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Complaint Investigation

Fresno Postacute Care

February 25, 2026 · Fresno, CA · 1233 A Street
Citations 1
CMS Rating 3/5
Beds 80
Provider ID 555426
Healthcare Facility
Fresno Postacute Care
Fresno, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

FRESNO POSTACUTE CARE in FRESNO, CA — inspection on February 25, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies

umbrella term for inflammation and erosion of the skin caused by prolonged or chronic exposure to

peri-area.

The PN was written by Licensed Vocational Nurse (LVN) 2.

During an interview on 2/12/26,

admitted to me he was not using gloves while applying the cream on 1/19/26, to Resident 2.During an interview on 2/13/26, at 3:15 p.m., with LVN 2, LVN 2 stated he recalled applying the cream to Resident 2's peri-area on the night of 1/19/26. LVN 2 stated that night, a Certified Nursing Assistant (CNA) 1, came to him and informed him that Resident 2 wanted cream applied to her peri-area. LVN 2 stated he took CNA 1 with him to Resident 2's room and applied the cream on top of her vagina, and then between her thighs and vagina because there was a lot of redness. LVN 2 stated that after the procedure, he went to wash his hands and noticed some cream on his bare fingers. LVN 2 stated the gloves he uses tend to rip. LVN 2 stated that later, an officer from the local police department telephoned him and asked him about this incident. LVN 2 stated I let him know my finger was bare. I told him my finger was exposed.

During an interview on 2/18/26, at 8:23 a.m., with CNA 1, CNA 1 stated she recalled going into Resident 2's room with LVN 2 the night of 1/19/26 to apply cream to Resident 2. CNA 1 stated, I was standing right next to him, shoulder to shoulder when he applied the cream to Resident 2's peri-area, over the vaginal area, on upper thighs. He was not wearing gloves.

During an interview on 2/19/26, at 10:42 a.m., with the Director of Nursing (DON), the DON stated, Nurses should wear gloves when any contact with the vagina. If a glove breaks, the protocol would be to stop the procedure right there and put on new gloves to protect the skin and stop transmission of micro-organisms.

There is a dignity issue as well. He should not have done that.During a review of the facility's Policy and Procedure (P&P) titled, Standards for Clinical Practice, dated 4/05, the P&P indicated, Appropriate Care is taken to ensure the resident's right to privacy and dignity, as well as the resident's health and safety are protected during the performance of any clinical procedure.

Prior to the initiation of any clinical procedure: Apply appropriate Personal Protective Equipment (gloves.) as required by the procedure.

Maintain the resident's privacy and dignity during the procedure.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FRESNO, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FRESNO POSTACUTE CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.