Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Hills Post Acute during CMS and state inspections, most recent first.
A resident admitted to hospice care and later expired had no documented coordinated plan of care between the facility and the hospice provider. The hospice form for coordinated care was left blank, including scheduled visits and signatures, and the DON and ADMN confirmed the care coordination documentation was not completed even though the facility policy and service agreement required coordination with hospice in the resident’s plan of care.
Missing IDT care conferences for four residents. The facility did not document an initial or quarterly IDT care conference for one resident with moderately impaired cognition, did not document an initial conference for one resident with intact cognition who said staff never invited her to a care conference, and did not document quarterly conferences for two residents with impaired cognition/memory problems and SFM representatives. The SSD and ADMN confirmed the missing documentation and stated the social services department was responsible for scheduling, conducting, and documenting these IDT meetings.
Kitchen staff failed to follow food safety standards when a dietary aide tested quaternary sanitizer with the wrong strip and incorrect timing, and a cook calibrated thermometers with the stems touching the bottom and sides of an ice water cup. The RD stated the aide had already received in-service on sanitizer testing, and the facility policy required thermometers to be clean, sanitized, and calibrated for accuracy.
Failure to Document and Support Advance Directives: The facility did not follow its AD and POLST policies for several residents when there was no documentation that ADs were verified, offered, assisted with, or obtained. For multiple residents, records showed no AD on file or POLST sections indicating no AD/AD not available, and the SSD and DON confirmed the missing documentation and that the SSD should have offered assistance with establishing ADs.
Expired and improperly labeled eye drops were found in active medication carts during observations with LPNs. Multiple bottles had past discard dates, missing open dates, or lacked resident identifiers, and one LPN stated eye drops should be labeled with the resident name, room number, and open date, then discarded 30 days after opening.
Failure to obtain informed consent before increasing a resident’s quetiapine dose. A resident with psychosis had consent on file for quetiapine 25 mg BID, but the order was later increased to 25 mg daily and 50 mg in the evening, and the EMAR showed the higher dose was administered. The RP stated she was not informed of the dose increase, risks and benefits, or asked for IC, and the DON confirmed staff did not notify the RP or obtain IC before giving the increased dose.
Unnecessary Psychotropic Medication Use Without Documented Non-Drug Approaches: A resident with depression and anxiety received lorazepam and sertraline without documented evidence that non-pharmacological approaches were attempted first. The EMAR showed no such documentation, and the DON confirmed there was no evidence of attempted non-drug approaches and no contraindication to trying them before the psychotropic medications were administered.
Failure to Complete SCSA After Hospice Discontinuation: A resident graduated from hospice and hospice orders were discontinued, but the MDS record showed no SCSA completed within the required timeframe after the significant improvement in health status. The MDSC confirmed the resident met SCSA criteria for major improvement and that the assessment was not completed as required.
Incomplete Care Plans for Fall Risk and Psychotropic Medication Use: The facility failed to follow a low-bed intervention for one resident with dementia-related diagnoses and fall risk, as the resident was observed in bed with the bed not in the lowest position despite the care plan. The facility also failed to develop a care plan for another resident receiving quetiapine for psychosis, and the DON confirmed the missing care plan during record review.
A resident’s comprehensive and individualized care plan was not updated after hospice services were discontinued. The resident still had multiple hospice-related care plan entries with current goals and objectives tied to hospice care, and the DON confirmed nursing staff should have reviewed, updated, and discontinued those hospice-related plans when the resident was no longer receiving hospice services.
A resident with COPD had an order to change oxygen tubing weekly, but during observation the tubing label showed it had not been changed within the ordered timeframe. Another resident with a pacemaker had no pacemaker information in the chart, and two LVs stated they only knew about a CGM on the resident's arm and did not recall any other device; the DON also could not locate the pacemaker details in the record.
Failure to reassess fall risk after a resident fell twice. A resident admitted with muscle weakness had fall reports for two falls, but the record showed no fall risk assessment after either event. The DON reviewed the chart and confirmed the resident was not assessed after the falls, despite the facility policy calling for review of fall history and recent falls.
