Health inspection·October 4, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm 3. The pantry floor had dark granular substance and a dark glob (a round clump of soft substance or thick liquid). 4. The floor underneath the pantry wire storage rack had scattered debris such as utensils, jelly cups, brown paper bag, napkins, hairnet, and saltine crackers in plastic wrap. Residents Affected - Many 5. In the pantry a one-foot length of vinyl base board molding peeled off and was on the floor. 6. The pantry storage counter holding a five-gallon water jugs had black substance buildup. 7. Two dead cockroach observed under the food preparation table, one dead cockroach beneath the three compartment sink area, and one dead cockroach caught in a web near the ceiling by the dishwasher. The DC stated, It is important to keep everything clean. During a concurrent observation and interview on 10/4/24 at 11:50 a.m., in the kitchen and pantry with Dietary Manager (DM), the DM validated the presence the brown to golden substance behind the stove, the dark substance buildup on the pantry floor, and the pantry storage counter, and accumulation of debris on the floor behind the stove, near the water inlet, the floor behind the ice machine, and the floor underneath the pantry wire storage rack. The DM stated it was important to keep the kitchen and pantry areas clean and we did not. The DM stated, We will clean it. During a review of the facility ' s Employee Handbook, dated 8/20/21, the Employee Handbook indicated, All employees are expected to keep their work areas clean and organized. During a review of the Food and Drug Administration ' s Food Code, dated 2022, the Food Code indicated, 6-501.12. PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. The Food Code indicated, 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control. (D) Eliminating harborage conditions. The Food Code indicated, 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 2 of 4 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 10/04/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program as evidenced by presence of multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, the three-compartment sink, and on the floor behind the two-hallway ice machine. Residents Affected - Many These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: During an interview on 10/4/24 at 8:05 a.m., with the Ombudsman, the Ombudsman stated on 7/2024 during her visit at the facility she saw a live cockroach in a resident room. The Ombudsman stated she took a photograph of the cockroach and showed it to the Administrator. During an interview on 10/4/24 at 9:43 a.m., with the Housekeeping Staff (HS) 1, HS 1 stated she was aware of the cockroaches in the facility. During an interview on 10/4/24 at 10 a.m., with HS 2, HS 2 stated there was a problem with cockroaches in the facility. During an observation on 10/4/24 at 11:20 a.m., at the hallway ice machine area near room [ROOM NUMBER], there were multiple dead cockroaches, debris on the floor behind the hallway ice machines. During a concurrent observation and interview on 10/4/24 at 11:30 a.m., in the kitchen with Dietary [NAME] (DC), the DC validated the presence of two dead cockroach under the food preparation table, one dead cockroach underneath the three-compartment sink, one dead cockroach caught in a web near the ceiling by the dishwasher. The DC stated, It is important to keep everything clean. During a concurrent observation and interview on 10/4/24 at 11:50 a.m., in the kitchen and pantry with Dietary Manager (DM), the DM validated the presence of cockroaches in the facility kitchen, and multiple dead cockroaches in the kitchen ' s floor beneath the food preparation area, three compartment sink, and two hallway ice machines. The DM stated it was important to keep the kitchen and pantry areas clean and we did not. During a review of a document from the facility ' s pest control company titled, Orkin Invoice/Service Ticket (OIST), dated 8/7/24, the OIST indicated, General Comments: Treated kitchen area using a roach gel bait. Staff is saying the roach problem is now moving into the pantry area. I believe we will need to set up a service to spray the kitchen at a future date. Treated room [ROOM NUMBER] for American roaches using a roach gel bait. What I can recommend: Keeping all areas clean and clean of food debris and grease build up will go a long way toward cutting roach populations. Observations: Activity-Live; Pest Type: Cockroaches; Recommendation: Treatment rendered. During a review of the OIST dated 8/28/24, the OIST indicated, General Comment: treated hallway ice machine and sink area using a roach gel bait including the kitchen area and pantry. Observations: Activity-Live; Pest Type: Cockroaches; Recommendation: Treatment rendered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 3 of 4 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 10/04/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm During a review of the Food and Drug Administration ' s Food Code, dated 2022, the Food Code indicated, 6-202.15. outer openings of a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings. Residents Affected - Many The Food Code indicated, 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control. (D) Eliminating harborage conditions. The Food Code indicated, 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056207 If continuation sheet Page 4 of 4