Inspection·May 11, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide chlordiazepoxide-clidinium (medication to help treat stomach disorders) as ordered by a physician for one of three sampled residents (Resident 1) when the medication was not administered two times a day for four days for treatment of Resident 1's gastritis (inflammation of the lining of the stomach). Residents Affected - Few This failure had the potential for Resident 1 to experience weight loss due to lack of appetite caused by abdominal pain. Findings: During a review of Resident 1 ' s admission Record(AR), the AR indicated, Resident 1 had diagnosis of hypertension (high blood pressure in the vessels that carry blood from the heart to the rest of the body), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), irritable bowel syndrome (a group of symptoms that affect your digestive system with excessive gas, abdominal pain and cramps), gastro-esophageal reflux (condition occurred by when stomach acid repeatedly flows back into the esophagus causing irritation) and gastritis (inflammation of stomach). Resident 1 was admitted to the facility on [DATE] for rehabilitation after C3 fracture (a break in the third cervical vertebra, which is part of spine in the neck). During a review of Resident 1's Physician order (PO), dated 3/2022, the PO indicated, [Brand name] chlordiazepoxide-clidinium capsule 5-2.5 MG (milligram-a unit of mass or weight equal to one thousandth of a gram) two times a day for gastritis was ordered on 2/25/22 at 9:05 p.m. During a review of Resident 1 ' s Medication Administration Record (MAR), dated [DATE], the MAR indicated, chlordiazepoxide-clidinium was not administered as ordered on 2/26, 2/27 and 2/28. During a review of Resident 1's MAR, dated March 2022, the MAR indicated, chlordiazepoxide-clidinium was not given on 3/1/22. The MAR indicated, the first dose of [chlordiazepoxide-clidinium] was administered on 3/2/22 at 4:30 p.m. During a review of Resident 1's MD [Doctor of Medicine]/NP [nurse practitioner] /PA [physician assistant] Progress Note dated 3/2/22 at 4:17 p.m., the MD/NP/PA Progress Note indicated, .[Resident 1] states that she has not been getting the [chlordiazepoxide-clidinium]. Because she is not getting [chlordiazepoxide-clidinium] she is having abd [abdominal] pain daily which causing her appetite to decline .Will discuss her order [chlordiazepoxide-clidinium] with nursing staff . (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056207 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Gardens Nursing and Rehabilitation Center 577 S. Peach Ave. Fresno, CA 93727 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)