Inspection·November 30, 2023

F 0554 not allowed to self-administer their medications. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/28/2023 at 2:25 PM, LVN #18 acknowledged she gave Resident #114 a tube of diclofenac sodium. Residents Affected - Few During an interview on 11/30/2023 at 11:51 AM, Assistant Director of Nursing #11 stated the expectation was that if a resident had not been assessed to self-administer medication, the resident should not have the medication in their possession. During an interview on 11/30/2023 at 12:28 PM, the Executive Director (ED) stated that before any resident was allowed to self-administer medication, an assessment must be completed. The ED acknowledged when Resident #114 had the medication in their room, the resident had not been assessed to self-administer the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 2 of 8 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 11/30/2023 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, record review, and facility policy review, the facility failed to provide a comfortable environment and a building in good repair for 2 (Resident #97 and Resident #114) of 3 sampled residents reviewed for the environment. Findings included: A review of a facility policy titled, Safe, Clean, Comfortable, and Homelike Environment, implemented in June 2023, revealed, Policy: In accordance with residents' rights, the facility will strive to provide a safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 1. A review of Resident #97's admission Record revealed the facility admitted Resident #97 on 04/02/2022 with diagnoses that included acute kidney failure, muscle weakness, and hypertension. A review of Resident #97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/09/2023, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. On 11/27/2023 at 10:04 AM, 11/28/2023 at 12:45 PM, and 11/20/2023 at 10:47 AM, the surveyor observed Resident #97 as the resident sat in a wheelchair in their room. The glass portion of the sliding glass door that opened to an outside patio was separated from the metal frame and left an approximately 1½ inches wide by 1-foot-long gap in the bottom left side of the sliding glass door. There was a white cloth pushed into the gap of the sliding glass door. Air could be felt when the surveyor stood next to the door. Resident #97 stated the sliding glass door had always had the same gap and the staff placed the cloth into the gap to seal the hole. In an interview on 11/29/2023 at 2:07 PM, the Director of Maintenance (DOM) stated he made rounds daily to inspect the facility but did not go into each resident's room each day. The DOM stated he had not noticed the hole in Resident #97's sliding glass door. The DOM stated Resident #97 had mentioned cracks around the sliding glass door in the past but not about the hole between the doorframe and glass. The DOM stated he expected a safe, clean, homelike building in good repair. During an interview on 11/29/2023 at 2:26 PM, the Environmental Services Supervisor (ESS) stated she made rounds three to four times a day but had not noticed the hole in Resident #97's sliding glass door. The ESS stated on daily rounds she looked for safety issues and inspected residents' beds, wiring, bed remotes, bathrooms, doors, and handles. The ESS stated she expected residents to have a safe, clean, homelike building in good repair. In an interview on 11/30/2023 at 9:45 AM, Assistant Director of Nursing (ADON) #11 stated she made rounds every morning and at the end of the shift but not in every room. Per ADON #11, Resident #97's room was assigned to ADON #9 to monitor since Resident #97 was a long-term resident. ADON #11 stated she expected a safe, clean, comfortable environment that was in good repair. In an interview on 11/30/2023 at 10:18 AM, the Executive Director (ED) stated the DOM and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 3 of 8 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 11/30/2023 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few maintenance technicians were supposed to monitor residents' rooms daily. The ED stated when the nurses, certified nursing assistants, or other staff observed an environmental concern, they should place the concern in the facility's electronic maintenance system. The ED stated he expected a safe, clean, homelike environment with all building components in good repair. In an interview on 11/30/2023 at 11:45 AM, ADON #9 stated she was responsible for conducting daily room-to-room rounds for long-term care residents. ADON #9 acknowledged Resident #97's room was in her daily room rounds. Per ADON #9, she had not noticed the sliding glass door in disrepair. 