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Complaint Investigation

Orchard Post Acute

April 30, 2026 · Fresno, CA · 4840 E.tulare Avenue
Citations 1
CMS Rating 3/5
Beds 99
Provider ID 056225
Healthcare Facility
Orchard Post Acute
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

ORCHARD POST ACUTE in FRESNO, CA — inspection on April 30, 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

FF0689
Quality of Life and Care Deficiencies

During an interview on 4/3026 at 12:59 p.m. with LVN 2, lvn2 stated the facility expectation was for the staff to provide residents with assistance they required and needed. LVN 2 stated when a resident was dependent on care, there should have been two staff members assisting the resident to perform the task. LVN 2 stated it was important to ensure two staff members were present during care of a resident who was dependent on staff to ensure the resident was safe and comfortable.

During a concurrent interview and record review on 4/30/26 at 1:31 p.m. with the director of nursing (DON), Resident 1's document titled, Section GG-Functional Abilities- Mobility, dated 3/2/26 was reviewed.

The document indicated, .

Safety and Quality of performance, if helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided.

Dependent- Helper does all of the effort.

Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.

Dependent- Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed.

Dependent- Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed.

The DON stated that Resident 1 was dependent on staff assistance for turning and repositioning while in bed.

The DON stated dependent meant the resident could not perform the task independently.

The DON stated the facility process was for Resident 1, who was total dependent on task to turn and reposition, to have two-person assistance unless otherwise specified in the EMR.

During an interview on 4/30/36 at 2:10 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the residents to receive the proper level of care that was needed.

During a record review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 2001, the P&P indicated, .Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living.

Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

During a record review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, .Our facility strives to make the environment as free from accident hazards as possible.

Resident safety and supervision and assistance to prevent accidents are facility wide priorities. the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Communicating specific interventions to all relevant staff.

Providing training as necessary.

Bed safety.

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 ORCHARD POST ACUTE 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.