Medication administration errors resulted in a 12% error rate, with 3 errors out of 25 opportunities. An LVN drew up 8 units of insulin aspart for a resident whose order was for 9 units, and another LVN gave a resident Zinc Sulfate 220 mg instead of 50 mg via G-tube and administered 1 drop of Artificial Tears in each eye instead of 2 drops as ordered.
A resident was served lunch without the cranberry juice listed on the tray card. CNA confirmed the juice was not provided, and the RD stated dietary staff should read tray cards with each meal and accommodate resident food preferences. The facility policy stated resident choices and preferences are to be reflected on tray cards for dietary guidance.
Food Not Prepared Palatable: A resident on a heart healthy, regular texture, NAS diet reported that vegetables were always mushy, overcooked, and flavorless, and did not feel like eating them with meals. During a tray observation, the regular texture zucchini served was bland, soft, and mushy; the cook confirmed it was oversoft and overcooked, and the RD agreed it was on the softer side and lacked flavor. The facility policy stated food should conserve nutritive value, flavor, and appearance and provide varied color and texture.
Missing Hospice Plan of Care: A resident admitted to hospice did not have a hospice plan of care located in the hospice binder at the nurse station. The DON stated she was unsure whether the resident's care plans were in the record or binder. The facility's hospice agreement required the hospice company to develop and provide a copy of each hospice patient's plan of care to the facility.
Staff failed to follow infection control practices during resident care and medication administration. A CNA carried soiled items out of a resident’s room with gloves on, an RN handled a water pitcher on her med cart with contaminated gloves, and an LVN did not cleanse her hands before giving eye drops or used a spoon that may have been contaminated when administering oral meds. Facility policies for glove use, eye drops, and medication administration were not followed.
A resident with multiple complex medical conditions experienced a change of condition due to a broken tooth, but the facility did not develop or implement a care plan to address this issue. Despite facility policies requiring care plans for acute changes, no interventions or monitoring were documented for the dental problem, as confirmed by the DON.
A facility failed to follow up on psychiatric recommendations for a resident with schizophrenia, delaying a new treatment plan by three weeks. The resident had been involved in altercations, prompting a psychiatric evaluation that recommended medication adjustments. The facility lacked a procedure to ensure timely access to these recommendations, which were available on an online portal.
The facility failed to report the results of abuse investigations to CDPH within the required five working days for two residents. In one case, a verbal abuse allegation was not reported on time, and in another, a psychological abuse allegation was faxed ten days after the facility was aware of it. The administrator could not verify the timely submission of these reports, contrary to the facility's policy.
The facility failed to follow its P&P on abuse reporting for two residents by not providing a thorough summary of findings, including interview information, to CDPH. The facility determined the abuse allegations were unsubstantiated but did not include specific evidence in the reports. The Administrator denied surveyor requests for investigative documents, citing them as protected.
A resident's MDS assessment inaccurately coded an antiplatelet medication as an anticoagulant, despite the resident's medical records indicating the use of clopidogrel bisulfate for blood clot prevention. The MDS Director confirmed the error, and the Administrator expected accurate coding, revealing a failure to follow CMS guidelines.
The facility failed to ensure a resident received necessary care and services, including developing a change in condition plan, monitoring for hypoglycemia, and following a post-op appointment order. The interdisciplinary team did not address the resident's cognitive decline, and there was no documentation of hypoglycemia protocol or post-op follow-up.
The facility failed to assess, notify the physician and responsible party, and document a pressure injury on the bilateral buttocks of a resident with type 2 diabetes and dementia, despite a physician's order for treatment. Interviews confirmed the lack of documentation and notification, contrary to the facility's policies.
