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Complaint Investigation

Grace Healthcare Center

May 27, 2026 · Fresno, CA · 2939 S. Peach Avenue
Citations 2
CMS Rating 1/5
Beds 101
Provider ID 555352
Healthcare Facility
Grace Healthcare Center
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

GRACE HEALTHCARE CENTER in FRESNO, CA — inspection on May 27, 2026.

Found 2 citations. 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

During a professional reference review from American Academy of Family Physician Journal, titled, Evaluating and Treating Unintentional Weight Loss in the Elderly, volume 65, number 4, dated 2/15/2002, the professional reference review indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death.

Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications.

Various studies demonstrated a strong correlation between weight loss and morbidity and mortality.

One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year .

During a professional reference review retrieved from https://aspenjournals.onlinelibrary.[NAME].com/doi/abs/10.1177/0884533611405794 titled, Enteral Nutrition for Older Adults in Nursing Facilities, dated 5/16/11, the professional reference review indicated, Older adults who reside in nursing facilities tend to be frail and to have multiple comorbidities, increased risk of unintended weight loss, and protein energy malnutrition.

Approximately 5.8% of nursing facility residents in the United States receive enteral feedings.

The prevalence is higher for residents with cognitive impairment, ranging from 18% to 34%. In cognitively impaired residents, the majority of tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources and high postinsertion mortality rates within 60 days of insertion.

Nursing facilities must abide by state and federal regulations and undergo stringent survey evaluation while balancing complex decisions related to initial placement of feeding tubes.

Informed choice, resident-centered care decisions, and the role of advanced directives are essential in the decision-making process. In nursing facilities, it is often the registered dietitian who alerts the healthcare team to determine whether a feeding tube is appropriate.

Once a tube is placed, healthcare practitioners must make careful decisions related to ordering, administering, and monitoring enteral nutrition (EN) delivery; adequacy of nutritional content; tolerance to feedings; monitoring for potential complications; and the possibility of return to oral feeding or, conversely, the decision to discontinue feedings.

Further evidence-based research is neede

555352 05/27/2026

Grace Healthcare Center 2939 S.

Peach Avenue Fresno, CA 93725

During a professional reference review from American Academy of Family Physician Journal volume 65, number 4, dated 2/15/02, indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death.

Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications.

Various studies demonstrated a strong correlation between weight loss and morbidity and mortality.

One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year .

During a professional reference review from Journal of Nutritional Disorders & Therapy, titled, Nutritional Dietary Recommendations for Acute Ischemic Stroke and their Outcomes, volume 13, issue 3, dated 6/29/23, the professional reference review indicated, Nutritional intake is a key component of stroke care that can influence the recovery and outcome of acute ischemic stroke patients. An early screening and assessment of dysphagia and nutritional status is recommended for all stroke patients.

Adequate hydration energy protein micronutrients fatty acids intake should be ensured while avoiding foods that can increase the risk of recurrent stroke or aspiration pneumonia.

Dietary modifications may be needed depending on the patient's comorbidities swallowing ability preferences needs. A multidisciplinary approach involves physicians, nurse, dietitian speech-language pathologists pharmacists caregivers is essential for providing optimal nutritional care for stroke patients.

Ensure adequate energy and protein intake to prevent or treat malnutrition, which is common in stroke patients and can impair recovery and increase mortality.

The recommended energy intake ranges from 25 to 35 kcal/kg/day, and the recommended protein intake ranges from 1.2 to 1.5 g/kg/day.

Provide oral nutritional supplements or enteral nutrition (tube feeding) if oral intake is insufficient or unsafe due to dysphagia or reduced appetite.

Enteral nutrition should be initiated within 24 to 48 hours after stroke onset if oral intake is less than 50% of the estimated needs.

Monitor fluid and electrolyte balance to prevent dehydration or overhydration, which can worsen cerebral edema or increase blood pressure.

The recommended fluid intake ranges from 30 to 40 ml/kg/day, depending on the patient's condition and urine output.

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 GRACE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

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.