Health inspection·September 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of three residents investigated, (Resident 1), when Resident 1 did not have a care plan for his broken tooth. This failure had the potential to result in the resident, not receiving the proper intervention and monitoring necessary to maintain his highest level of well-being. Findings: During the observation of Resident 1 on 8/12/25 at 3:00 p.m., Resident 1 was in his room, laying in bed. He's alert, oriented, calm, comfortable and verbally responsive. Resident 1 confirmed that he had a broken tooth, but it was already extracted. Review of Resident 1's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including encounter for palliative care (specialized medical approach that focuses on improving the quality of life for people with serious or life-threatening illnesses), alcoholic cirrhosis of liver (chronic condition characterized by permanent scarring of the liver tissue) with ascites (abdominal swelling caused by accumulation of fluid, most often related to liver disease) and type 2 diabetes mellitus (chronic condition characterized by high blood sugar, insulin resistance, and relative lack of insulin) with other specified complication (secondary disease, condition, or issue that arises during the course of a primary disease or after a medical procedure or treatment). Review of Resident 1's care plans indicated, Resident 1 did not have a care plan created when he had a change of condition (any significant, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains that may require a change in their plan of care) for his broken tooth, including the interventions to be done and the monitoring of it. During the concurrent review of Resident 1's care plans and interview with the director of nursing (DON) on 8/12/25 at 2:20 p.m., DON acknowledged that Resident 1 did not have a care plan initiated for his change of condition, for having a broken tooth. DON further acknowledged that a care plan should have been made for Resident 1's broken tooth to address Resident 1's needs but there was no care plan at all, and she further stated that she would update his care plan. During another interview with DON on 9/10/25 at 1:00 p.m., DON verified that for Resident 1's broken tooth, a care plan should have been created for proper monitoring, interventions and follow up. Review of the facility's policy and procedure titled, Care Plan, Episodic, dated August 2014 indicated, It is the policy of the facility to develop an episodic/short term care plan for acute temporary changes and/or condition. Entries will be realistic and have measurable goals and timeframes and responsibility for meeting the specific goals Review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 2008 indicated, It is the policy of the facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life The Page 1 of 2 056037 056037 09/10/2025 Pacific Hills Post Acute 370 Noble Court Morgan Hill, CA 95037

F 0656 Level of Harm - Minimal harm or potential for actual harm Care Plan is individualized by identified resident problems, unique characteristics, strengths, and individual needs Review of the facility's policy titled, Change of Condition, dated 2016 indicated, Purpose: To appropriately assess, document and communicate changes of condition To provide treatment and services to address changes in accordance with resident needs and existing Advance Directives Residents Affected - Few 056037 Page 2 of 2