2. Review of Resident #114's admission Record, revealed the facility admitted the resident on 09/11/2023 with diagnoses that included wedge compression fracture of thoracic 11 and thoracic 12 vertebra, spondylosis of the lumbar region, intervertebral disc degeneration of the lumbar region, and abnormalities of gait and mobility. Review of Resident #114's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. On 11/28/2023 at 9:06 AM, Resident #114 stated the cold water from the faucet in their bathroom did not work. When the surveyor turned the faucet to the on position on the cold-water side, no water flowed from the spout. During an interview on 11/28/2023 at 12:02 PM, Resident #114 stated they had not had cold water in their bathroom since they were admitted to the facility. Resident #114 stated they informed several staff about the lack of cold water. Resident #114 stated they went to the room next door to wash their hands and have access to cold water. On 11/29/2023 at 7:43 AM, the surveyor noted no cold water flowed from the faucet in Resident #114's room. In an interview on 11/29/2023 at 2:05 PM, the Director of Maintenance (DOM) stated he had not received a request to fix the lack of cold-water in Resident #114's room. On 11/29/2023 at 2:29 PM, the DOM confirmed cold water did not flow from the faucet in Resident #114's room The DOM stated it was likely that the nursing staff turned the valve off underneath the sink to stop the cold water from flowing out of the spout. During an interview on 11/30/2023 at 12:05 PM, Assistant Director of Nursing (ADON) #11 stated it was the nursing staff's responsibility to ensure the residents had a safe and clean environment. ADON #11 stated she was not aware Resident #114 lacked access to cold water in their room. Durin an interview on 11/30/2023 at 12:18 PM, the Executive Director stated it was his expectation that all resident rooms were in good order and repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 4 of 8 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 11/30/2023 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on the interviews, record review, and policy review, the facility failed to ensure 1 (Resident #72) of 4 sampled residents reviewed for nutrition was provided assistance with their meals. Residents Affected - Few Findings included: Review of a facility's policy titled, Weight Management, dated August 2014, revealed Residents identified to be at risk of weight variance, will have routine assessment and care plan interventions implemented in accordance with Advance Directives. The objective of this process if to assess, and manage weight variances. The policy specified, 14. Evaluate meal and intake patterns for irregularities; Consider smaller, more frequent meals, or adding calorie dense foods to meals with higher consumption. * Provide oversight of meal intake and offer appropriate substitutes as indicated. Post available substitutes in designated area for staff awareness. * Evaluate level of assistance /supervision needs. Determine if restorative dining, social dining or additional dining assistance during meals is indicated. Review of Resident #72's admission Record revealed the facility admitted the resident on 03/04/2023. Per the admission Record, Resident #72 had diagnoses to include morbid obesity and dementia. Review of Resident #72's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #73 required extensive assistance with eating. Review of Resident #72's care plan initiated on 03/05/2023, revealed the resident had a self-care deficit and required assistance with activities of daily living. Intervention indicated the resident required one-person physical assistance with eating. During the lunch meal observation on 11/27/2023 at 1:13 PM, Resident #72 was not assisted by staff to eat their meal. During the lunch meal observation on 11/28/2023 at 12:46 PM, Resident #72 was not assisted by staff to eat their meal. In an interview on 11/29/2023 at 8:41 AM, Certified Nursing Assistant (CNA) #13 stated Resident #72 did not require staff assistance with eating. According to can #13, she was told the resident was able to eat without staff assistance. In an interview on 11/29/2023 at 1:23 PM, Resident #72's Responsible Party (RP) stated they were told in a care plan meeting on 11/17/2023 that Resident #72 would be fed during meals. In an interview on 11/29/2023 at 3:01 PM, CNA #14 stated Resident #72 did not require assistance with eating. During an interview on 11/29/2023 at 3:15 PM, the Registered Dietician stated he was not aware Resident #72 required assistance with eating. In an interview on 11/29/2023 at 3:35 PM, Licensed Vocational Nurse (LVN) #2 acknowledged he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 5 of 8 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 11/30/2023 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)

F 0692 assigned to care for Resident #72. LVN #2 stated he was Resident #72 required assistance with eating. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/29/2023 at 3:41 PM, CNA #15 stated Resident #72 required feeding assistance with meals. Residents Affected - Few During an interview on 11/29/2023 at 4:20 PM, CNA #17 stated Resident #72 required help with meal setup. Per CNA #17, Resident #72 was able to feed themself. During an interview on 11/30/2023 at 10:41 AM, Assistant Director of Nursing (ADON) #11 stated if a resident had documented on their care plan to have one person physical assistance with meals, , the nursing staff must provide physical assistance with eating. In an interview on 11/30/2023 at 12:28 PM, the Executive Director stated if the resident was care planned for assistance with eating, the nursing staff must ensure the resident received assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 6 of 8 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 11/30/2023 