Missing Hospice Care Coordination Documentation
Penalty
Summary
Failure to arrange for hospice services or assist with transfer to a facility that would arrange hospice services occurred for one resident who was admitted to hospice care and later expired in the facility. The resident’s face sheet indicated the resident was self-responsible for decision making, and the MDS showed a BIMS score of 13/15. The physician ordered a hospice referral and then admission to hospice care for cerebral atherosclerosis, and nursing progress notes documented that the resident was placed on hospice care. A hospice document showed an admit date and diagnosis of cerebral atherosclerosis, but the sections for nurse, social worker, chaplain, and nurse aide scheduled visits were left blank and incomplete. The hospice provider’s document titled Coordinated Care Plan for Facility Patients was also left blank, with no documented coordinated care plan between the facility and hospice provider. That document did not show that the plan of care and coordination were reviewed and signed by the resident, facility staff, and hospice staff. During interviews, the LVN stated that lack of documented care coordination increased the risk of confusion for nursing staff in meeting the resident’s care needs and addressing the medical condition. The DON confirmed there was no documented care coordination and stated the hospice provider should have completed the document and reviewed it with facility staff and the resident, while the ADMN stated the hospice provider should have completed the care coordination documentation before the resident was admitted to hospice care. The facility policy required collaboration with the hospice representative and coordination of facility staff participation in the hospice care planning process, and the service agreement required the facility to coordinate with hospice in developing a plan of care for each hospice patient.
Missing IDT Care Conferences for Four Residents
Penalty
Summary
The facility failed to schedule, conduct, and document interdisciplinary team (IDT) care conferences with residents and/or their representatives for four sampled residents. The report states there was no documentation of an initial or quarterly IDT care conference for one resident admitted on 1/25/2026, whose face sheet identified a significant family member as the representative and whose MDS showed a BIMS score of 10/15, indicating moderately impaired cognition. During interviews, the MDSC and SSD confirmed that the social service department was responsible for scheduling, conducting, and documenting these conferences and that no documented evidence existed for the resident's initial or quarterly care conferences. For another resident admitted on 4/23/2026, who was self-responsible for daily decision making and had a BIMS score of 15/15, the record contained no documented evidence of an initial IDT care conference. The resident stated staff did not arrange or invite her to attend a care conference after admission, and that her significant family member requested a meeting with the facility team. The SSD confirmed there was no documented evidence of an initial IDT care conference after admission and stated the resident should have completed an initial care conference to discuss plan of care needs. The report also found no documented evidence of quarterly IDT care conferences for two additional residents. One resident, admitted on 7/17/2025, had a significant family member as representative and a BIMS score of 7/15, indicating severely impaired cognition. Another resident, admitted on 12/17/2024, also had a significant family member as representative and had short-term and long-term memory problems noted on the MDS. The SSD confirmed there were no quarterly IDT care conferences scheduled or conducted for either resident, and the administrator stated the SSD was responsible for scheduling, conducting, and documenting initial and quarterly IDT care conferences for all residents, with initial conferences within 72 hours after admission and quarterly thereafter.
Incorrect sanitizer testing and thermometer calibration in kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when dietary staff incorrectly tested the quaternary sanitizer solution in the kitchen. During observation, a dietary aide immersed a chemistry test strip into a red bucket of sanitizing solution for about 5 seconds and then compared it to the color chart, stating the result was zero PPM but should be 150. Another dietary aide later tested the same type of solution with a different strip and stated it was between 150-200, noting that the first aide had used the wrong test strips. The registered dietitian stated the first aide had received in-service training on sanitizer testing upon hiring one month earlier and should know the proper technique and equipment to use.
Failure to Document and Support Advance Directives
Penalty
Summary
The facility failed to follow its advance directive and POLST policies for five residents when there was no documented evidence that advance directives were verified, offered, assisted with, or obtained. For Residents 1, 23, and 123, review of the admission records and clinical records showed no advance directive on file, and social services notes did not document any verification, offer, assistance, or obtaining of an advance directive. Their POLST forms also indicated “No Advance Directive” in section D. During a concurrent interview and record review, the Social Service Director confirmed there was no documentation of advance directives for these residents and stated she should have verified, offered, assisted, or obtained one. For Resident 57, the face sheet showed admission to the facility on 4/2/2025, and the POLST form indicated “Advance Directive not available,” with no documented evidence that the facility offered or assisted with execution of an advance directive. For Resident 97, the face sheet showed admission to the facility on 10/18/2017, and the POLST form indicated “No Advance Directive,” with no documented evidence that the facility offered or assisted with execution of an advance directive. The DON confirmed the POLST documentation for Resident 97 and stated the SSD should have offered and assisted with advance directives for Resident 57. Facility policy stated that if a resident or representative indicates no advance directive has been established, staff will offer assistance in establishing one, and that upon admission the facility will ask whether an advance directive exists and provide information regarding the resident’s right to make such decisions.
