Other·August 30, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 8/15/17 through 8/18/17. The facility was licensed for 99 beds. The census at the time of the survey was 99 including one bed hold. The sample size was 20. A Class "B" Citation was identified (see F323). Representing the California Department of Public Health: 38174, Health Facility Evaluator Nurse; 35157, Health Facilities Evaluator Nurse; 38243, Health Facilities Evaluator Nurse; 34383, Health Facilities Evaluator Nurse; and 36043, Health Facilities Evaluator Nurse.

F152 SS=D RIGHTS EXERCISED BY REPRESENTATIVE F152 CFR(s): 483.10(b(3)-(7) 09/19/2017 (b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident’s rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated. (i) The resident representative has the right to exercise the resident’s rights to the extent LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 1 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE those rights are delegated to the representative. (ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law. (b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law. (b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law. (b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law. (b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The courtappointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. (i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 2 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE outside the representative’s authority. (ii) The resident’s wishes and preferences must be considered in the exercise of rights by the representative. (iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one sampled resident (5) and one non-sampled resident (30) were appropriately assisted by the legally appointed individual/representatives to exercise their rights. This failure had the potential of not promoting and maintaining the residents' highest practicable mental, physical and psychological well-being. Findings: 1. Resident 30's clinical record was reviewed. The resident was admitted to the facility with diagnoses including dementia (a gradual loss of memory and cognition) without behavioral disturbance, epilepsy (a disorder of the nervous system that can cause people to suddenly become unconscious and to have violent, uncontrolled movements of the body), anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected), paranoid schizophrenia (a disease of disordered thoughts causing someone to be unreasonably suspicious of other people), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Record review of Resident 30's minimum data set (MDS, an assessment tool) dated 6/19/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 3 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated his cognitive skills for daily decision making were severely impaired. Review of Resident 30's Physician Orders for 8/1/17-8/31/17, indicated: "MD determines that Resident does not have the Mental Capacity to make healthcare decisions as per History & Physical or Transfer orders or preferred intensity of care". Review of Resident 30's face sheet dated August 17, 2017 indicated the facility's interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) was designated as the responsible party (RP, health care decision maker). During an interview with the social service assistant (SSA) on 8/17/17, at 4:15 p.m., she confirmed the IDT as the responsible party (RP) for Resident 30. The SSA reviewed Resident 30's clinical record and was unable to find documentation indicating an interdisciplinary team meeting was conducted to designate the IDT as the responsible party. 2. Review of Resident 5's clinical record indicated she was readmitted to the facility with diagnoses including dementia. Resident 5's MDS dated 4/28/17 indicated Resident 5 had a BIMS (Brief interview of mental status) score of 7 (ranging from 0 to 15, 7 indicating severe impairment). Review of Resident 5's Physician Orders dated 4/21/17 indicated she did not have the mental capacity to make healthcare decisions. On 4/21/17, Resident 5 signed consent to treat, consent to the disclosure of her medical record and consent to photograph. Resident 5 also signed an undated consent for immunization and admission bedhold acknowledgement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 4 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with licensed vocational nurse E (LVN E) on 8/15/17 at 2:00 p.m., she indicated that Resident 5 was confused and she would not let Resident 5 sign a document but would call a family member. During an interview and record review with the director of nursing (DON) on 8/15/17 at 2:10 p.m., she claimed that if the physician's order indicated Resident 5 had no capacity to make healthcare decisions, Resident 5 should not be allowed to sign the above documents. Review of the facility policy titled "Epple Bill", dated November 2016, indicated "To determine the existence of a person with legal authority, the physician must interview the resident, review the medical record and consult with facility staff, as appropriate, and with family and friends of the resident, if any have been identified. The Ombudsman must be contacted also and verify that there is no available or willing representative for the resident. Where informed consent is required and the physician has determined that the resident lacks capacity to make health care decisions and there is no person with legal authority to make those decisions on behalf of the resident, the facility shall conduct an interdisciplinary team (IDT) (sometimes referred to as an Epple Committee) to review the prescribed medical intervention prior to its administration. The IDT shall oversee the care of the resident, utilizing a team approach to assessment and care planning. The team shall include the resident's physician, the registered professional nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and where appropriate, a resident representative, in accordance with federal and state requirements. The Ombudsman must be contacted and must validate the resident does not have any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 5 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE representative who can make decisions on his/her behalf".

