Grace Healthcare Center: Hazardous Equipment Failures - CA
The September 2025 inspection, triggered by a complaint, cited the facility for failures in identifying and addressing hazards in the resident environment. Inspectors reviewed the facility's own policies, which stated that any element of the resident environment with the potential to cause injury and accessible to a vulnerable resident is considered hazardous, and that resident vulnerability is based on individual factors including functional status, cognitive abilities, and medical condition.
The facility's policy on assistive devices was equally direct: equipment is to be assessed for appropriateness to the resident's condition, including lower extremity strength, range of motion, balance, and cognitive abilities, and must be measured to fit the resident's size and weight. Wheelchairs are listed explicitly among the mobility devices covered by that policy.
Inspectors found those standards were not being met.
The facility's own job description for its Assistant Director of Nursing assigns that position responsibility for conducting regular rounds to monitor resident care, assessing residents' physical and psychosocial status, and ensuring a safe environment. The description also places responsibility for care planning and compliance with federal, state, and local standards squarely on that role.
The inspection found actual harm resulted, affecting a small number of residents.
Grace Healthcare's written policies described a system of ongoing hazard assessment designed to catch risks before they hurt someone. Vulnerability to hazards may change over time, the policy noted, and ongoing assessment helps identify when elements in the environment pose hazards to a particular resident. The inspectors found that system had not worked as written.
What the records described as a comprehensive, resident-specific safety program and what inspectors found inside the facility were not the same thing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grace Healthcare Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GRACE HEALTHCARE CENTER in FRESNO, CA was cited for violations during a health inspection on September 5, 2025.
The September 2025 inspection, triggered by a complaint, cited the facility for failures in identifying and addressing hazards in the resident environment.
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.