Health inspection·November 5, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have a procedure in place to ensure a resident who displays, or who has a mental disorder, receives appropriate treatment and services to correct the assessed problem for one of two sampled residents (Resident 1). The facility did not implement the psychiatry recommendations timely for Resident 1 after their assessment and psych evaluation was completed due to the facility not having a procedure to follow up with the recommendations from outside referrals. Residents Affected - Few This failure resulted in a delay of starting Resident 1's new treatment plan by three weeks. This failure had the potential to negatively affect Resident 1's behavior and the safety of other residents in the facility. Findings: During a review of Resident 1's Diagnosis Information, undated, document indicated, Resident 1 was diagnosed with Schizophrenia, Unspecified [a serious mental health condition that affects how people think, feel and behave]. During a review of Resident 1's Care Plan dated, 6/28/22 indicated, a Focus of Potential Behavior disturbance Related to DX [diagnosis of] Schizophrenia manifested by restlessness with agitation.Interventions/Tasks. Monitor for behavior. During a review of Resident 1's Care Plan dated, 2/26/24 indicated, a Focus of Resident has a positive indication of Mental Illness.Interventions/Tasks.follow up with psych service as needed. During a review of Resident 1 and Resident 2's Verification of Incident Investigation dated 9/10/24, indicated and allegation of physical abuse was investigated between Resident 1 (alleged aggressor) and Resident 2 (alleged victim). During a review of Resident 1's Progress Note dated 9/6/24 note indicated, given he [Resident 1] has had 2 altercations with other PT's [patients] recently NP [Nurse Practitioner] will order a Psych eval [Psychiatric Evaluation] to evaluate possible restart of Zyprexa [antipsychotic medication that can treat several mental health conditions like schizophrenia]. Signed by Resident 1's Physician. During an interview on 10/8/24, at 1:45 pm, with Social Services Director (SSD) SSD stated, she sent the referral to the NP for a psych eval for Resident 1. SSD stated, she did not see the recommendation by the NP until today (10/8/24), and the medication order from her recommendation was ordered today. SSD stated the facility did not have a procedure how to follow up the recommendations from the psychiatry referral made by the NP. Page 1 of 2 056037 056037 11/05/2024 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Psychiatry Diagnostic Interview(psych eval) dated 9/18/24, Interview indicated, NP conducted a psych eval on Resident 1. Interview indicated, Reason for visit: Diagnostic evaluation due to altercation with another resident, concern for agitation or aggression.Recommend increase Mirtazapine [antidepressant medication] to 15 mg nightly for depression m/b [manifested by] verbalizations if sadness.Consideration should be given to adding mood stabilizing agents such as Depakote sprinkles [This medication is used to treat seizure disorders and mental/mood conditions] 125 mg BID [twice daily] for irritability and aggression, given two aggressive episodes in the past year and mild agitation with staff in hallways.Redirect patient when possible. Use caution given his history of physical aggression. During an interview on 10/10/24 at 8:06 a.m., with NP, NP stated, she performed a psychiatric assessment for Resident 1 on 9/18/24 and uploaded her eval/assessment with her recommendations that same day. NP stated, she does not send the recommendations to the facility, but the staff there have access to an online portal and can access her recommendations as soon as she uploads them. NP stated she was not contacted by the facility until 10/8/24 when they asked her for the psych assessment for Resident 1 and she provided a copy. During a review of Job Description for Social Services Director, undated, Job Description indicated, Manages department to assure assessments, discharges and psychological needs of residents are met. 056037 Page 2 of 2