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 09/19/2017 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there isFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 6 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the physician for one of 20 sampled residents (14) when Resident 14 refused the antibiotic (medication used to treat infections), requested to have intravenous (IV, medication given into the vein) line and be transferred to the emergency department (ED) for insertion of intravenous access for an IV line. This practice had the potential to cause a delay of treatment and inability to address the condition timely. Review of Resident 14's clinical record indicated he was admitted to the facility with diagnoses including UTI (urinary tract infection), overactive bladder and paraplegia (paralysis of the lower half of the body). The Minimum Data Set (MDS, an assessment tool) dated 1/28/17 indicated Resident 14 had a BIMS (Brief interview of mental status) score of 14 (ranging from 13 to 15, 14 being cognitively intact). Review of Resident 14's Office Visit form, dated 8/9/17, indicated a physician's order for clindamycin (medication to treat bacterial infections) 300 milligrams (mg, unit measurement) by mouth three times daily. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 7 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Resident 14 on 8/16/17 at 1:25 p.m., he stated that on 8/9/17 he came from an appointment with his primary physician and had an order to take clindamycin. Resident 14 indicated that he requested to have IV clindamycin instead of taking it by mouth, to licensed vocational nurse P (LVN P). According to Resident 14, LNV P said he told him the order was only to take by mouth. Resident 14 told LVN P that he wanted to be transferred to the ED to get the IV medication. Resident 14 claimed he refused to take the antibiotic by mouth because, "They don't want to give me an IV and be transferred to the ED for this. I had IV antibiotic here before". During a interview with LVN P on 8/17/17 at 12:40 p.m., he claimed he received the office visit form from Resident 14 on 8/9/17. LVN P stated that on 8/9/17 he notified the attending physician (AP) about the clindamycin medication. Review of Resident 14's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication), dated 8/9/17 at 7:45 p.m., indicated LVN P carried out an order for clindamycin 300 mg cap (capsule) 1 capsule three times daily for ten days. There was no documentation of AP notification regarding Resident 14's refusal to take the medication, that he wanted to have it through an IV, and requested to be transferred to the ED. During an interview and record review with nurse supervisor B (NS B) on 8/17/17 at 2:00 p.m., she indicated if Resident 14 had refused the medication, wanted to have an IV, and be transferred to the ED, the AP should have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 8 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notified right away to get the proper treatment. NS B confirmed there was no notification of the AP on 8/9/17. During an interview with the AP on 8/18/17 at 11:30 a.m., he stated he was not notified about Resident 14's refusal to take the medication, wanting to have an IV medication and be transferred to the ED. The AP claimed he should have been called. The AP stated that in this kind of situation with Resident 14, the AP would have talked to Resident 14 and explained the situation as Resident 14 listens to him. A review of the facility's 2016 "Change of Condition" policy indicated if change of condition did not require an immediate 911 transfer, notify physician and responsible party of assessment findings.

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 09/19/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide privacy and respect for one of 24 sampled residents (Resident 14). This failure had the potential to affect the resident's self-esteem. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 9 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Review of Resident 14's clinical record indicated he was admitted to the facility with diagnoses including UTI (urinary tact infection), overactive bladder, anxiety and paraplegia (paralysis of the lower half of the body). The Minimum Data Set (MDS, an assessment tool) dated 1/28/17 indicated Resident 14 had a BIMS (Brief interview of mental status) score of 14 (ranging from 13 to 15, 14 being cognitively intact). During an initial tour on 8/15/17 at 7:45 a.m., Resident 14 was in the bed located by the door and had his curtains closed. An oxygen concentrator (a device used to deliver oxygen) being used by his roommate in the next bed, was situated by Resident 14's bedside table in between the beds. During a concurrent observation and interview with licensed vocational nurse E ( LVN E), she opened Resident 14's curtain and fixed the oxygen concentrator without asking Resident 14 permission. She stated the oxygen concentrator belonged to Resident 14's roommate. LVN E stated there were not enough electric outlets, and the oxygen concentrator was connected to an extension cord. LVN E stated the oxygen concentrator should not have been occupying Resident 14's space. During an interview with Resident 14 on 8/16/17 at 1:25 p.m., he stated the staff would open his curtains without asking his permission whenever his roommate used the oxygen concentrator. He further stated the oxygen concentrator noise bothered him and at times it was hard to fall asleep. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 10 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's 6/15, "Resident Rights " policy indicated it was to provide residents with a comfortable, private and safe environment to live...every resident has to be treated with consideration and full recognition of dignity and individuality including privacy in treatment and care of personal needs.

