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A middle-range Medicare rating. Review each component and visit in person before deciding.
based on 44 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Pacific Gardens Nursing and Rehabilitation Center has a middle-range Medicare overall rating. Strengths include compassionate and attentive nursing/cna staff. Some reviewers note concerns about understaffing leading to slow response times (mentioned by 2 reviewers). Review the health-inspection, staffing, and quality-measure components separately, then visit in person.
Families can expect highly compassionate and dedicated nursing and CNA staff, with many reviewers praising specific individuals for their kindness and professionalism. However, there are serious concerns regarding understaffing, inconsistent rehabilitation therapy, and instances of inadequate medical monitoring.
Quality Themes
Strengths
Concerns
Rating Trends
Tap a year to see what changed
Distribution · 47 analyzed
The owner provides personalized responses that specifically mention the names of staff members and the specific care qualities highlighted by the reviewer. The tone is consistently warm, professional, and appreciative.
Personalized based on this facility's data
Key Review Excerpts
“My father spent about 3 months at this facility after breaking his hip/femur. Overall, the staff did a good job providing care even when he was disoriented and not particularly cooperative; someone was always watching at the nurses' station when he couldn't stay in his bed alone.”
“I was a state surveyor for over 20+ years and I have NEVER seen such stellar work, esp. on the MEDICARE SIDE where I’ve been a patient after brain surgery.”
“My mother was at this facility for several weeks. As others have stated, this place is understaffed. They don't appear to care very much about patients. My mother's blood sugar was extremely elevated, and not being addressed; which resulted in health conditions that she did not previously have.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
9
measures
8
measures
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents needing more daily help over time
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility shows concerning patterns with families filing 7 complaints over recent years about serious issues including pressure ulcer care, food safety, and pest control. The main recurring problems are in resident rights, fire safety systems, and care planning, with many deficiencies appearing repeatedly across multiple surveys, suggesting ongoing challenges with maintaining standards. While all violations have correction plans, the frequency of complaints and repeat deficiencies should prompt careful evaluation during any visit.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Smoke Deficiencies
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Rights Deficiencies
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
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.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Put firmly secured handrails on each side of hallways.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Federal Penalties
Fine
Feb 7, 2025
$30,654
Pacific Gardens Nursing and Rehabilitation Center
for profit
Covenant Care
12 facilities nationwide
Chain avg rating: 2.8/5 · Rank 12 of 24
Owners
Covenant Care California, LLC
Owner · Organization
Covenant Care, LLC
Owner · Organization
Centre Capital Investors V, Lp
Owner (parent company) · Organization
Centre Covenant Purchaser (b), LLC
Owner (parent company) · Organization
Centre Covenant Purchaser (q), LLC
Owner (parent company) · Organization
Centre Covenant Purchaser (s), LLC
Owner (parent company) · Organization
Centre V Secondary Fund, L.p.
Owner (parent company) · Organization
Covenant Holdco, LLC
Owner (parent company) · Organization
Covenant Subco, LLC
Owner (parent company) · Organization
State Treasurer of Mich Custodian of Public School Empl Rtmnt Systems
Owner (parent company) · Organization
Stockwell Fund II Lp
Owner (parent company) · Organization
Evans, Mary
Owner (parent company)
Levin, Robert
Owner (parent company)
Sims, Christine
Owner (parent company)
Torok, Andrew
Owner (parent company)
Key personnel
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Google Reviews
44 reviews from families & visitors
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