Pacific Gardens Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pacific Gardens Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, patternF684Jul 27, 2021

  Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 3) were provided with wound treatment in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Licensed Nurses (LNs) failed to perform Resident 1's physician prescribed wound care for four consecutive days of .cleanse S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .; and 2. LNs failed to perform Resident 3's day shift wound care on 12/1/20, 12/3/20, 12/4/20, 12/5/20, 12/6/20, 12/7/20 and evening shift on 12/4/20 and 12/7/20 and the weekly wound assessment on 12/2/20. […]

• Actual harm, isolatedF688Feb 7, 2025

  Based on observation, interview, and record review, the facility failed to provide required treatment and services to one of five residents (Resident 20), when Resident 20 did not receive restorative nursing assistant (RNA - helps patient regain physical skills through therapeutic care including mobility exercises, dressing, eating and bathing) services ordered by the physical therapist (PT-a person qualified to treat disease, injury or deformity by physical methods such as massage, heat treatment and exercise) once PT was discontinued on 3/6/24. […]

• Actual harm, isolatedF686Mar 15, 2024

  Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when Resident 1 was assessed as a moderate risk for developing pressure ulcers and the nursing care plan of daily and weekly skin assessments was not implemented from 1/6/24 to 1/19/24 for early recognition of skin changes and implementation of appropriate interventions to prevent pressure ulcer. […]

• Actual harm, isolatedF692Jun 21, 2022

  Based on interview, and record review clinical record, and professional reference review, the facility failed to implement a comprehensive systemic approach to ensure residents maintained acceptable parameters of nutritional and hydration status (desirable body weight range) and did not experience unplanned severe weight loss (a loss of greater than 5% [percent] of weight in one month's time) and dehydration (a condition where the body loses too much water and other fluids to carry out normal organ functions) for one of three residents (Resident 1) when the Registered Dietician (RD) did not accurately assess the nutritional status of Resident 1 and develop and implement interventions meant to address unintended weight loss in accordance with professional standards and facility policy and… […]

• No harm, potential for more than minimal, widespreadF812Oct 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions was maintain in the kitchen when: 1. [NAME] to golden-colored buildup behind the stove and floor behind the stove had accumulation of debris. 2. The floor in the corner next to water inlet, behind the ice machine, between the pantry and kitchen had soiled napkins, straw, beverage cup, wrapper, and food debris. 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. 5. […]