and called for pineapple rings instead. When questioned, the cook confirmed residents on kidney diets should get pineapple rings, not fries, and acknowledged the dietary aide should have called out the restriction.
The portion problems extended beyond special diets. Seven residents on pureed diets received smaller scoops than their meal plans required. Kitchen staff used a number 12 scoop for pureed roast beef when they should have used a number 8 scoop, giving residents significantly less food.
"I expect the kitchen staff to follow the portion sizes on the menu spreadsheet and not to guess what the portion sizes are," the registered dietitian told inspectors.
The chaos reached residents who hate specific foods. Three residents received chocolate pudding despite their meal tickets clearly indicating they dislike chocolate or pudding. Resident 23's ticket showed "Dislikes: Eggs, Fish, Meat, Coffee, Chocolate," but kitchen staff put chocolate pudding on the tray anyway.
"Resident 23 needed a different dessert," the dietary aide admitted when confronted.
Resident 29 faced a different problem. He told inspectors he didn't like ham and preferred potatoes, but his breakfast contained ham and no potatoes. He said he had communicated his preferences to kitchen staff before, but they never updated his meal ticket.
"He would not eat his breakfast due to his preferences not being given to him," inspectors noted.
The certified dietary manager confirmed Resident 29's food preferences weren't listed on his meal ticket, despite the resident communicating them directly. The manager acknowledged it was his responsibility to update meal tickets and admitted Resident 29 was upset about not receiving his preferred foods.
"If he did not receive his preferred food he would not eat," the manager said.
Food quality compounded the service problems. Resident 12 called the food "dreadful" and said the broccoli was "too watery and felt like it was cooked for days." The rice and mashed potatoes "did not taste good," and lunch and dinner were "not appetizing at all."
When inspectors sampled the curry lemon chicken lunch, they found the peas were "firm, undercooked and starchy," the chicken was "dry and had mild curry taste," and the garlic rice "tasted like plain brown rice." The certified dietary manager confirmed the peas were firm and could taste the curry better on pureed chicken than the regular version.
Resident 177 was blunt: "The food tasted horrible and the cook did not know how to cook anything. The food was either overcooked or undercooked."
The facility's own resident council minutes from May and June 2024 documented ongoing complaints about "portion size, food preference" and noted "food continuously coming out late."
Meanwhile, cockroaches infested the kitchen and hallways. Inspectors observed cockroaches crawling on the kitchen wall near the dish machine, on the floor by the handwashing station, and under the food preparation table near the three-compartment sink.
A dietary aide confirmed she saw the cockroaches and said "the kitchen had issues with cockroaches in the past." The certified dietary manager acknowledged kitchen staff had told him about the cockroach problems.
The pest problem extended beyond the kitchen. Inspectors found a cockroach crawling on the hallway floor near the shower room, where it disappeared into a crack in the floor. Another cockroach was later spotted inside the shower room itself.
Resident 30 told inspectors he had "been seeing cockroaches often in the facility."
The pest control technician said he had visited twice in June and July and recommended sealing cracks in the kitchen corners near the dish machine area, but wasn't sure if the work had been completed.
Additional problems plagued the facility's operations. Pureed chicken spread across plates instead of holding its shape, creating a potential choking hazard for seven residents with swallowing difficulties. The facility's diet manual specifically required pureed food to "hold its shape."
Staff also failed basic infection control. A nursing assistant exited a resident room carrying soiled linen, disposed of it, then pushed a linen cart without washing his hands.
"Hand hygiene was important to prevent the spread of germs across surfaces," the assistant acknowledged when questioned.
Medical records contained errors that could affect end-of-life care. One resident's physician order for life-sustaining treatment had his last name spelled incorrectly. Two other residents had incomplete or inaccurately dated forms that weren't properly signed.
Four residents lived in a room with such a strong urine odor that one complained of headaches from the smell. The infection preventionist said the odor was "very strong as if it was in the walls and floor" and "not acceptable for the residents in this room."
Despite two deep cleanings, the maintenance supervisor confirmed the urine odor persisted and said he "would not want to live in this room."
The administrator acknowledged the residents "should not have to be in a room that smells like urine" and suspected the odor was trapped in the laminate flooring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fresno Postacute Care from 2024-08-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FRESNO POSTACUTE CARE in FRESNO, CA was cited for violations during a health inspection on August 16, 2024.
"The kitchen does not have enough sippy cups to go on residents' meal trays," one dietary aide told inspectors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.