F250 SS=D PROVISION OF MEDICALLY RELATED SOCIAL SERVICE CFR(s): 483.40(d)

F250 09/19/2017 (d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide medically-related social services for one of 20 sampled residents (16). Resident 16 had $87 missing and the resident had no follow-up regarding the result of the investigation by the facility. This failure had the potential to negatively affect the mental and psychosocial well-being of the resident. Findings: Review of Resident 16's Minimum Data Set (MDS, an assessment tool) dated 7/3/17 indicated she was cognitively intact and could make decisions. During a group meeting on 8/15/17 at 10:10 a.m., Resident 16 stated she had $87 missing and it happened three weeks prior. She stated she reported the missing money to the social service assistant (SSA) but the SSA never came back and talked to her about the missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 11 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE money. Resident 16 stated she found it strange regarding what happened to her money. During interview and record review with the SSA on 8/15/17 at 3 p.m., she stated she was aware missing money of Resident 16's and it was reported to her on 7/30/17. There was no documentation the SSA followed up regarding Resident 16's missing money. Review of the facility's 11/2016 policy, "Theft and Loss Report", indicated missing property not located by nursing staff or the laundry department within 24 to 48 hours was to be referred to the Social Service Department. Social Services will inform the resident and family of their right to file a grievance with facility administration or the ombudsman. The facility department heads are responsible for follow-up of missing item complaints received. Review of the facility's, "Job Description of Social Service Assistant", undated, indicated the SSA follows up on missing items or property and provides a positive approach to effectively solve the problem.

F252 SS=D SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 09/19/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 12 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a home-like environment for one sampled resident (14) when a personal electric fan was not maintained in a clean order. This practice had the potential to affect the resident's physical and emotional well-being. Findings: Review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 1/28/17 indicated Resident 14 had a BIMS (Brief interview of mental status) score of 14 (ranging from 13 to 15, 14 being cognitively intact). During an observation on 8/16/17 at 1:25 p.m., Resident 14's black electric fan was operating and had a thick accumulation of gray particles on its front grill and blades. During a concurrent interview with Resident 14, he stated that the fan has been "dirty" and the facility was not doing anything about it. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 13 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with licensed vocational nurse D ( LVN D) on 8/16/17 at 1:35 p.m., he confirmed the above observation. He stated it should have been cleaned. During an interview with the housekeeping supervisor (HS) on 8/17/17, she stated Resident 14 was known to have the door and curtains closed all the time and it was a challenge to clean the resident's room. The HS stated the facility knew of this problem and she was not aware of the fan condition. There was no indication in Resident 14's clinical record indicating refusal to clean his room . During an interview with the SSA on 8/17/17 at 1:30 p.m., she claimed Resident 14 had been refusing to clean the room since admission to the facility. A care plan for Resident 14's refusal of housekeeping was added on 8/16/17. A review of the facility's 8/2014 "Housekeeping Manual" policy indicated to ensure that resident rooms and bathrooms were sanitary, odor free and safe. Housekeeping to check all areas above eye level and dust as needed.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 09/19/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 14 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 15 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to update a care plan for one of 20 sampled residents (8) related to falls. Resident 8's care plan for falls, dated 4/27/17, 5/7/17, 5/11/17, 5/21/17, and 6/6/17 was not updated and revised to prevent future falls. These failures had the potential to result in the inability to identify the resident's individualized care issues and implement person-centered care plans to address the respective identified needs. Findings: Review of Resident 8's clinical record indicated he was admitted with diagnoses including falls, dementia (memory problem), dysphasia (communication disorder), Alzheimer's disease (progressive mental deterioration), muscle weakness, and lack of coordination. His Minimum Data Set (MDS, an assessment tool) dated 2/25/17, indicated the resident had a severely impaired cognition (mental process) and required assistance for bed mobility, transfer, ambulation, toileting, and personal hygiene. Resident 8's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) Fall Report of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 16 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Incident indicated he had falls on 3/14/17, 3/16/17, 3/19/17, 4/6/17, 4/18/17, 4/27/17, 4/29/17, 5/7/17, 5/11/17, 5/12/17, 5/21/17, 5/29/17, 6/6/17, and 8/17/17 (total of 14 falls). During an interview and record review with registered nurse J (RN J) on 8/18/17 at 9:40 a.m., she was unable to find the fall care plan dated 4/27/17, 5/7/17, 5/11/17, 5/21/17 and 6/6/17. She also stated the licensed nurse should have initiated the fall care plan for Resident 8. During an interview with the director of nursing (DON) on 8/18/17 at 11:30 a.m., she stated the fall care plan should have been updated and revised for each fall for Resident 8. Review of the facility's 1/2017 policy, "Care Plan, Comprehensive", indicated care plans are individualized through the identification of resident concerns, unique characteristics, strengths, and individual needs. Resident progress is regularly evaluated, the approaches reviewed and revised or updated as appropriate. Problem solution and changes in goals and approaches may be identified and initiated.