Expired and Improperly Labeled Eye Drops Found in Medication Carts
Penalty
Summary
The facility failed to ensure medications were stored and labeled appropriately when expired eye drop medications were found in active use areas of Station 3 and Station 4 medication carts. During an observation of the Station 3 medication cart with LVN F, one Artificial Tears bottle for the resident in room [ROOM NUMBER]B was labeled as opened on 9/25/25, and one Refresh Tears bottle for the resident in room [ROOM NUMBER]A was labeled opened on 10/16/25. These medications were found in the medication cart after their labeled open dates. During an observation of the Station 4 medication cart with LVN E, multiple eye drop bottles were found with discard dates that had passed or with incomplete labeling. These included latanoprost 0.005% for Resident 61 labeled discard on 11/9/25, latanoprost 0.005% for Resident 97 labeled discard after 11/3/25, olopatadine Hcl 0.2% for Resident 83 labeled discard on 11/30/25, an Artificial Tears bottle for the resident in room [ROOM NUMBER]A labeled discard on 10/25/25, another Artificial Tears bottle for the resident in room [ROOM NUMBER]A with no open date, a Refresh Tears bottle for the resident in room [ROOM NUMBER]C labeled open on 9/15/25, a Refresh Tears bottle for the resident in room [ROOM NUMBER]A labeled open on 9/28/25, and a Systane Zaditor bottle labeled open on 10/21/25 with no resident name or room number. During interview, LVN E stated eye drop medication should be labeled with resident name, room number, open date, and discarded 30 days after opening. The facility policy also stated nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner and that outdated medications are to be returned to or destroyed by the dispensing pharmacy.
Failure to Obtain Informed Consent for Increased Psychotropic Dose
Penalty
Summary
The facility failed to obtain informed consent before increasing Resident 57’s quetiapine dose. Resident 57 was admitted with diagnoses including psychosis and had an assigned responsible party. The record showed an informed consent for quetiapine 25 mg twice daily dated 4/2/2025, but the medication order was later increased on 5/21/2025 to quetiapine 25 mg every day and 50 mg in the evening for psychosis. The EMAR for October, November, and December 2025 showed the resident received quetiapine 25 mg at 0900 and 50 mg at 1700 each day. During a telephone interview, the resident’s responsible party stated she was not aware of the dose increase and said the facility did not inform her of the increased medication dose or the risks and benefits, and did not obtain informed consent for the increased dose. The DON confirmed the resident was receiving quetiapine 25 mg once daily and 50 mg every evening, confirmed the original informed consent was for 25 mg twice daily, and stated nursing staff did not inform the responsible party or receive informed consent when the dose was increased. The facility policy stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives.
Unnecessary Psychotropic Medication Use Without Documented Non-Drug Approaches
Penalty
Summary
The facility failed to ensure that Resident 35 was free from unnecessary psychotropic medications when there was no documented evidence that non-pharmacological approaches were attempted before lorazepam and sertraline were administered. Resident 35 was admitted on 12/17/2024 and had diagnoses of depression and anxiety. The physician orders included lorazepam 81 mg twice daily for anxiety, dated 11/11/2025, and sertraline 100 mg daily for depression, dated 10/23/2025. Review of Resident 35’s EMAR for November 2025 and December 2025 showed no documented evidence of non-drug approaches being attempted before the psychotropic medications were given. During a concurrent record review and interview, the DON reviewed the orders and EMAR and confirmed there was no documented evidence of attempted non-drug approaches before both medications were administered, and that there was no contraindication for the resident to attempt non-drug approaches. The facility policy titled Psychotropic Medication Use stated that non-pharmacological approaches will be attempted unless clinically contraindicated.