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident #208's admission Record indicated the facility admitted the resident on 11/19/2023, with diagnoses that included acute respiratory failure with hypoxia and obstructive sleep apnea. Residents Affected - Some Review of Resident #208's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2023, revealed Resident #208 resident received oxygen. Review of Resident #208's care plan, initiated 11/21/2023 revealed the resident had oxygen therapy related to acute respiratory failure. Interventions indicated the resident received continuous oxygen at a rate of two liters per minute. Review of Resident #208's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for continuous oxygen at two liters per minute by way of nasal canula for acute respiratory failure with hypoxia. On 11/29/2023 at 8:30 AM, the surveyor observed Resident #208 receiving oxygen by way of a nasal canula with the oxygen concentrator set at three liters per minute. During a concurrent observation and interview on 11/29/2023 at 9:19 AM, Registered Nurse (RN) #1 stated Resident #208 was ordered to receive oxygen at two liters per minute. RN #1 observed the resident's oxygen flow rate and adjusted to the ordered three liters per minute. During an interview on 11/30/2023 at 11:50 AM, Assistant Director of Nursing #11 stated she expected oxygen to be delivered at the ordered flow rate. During an interview on 11/30/2023 at 12:46 PM, the Executive Director stated he expected the nurses to administer oxygen according to the physician orders. 3. Review of Resident #106's admission Record revealed the facility admitted the resident on 11/02/2023, with a diagnosis to include chronic obstructive pulmonary disease (COPD). Review of Resident #10's care plan, initiated on 11/03/2023, revealed the resident had diagnoses of emphysema/COPD related to exposure to industrial pollutants. Interventions directed the staff to administer oxygen as ordered. Review of Resident # 106's Order Summary Report, with active orders as of 11/29/2023, revealed an order dated 11/21/2023, for oxygen at two liters per minute as needed for COPD. On 11/29/2023 at 9:05 AM, the surveyor observed Resident #106 receiving oxygen by way of nasal canula at one and a half liter per minute. During a concurrent observation and interview on 11/29/2023 at 9:11 AM, Licensed Vocational Nurse (LVN) #2 confirmed Resident #106's oxygen flow rate was set at one and a half liters per minute. In an interview on 11/30/2023 at 11:51 AM, Assistant Director of Nursing #11 stated she expected the staff to follow the physician orders regarding oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 7 of 8 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 11/30/2023 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 11/30/2023 at 12:28 PM, the Executive Director stated he expected staff to follow the physician's order. Based on observations, interviews, record reviews, and policy review, the facility failed to ensure 1 (Resident #10) of 5 sampled residents reviewed for respiratory care had an order to receive oxygen. The facility further failed to ensure 2 (Resident #106 and Resident #208) of 5 sampled residents received oxygen at the flow rate ordered by the physician. Findings included: Review of a facility policy titled, Oxygen Administration, dated August 2014, revealed, Purpose To administer oxygen to the resident with insufficient oxygen is being carried by the blood to the tissues. The policy specified, e. Set the flow meter to the rate ordered by the physician. 1. Review of Resident #10's admission Record revealed the facility admitted Resident #10 on 11/02/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of Resident #10's care plan initiated on 11/03/2023, revealed the resident had diagnoses of emphysema/COPD related to exposure to industrial pollutants. Interventions directed the staff to administer oxygen as ordered. A review of Resident #10's Order Summary Report, with active orders as of 11/27/2023, revealed no order for oxygen. A review of Resident #10's Progress Notes for the time period 11/03/2023 through 11/28/2023, revealed staff documented the resident received oxygen by way of a nasal canula. On 11/27/2023 at 11:25 AM, the surveyor observed Resident #10 in bed. The resident's oxygen concentrator was set to deliver oxygen at three liters per minute. On 11/28/2023 at 1:04 PM, the surveyor observed Resident #10 receiving oxygen at three liters per minute. During an interview on 11/28/2023 at 1:05 PM, Certified Nursing Assistant (CNA) #7 stated Resident #10 had always worn oxygen. During an interview on 11/28/2023 at 1:14 PM, CNA #12 stated Resident #10 had always worn oxygen. During a concurrent observation and interview on 11/28/2023 at 3:42 PM, Licensed Vocational Nurse (LVN) #10 stated Resident #10 did not have a physician's order for oxygen until 11/28/2023. LVN #10 stated the resident should have had a physician's order for oxygen. During an interview on 11/29/2023 at 9:49 AM, Assistant Director of Nursing (ADON) #9 acknowledged she called the physician on 11/28/2023 and got an oxygen order for Resident #10 to receive oxygen. ADON #9 stated the resident should have had an order for oxygen prior to 11/28/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 8 of 8