Health inspection·October 9, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report the results of its abuse investigations to the State Agency (California Department of Public Health-CDPH) within five working of the incident for two of three sampled Residents (Resident 1 and Resident 2). When: 1. The facility failed to report the results of the investigation of Resident 1's verbal abuse allegation to CDPH within five working days of the alleged incident. 2. The facility failed to report the results of the investigation of Resident 2's psychological abuse allegation to CDPH within five working days of the alleged incident. These failures resulted in CDPH being unaware of the outcome of Resident 1's verbal abuse allegation investigation and Resident 2's psychological abuse allegation investigation. This failure also had the potential for Resident 1 and Residents 2's abuse allegations to not be investigated thoroughly. Findings: 1. During a review of Resident 1's SOC 341 (Abuse allegation reporting form) dated 5/28/24, SOC 341 indicated, an abuse allegation was reported to facility on 5/27/24 at approximately 3 p.m. SOC 341 indicated, a verbal abuse from a staff member to Resident 1 was alleged. During a review of Resident 1's Verification of Incident Investigation(also known as 5-day report), dated 6/4/24, indicated, alleged incident occurred on 5/27/24, and reported to CDPH 5/28/24. 5 day report indicated, a family member of Resident 1 alleged verbal abuse occurred with a facility staff member and Resident 1 on 5/27/24. There is no indication or date the report was sent to CDPH. During an interview on 8/22/24, at 4 p.m., with Administrator, Administrator stated, she did not have any documented evidence the facility sent a 5 day report to CDPH for Resident 1's abuse allegation within 5 working days of the allegation. 2. During a review of Resident 2's SOC 341 dated 5/3/24, SOC 341 indicated, an abuse allegation from a staff member against Resident 2 was alleged to occur on 5/2/24 around 7:30 p.m. SOC 341 indicated, a psychological abuse incident was alleged between a staff member and Resident 2. During a review of Resident 2's Verification of Incident Investigation(also known as 5-day report), dated 5/8/24, document indicated, the facility determined Resident 2's abuse allegation was unsubstantiated. Document indicated, it was faxed to CDPH on 5/13/24, 10 days after the facility was aware of the allegation. Page 1 of 3 056037 056037 10/09/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0609 Level of Harm - Minimal harm or potential for actual harm During an interview on 8/22/24, at 9:34 a.m., with Administrator, Administrator stated she believes the 5-day report was sent to CDPH after she signed the document. Administrator was unable to verify the date the facility sent the 5-day report for Resident 2. Administrator stated, she could not confirm when the 5-day report was sent to CDPH for Resident 2. There was no documented evidence the 5 day report of investigation was sent to CDPH. Residents Affected - Few During a review of Resident 2's Verification of Incident Investigation(also known as 5-day report) dated 5/13/24, indicated, the 5 day-report was faxed to CDPH on 5/13/24 (Ten days after facility was aware of allegation). During a review of the Facility's Policy and Procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, the P&P indicated, 6. Investigation Injuries of unknown source, suspected or alleged abuse, neglect, and involuntary seclusion, misappropriation of resident property or funds, mistreatment, and suspicions of a crime will be investigated with results reported in accordance with facility policies and federal and state regulations. 056037 Page 2 of 3 056037 10/09/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting for two of three sampled residents (Resident 1 and Resident 2) when: Residents Affected - Few The facility failed to provide thorough summary of findings including information obtained in interviews for abuse investigations for Resident 1 and Resident 2, to the State Agency (CDPH-California Department of Public Health) upon request. This deficient practice resulted in CDPH being unaware if the abuse allegations by Resident 1 and Resident 2 were investigated thoroughly. Findings: During a review of Resident 1's SOC 341 (mandated abuse allegation reporting form) dated 5/28/24, SOC 341 indicated, an abuse allegation was reported to facility on 5/27/24 at approximately 3 p.m. SOC 341 indicated, a verbal abuse from a staff member against Resident 1 was alleged. During a review of Resident 1's Verification of Incident Investigation (also known as 5-day report) dated 6/4/24, document indicated, the facility determined Resident 1's abuse allegation was unsubstantiated(not supported by evidence). Report indicated, no other specific evidence related to the investigative findings, such as interviews or medical record reviews. During a review of Resident 2's SOC 341 dated 5/3/24, SOC 341 indicated , an abuse allegation from a staff member against Resident 2 was alleged to occur on 5/2/24 around 7:30 p.m. During a review of Resident 2's Verification of Incident Investigation dated 5/8/24, document indicated, the facility determined Resident 2's abuse allegation was unsubstantiated. Document indicated, no other specific evidence related to the investigative findings, such as interviews or medical record reviews. During an interview on 8/22/24, at 9:34 a.m., with Administrator, Administrator stated, she was unable to provide the investigative interviews, follow-up actions, or any other evidence of the facility's thorough summary of investigation or findings for both abuse allegations (Resident 1 and Resident 2) because they are protected documents. The surveyor had two request regarding the abuse investigative documents for Resident 1 and Resident 2 but the Administrator denied the request for both times. During a review of the facility's P&P titled, Alleged or Suspected Abuse and Crime Reporting dated 2022, the P&P indicated, 6. Investigation .The facility will complete a Verification of Incident Investigation giving a brief description of incident, thorough summary of findings including information obtained in interviews, follow-up actions taken and notifications made. This verification may be provided to federal or state survey agencies upon request. 056037 Page 3 of 3