Failure to Complete SCSA After Hospice Discontinuation
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) within 14 days after hospice care was discontinued for Resident 57. Resident 57 was admitted to the facility on 4/2/2025, and physician orders show hospice care was discontinued on 11/18/2025. The nurse practitioner’s note from 11/18/2025 stated that Resident 57 graduated from hospice. A review of the MDS assessments showed no documented evidence that an SCSA was completed within 14 days after hospice was discontinued. During a concurrent record review on 12/4/2025, the MDS coordinator confirmed that Resident 57 had graduated from hospice, that hospice orders were discontinued on 11/18/2025, and that no SCSA for improvement in health status had been completed within the required timeframe. The facility policy titled Comprehensive Assessments stated that an SCSA must be completed when the interdisciplinary team determines a resident meets significant change guidelines for major improvement or decline.
Incomplete Care Plans for Fall Risk and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop or implement comprehensive, person-centered care plans for two residents. For one resident with Alzheimer’s disease, syncope, and anxiety, the care plan for risk for falls and injuries included a low bed intervention dated 12/18/2024, but during room rounds the resident was observed in bed with the bed not in the low position. A CNA confirmed the bed was not positioned low while the resident was in bed and stated the bed should have been kept in the lowest position; the DON also stated staff should have followed the low bed intervention. For another resident with psychosis, the medication order summary showed quetiapine 50 mg at bedtime for psychosis, but the care plans did not include any documented comprehensive care plan for the use of quetiapine. During a concurrent interview and record review, the DON reviewed the medication orders and care plans and confirmed the resident should have had a care plan for quetiapine use. The facility policy on goals and objectives stated care plan goals and objectives are the desired outcome for a specific resident problem, and the psychotropic medication policy stated medication use should be addressed in accordance with nurse assessments, monitoring parameters, clinical standards of practice, manufacturer specifications, and the resident’s comprehensive plan of care.
Failure to Update Hospice-Related Care Plan After Hospice Discontinued
Penalty
Summary
The facility failed to update and revise Resident 57’s comprehensive and individualized care plans after hospice services were discontinued. Resident 57 was admitted on 4/2/2025, and hospice care was discontinued on 11/18/2025. The resident’s care plans included multiple hospice-related entries, including hospice services, self-care deficit, risk for falls and injuries, mood problem, depression, potential for pressure ulcer development, impaired skin integrity, incontinent bowel and bladder, actual/chronic pain related to hospice care, psychosocial well-being problem on hospice, long term stay for custodial care/hospice, and altered nutrition and hydration on hospice care. Review of the care plans showed current goals and objectives still related to hospice care even after hospice had been discontinued. During a concurrent record review with the DON on 12/4/2025 at 10:42 a.m., the DON confirmed that nursing staff should have reviewed, updated, and discontinued the hospice-related care plans when the resident was no longer on hospice services. The facility’s undated care planning policy stated that goals and objectives are reviewed and/or revised when there has been a significant change in the resident’s condition.
Failure to Follow Oxygen Tubing and Pacemaker Documentation Orders
Penalty
Summary
Resident 87 had a diagnosis of COPD and physician orders dated 11/18/25 and 10/23/25 for oxygen at 2 liters per minute as needed and to change the oxygen tubing every week and as needed. During an observation with LVN B on 12/1/25 at 10:49 a.m., Resident 87's oxygen tubing had a label dated 11/16/25, showing the tubing had not been changed weekly as ordered. Resident 132 was admitted with a diagnosis of presence of cardiac pacemaker, and a physician order dated 11/29/25 directed the licensed nurse to monitor for signs and symptoms of pacemaker malfunction every shift and notify the physician. During interviews on 12/4/25, LVN C stated Resident 132 had a CGM on his arm and did not have any other device, and LVN D also stated he had a CGM and did not recall any other device. Review of Resident 132's medical records showed a lack of pacemaker information, and the DON later reviewed the record and could not locate the pacemaker information, stating it should be reported in the medical records.
Failure to Reassess Fall Risk After Resident Falls
Penalty
Summary
The facility failed to identify fall risk for Resident 87 after he fell on two occasions, including one fall on [DATE] and another on 11/25/25. Resident 87 was admitted with a diagnosis of muscle weakness, and review of his clinical record and fall reports showed there were no indications that he was assessed for fall risk after either fall. During interview, the DON reviewed the record and confirmed that Resident 87 was not assessed for fall risk after the falls and stated that residents should be assessed for fall risk after a fall. The facility policy, Fall Risk Assessment, dated 3/2018, stated that nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
A medication error rate of 12% was identified after 3 medication errors occurred out of 25 opportunities during medication administrations for two residents. During a medication pass observation with LVN E, Resident 27 was to receive 9 units of insulin aspart before meals per the physician order, but LVN E drew up 8 units and was about to administer that amount. LVN E confirmed that 8 units had been drawn instead of the ordered 9 units. During another medication pass observation with LVN C, Resident 72 received Zinc Sulfate 220 mg crushed and mixed with water via G-tube, and Artificial Tears Solution was administered as one drop in each eye. The physician orders for Resident 72 indicated Zinc Sulfate 50 mg via G-tube and two drops of Artificial Tears Solution in each eye three times a day. During interview, LVN C reviewed the orders and confirmed that he administered 220 mg of Zinc Sulfate instead of 50 mg and one drop of Artificial Tears instead of two drops in each eye.
Missed Meal Preference on Tray Card
Penalty
Summary
The facility failed to accommodate a resident’s food preference when Resident 85 received a lunch meal without the cranberry juice listed on the tray card. During a dining room observation on 12/1/2025 at 12:26 p.m., Resident 85 was served lunch without cranberry juice. The resident’s lunch tray card for that meal specified cranberry juice, mildly thick, 1/2 cup, and the resident’s face sheet showed the resident had been admitted to the facility on 12/31/2025. During an interview on 12/1/2025 at 12:36 p.m., CNA J confirmed the tray card indicated cranberry juice and that Resident 85 did not receive it with the lunch meal. CNA J stated the resident should have received the cranberry juice and that kitchen staff should have sent it. During an interview on 12/5/2025 at 8:50 a.m., the RD stated kitchen staff should read meal tray cards with each meal and accommodate resident food preferences, and that kitchen staff should have sent cranberry juice to Resident 85 with lunch. The facility policy stated reasonable efforts would be made to accommodate resident choices and preferences, and that food preferences are implemented on the resident’s tray card for dietary staff guidance in meal preparation.
Food Not Prepared Palatable
Penalty
Summary
Food was not prepared palatable for one of eight sampled residents, Resident 97, when the vegetable served was overcooked and lacked flavor. During an interview, Resident 97 stated that vegetables were always served mushy, overcooked, and with no flavor, and that this made the resident not feel like eating vegetables with meals. Resident 97’s face sheet showed admission to the facility on 10/18/2017, and the order summary listed a heart healthy diet with regular texture and no added salt dated 12/21/2022. The facility’s lunch menu for 12/4/225 listed seasoned zucchini as the vegetable item. During a lunch tray observation and interview with the cook and RD, the regular texture zucchini tasted bland and was soft and mushy; the cook confirmed it was oversoft, overcooked, and bland, and the RD stated it was on the softer side and tasted bland, adding that it should have been cooked for less time to prevent the softness. The facility policy stated food shall be prepared by methods that conserve nutritive value, flavor, and appearance and provide meals varied in color and texture.
Missing Hospice Plan of Care
Penalty
Summary
The facility failed to ensure communication with the hospice facility for one of seven residents, Resident 7, who had been admitted to hospice, when a plan of care from hospice was not located. During a record review of Resident 7's hospice binder at nurse station 2, the binder lacked a plan of care. During an interview, the DON stated she was not sure about the hospice care plans for Resident 7 and said she would check whether care plans were in the resident's record or hospice binder. The facility's agreement with the hospice facility stated that the hospice company was to establish, modify as appropriate, and provide the facility with a copy of a Hospice Plan of Care for each hospice patient admitted to the facility. The agreement also stated that for each residential hospice patient, the hospice company would develop a Hospice Plan of Care and furnish the facility a copy at the time the resident was admitted to hospice or, if the resident became a resident after hospice admission, at the time of facility admission.
Infection Control Breaks During Resident Care and Medication Pass
Penalty
Summary
The facility failed to implement infection control practices during multiple observed care activities. During an observation on 12/1/25, CNA I was assisting Resident 45 with changing his brief and carried a bag containing a soiled diaper out of the resident’s room and into the hallway with gloved hands before placing it in the hamper. During a concurrent interview, CNA I stated she should have removed her gloves in Resident 45’s room before walking into the hallway. The facility’s policy on Personal Protective Equipment - Using Gloves, dated 9/2010, stated used gloves should be discarded into the waste receptacle inside the examination or treatment room. Additional observations during medication administration showed further breaks in infection control practice. RN G sanitized her hands and put on gloves before administering medications to Resident 117, then used the same gloves to pick up the water pitcher on her medication cart and pour water for the resident. LVN H administered eye drops to Resident 93 after giving oral medications without cleansing her hands first, despite the facility’s eye drop policy stating hands should be washed and dried thoroughly before putting on gloves. LVN H also administered oral medications to Resident 76 using a spoon that had been placed on the resident’s overbed table, and she acknowledged the table might not be clean and could contaminate the spoon. The facility’s medication policy stated medications are to be administered in a safe and timely manner, and as prescribed.
Failure to Develop and Implement Care Plan for Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan for a resident who experienced a change of condition due to a broken tooth. The resident, who had a medical history including palliative care, alcoholic cirrhosis of the liver with ascites, and type 2 diabetes mellitus with complications, was observed to be alert, oriented, and comfortable. The resident confirmed that the broken tooth had already been extracted. However, review of the care plans revealed that no care plan was created at the time of the change of condition to address the broken tooth, including necessary interventions and monitoring. Interviews with the DON confirmed that a care plan should have been initiated for the resident's broken tooth to ensure proper monitoring, interventions, and follow-up, but this was not done. Review of facility policies indicated that both episodic and comprehensive care plans are required for acute changes in condition, with measurable goals and timeframes. Despite these policies, the facility did not create or implement a care plan for the resident's dental issue, resulting in a failure to address the resident's needs as required.
Failure to Implement Timely Psychiatric Recommendations
Penalty
Summary
The facility failed to implement a procedure to ensure timely follow-up on psychiatric recommendations for a resident diagnosed with schizophrenia. This deficiency was identified when the facility did not act on the psychiatry recommendations for the resident after a psychiatric evaluation was completed. The delay in implementing the new treatment plan lasted three weeks, which could have negatively impacted the resident's behavior and the safety of other residents. The resident had been involved in altercations with other patients, prompting a psychiatric evaluation to consider medication adjustments. The psychiatric evaluation recommended increasing the resident's Mirtazapine dosage and considering the addition of Depakote for irritability and aggression. However, the facility did not access these recommendations promptly due to the absence of a procedure for following up on external psychiatric referrals. The Social Services Director acknowledged the lack of a procedure and only became aware of the recommendations weeks later. The Nurse Practitioner confirmed that the evaluation and recommendations were uploaded to an online portal accessible to the facility staff, but the facility did not review them until much later.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of its abuse investigations to the California Department of Public Health (CDPH) within the required five working days for two residents. In the first case, a verbal abuse allegation involving a staff member and a resident was reported to the facility, but there was no documented evidence that the investigation results were sent to CDPH within the stipulated timeframe. The incident was reported to the facility on May 27, 2024, and the investigation was completed by June 4, 2024, but the facility administrator could not provide evidence of timely submission to CDPH. In the second case, a psychological abuse allegation was made against a staff member involving another resident. The facility determined the allegation to be unsubstantiated, but the report was faxed to CDPH ten days after the facility became aware of the incident, exceeding the five-day requirement. The administrator was unable to verify the exact date the report was sent, and there was no documented evidence to confirm the timely submission. The facility's policy requires that such investigations be reported in accordance with federal and state regulations, which was not adhered to in these instances.
Failure to Provide Thorough Abuse Investigation Summary
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding Alleged or Suspected Abuse and Crime Reporting for two residents. For both residents, the facility did not provide a thorough summary of findings, including information obtained from interviews, to the California Department of Public Health (CDPH) upon request. This deficiency was identified during a review of the mandated abuse allegation reporting forms (SOC 341) and the Verification of Incident Investigation reports for both residents. The reports indicated that the facility determined the abuse allegations were unsubstantiated but did not include specific evidence or details from interviews or medical record reviews. During an interview, the facility's Administrator stated that she could not provide the investigative interviews, follow-up actions, or any other evidence of a thorough investigation for the abuse allegations, citing them as protected documents. Despite two requests from the surveyor for the investigative documents, the Administrator denied access both times. The facility's P&P clearly states that a Verification of Incident Investigation should include a brief description of the incident, a thorough summary of findings, follow-up actions, and notifications, which can be provided to federal or state survey agencies upon request.
Inaccurate MDS Assessment for Medication Classification
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, resulting in a discrepancy in medication classification. The resident, who was admitted with a medical history of congestive heart failure, peripheral vascular disease, and hypertension, was receiving clopidogrel bisulfate, an antiplatelet medication, for blood clot prevention. However, the MDS assessment incorrectly coded the resident as having received an anticoagulant medication during the seven-day look-back period. The error was identified during a review of the resident's medical records and confirmed through interviews with the MDS Director and the Administrator. The MDS Director acknowledged that clopidogrel bisulfate is an antiplatelet medication and should have been coded as such. The Administrator expressed an expectation for MDS assessments to be accurately coded, highlighting the facility's failure to adhere to the coding instructions outlined in the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to ensure that Resident 1 received the necessary care and services, leading to several deficiencies. The interdisciplinary team (IDT) did not develop a change in condition plan of care for Resident 1 despite a noticeable decline in cognition and other health issues. The IDT did not address Resident 1's decline in cognition, and there was no plan of care developed. This was confirmed by the Director of Nursing (DON), Certified Nursing Assistant (CNA), and other staff members who acknowledged the lack of a comprehensive plan to address the resident's condition changes. Additionally, the facility did not closely monitor Resident 1 for signs and symptoms of hypoglycemia, nor was there documentation of a hypoglycemia protocol in the resident's clinical record. Despite multiple instances of critical low blood sugar levels, there were no documented assessments, repeat blood sugar checks, or interventions performed to address these critical levels. Interviews with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurses (LVNs) confirmed that the necessary steps to manage hypoglycemia were not taken. Furthermore, the facility failed to follow Resident 1's physician order for a post-operative follow-up with the surgeon. The DON confirmed that the post-op appointment was not followed as ordered, and there was no documentation indicating that Resident 1 attended the appointment. The order was not properly transcribed to the Medication Administration Record (MAR), and the social services department did not receive the appointment information to set up transportation. This oversight was acknowledged by the DON and other staff members involved.
Failure to Document and Notify Pressure Injury
Penalty
Summary
The facility failed to properly assess, notify the physician and responsible party, and document a pressure injury on the bilateral buttocks of a resident. The resident, who was admitted with diagnoses including type 2 diabetes and dementia, was identified as being at moderate risk for pressure sores upon admission and later assessed as high risk. Despite a physician's order to clean and treat the buttocks area, there was no documentation of the pressure injury assessment, measurements, or notifications to the physician or responsible party on the specified date. During interviews, the licensed vocational nurse confirmed the lack of documentation and notification regarding the pressure injury. The Director of Nursing also acknowledged the absence of proper assessment and documentation, stating that the nursing staff should have performed these actions. The facility's policies and procedures require documentation of assessment findings and communication with the physician and responsible party, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Morgan Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgan Hill Healthcare Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Gilroy Healthcare Center | 8.8 mi | ★★★★★ | 2 | 0 |
| Manresa Healthcare Center | 15.2 mi | ★★★★★ | 12 | 0 |
| Watsonville Nursing Center | 15.4 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 15.4 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.