F280 SS=D RIGHT TO PARTICIPATE PLANNING CAREREVISE CP CFR(s): 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2)

F280 09/19/2017 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 17 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the personcentered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-(i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident’s strengths and needs. (iii) Incorporate the resident’s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 18 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct the interdisciplinary team (IDT, team members from different departments involved in a resident's care) post fall follow-up for two of 20 sampled residents (9 and 12). These failures had the potential to delay care planning to identify the specific care and services necessary to meet the residents' needs. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 19 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Review of Resident 9's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) indicated that on 7/14/17 Resident 9 had an unwitnessed fall. There was no indication that the IDT post fall follow-up was done. 2. Review of Resident 12' s SBAR indicated that on 6/8/17 and 7/6/17, Resident 12 had two unwitnessed falls. There was no indication that the IDT post fall follow-up was done. During an interview and record review with nurse supervisor A (NS A) on 8/16/17 at 3:40 p.m., she confirmed there were no IDT followups done for both residents and should have been done 72 hours post fall. NS A stated the IDT post fall follow-up was essential to reevaluate the plan of care regarding falls. A review of the facility's 8/14, "Fall Management", indicated that documentation may include an IDT Post-occurrence review.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 09/19/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 20 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide services according to accepted standards of clinical practice for one of 20 sampled residents (11) and one non-sampled resident (30). For Resident 11, the licensed nurses administered two doses of furosemide (water pill, treats fluid retention in people with congestive heart failure) and potassium chloride (supplement used to treat low amounts of potassium in the blood, helps the heart work properly). For Resident 30, there were no physician orders, care plan, and interdisciplinary team (IDT) notes for use of socks on both arms. These failures had the potential to cause health complications to the residents. Findings: 1. Review of Resident 11's clinical record indicated he was admitted to the facility with diagnoses including congestive heart failure. Review of the physician's order dated 7/14/17 indicated to give Furosemide 40 mg (mg, unit of measurment), one tablet by mouth one time a day for edema, and to hold from 7/17/17 to 7/23/17. On 7/20/17, a physician's order indicated to give Furosemide 80 mg by mouth one time a day for edema with no stop date. On 7/14/17, a physician's order indicated to give Potassium Chloride Liquid 20 milliequivalent (meq, unit of measurement) /15 milliliter (ml, unit of measurement) 7.5 ml. by mouth one time a day for supplement. On hold from 7/1717 to 7/20/17. On 7/20/17, a physician's order indicated to give 20 meq/15 ml daily. No stop date was ordered. Review of Resident 11's Medication Administration Record (MAR), dated 7/21/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 21 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated furosemide 40 mg and 80 mg were given to the resident. On 7/24/17, Resident 11 received a total of 22.5 ml. of potassium chloride. Review of Resident 11's SBAR (situation, background, assessment, and recommendation, a communication and assessment tool used by nurses for a resident's change of condition) Medication Regimen Report of Incident, dated 7/21/17 and 7/25/17, indicated the resident had medication errors in two separate incidents. Review of Resident 11's Care Plan, dated 7/21/17, indicated the resident received two different doses of potassium and furosemide. During an interview with licensed vocational nurse F (LVN F) on 8/17/17 at 3:45 p.m., she acknowledged she administered two doses of potassium to Resident 11. During an interview with LVN L on 8/17/17, at 4:20 p.m., she stated when she received the new orders for potassium and furosemide, she forgot to discontinue the current orders. LVN F stated they should have been discontinued. Review of the facility's policy and procedure titled, "Processing Physician Orders", dated 4/2011, indicated upon receipt of a new telephone order the licensed nurse will transcribe to the telephone order form. Review of the facility's policy and procedure titled, "General Dose Preparation and Medication Administration", dated 1/1/13, indicated verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct rate, and for the correct resident. 2. Review of Resident 30's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 22 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated he was admitted to the facility with diagnoses including dementia (a gradual loss of memory and cognition) without behavioral disturbance, epilepsy (a disorder of the nervous system that can cause people to suddenly become unconscious and to have violent, uncontrolled movements of the body), anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected), paranoid schizophrenia (a disease of disordered thoughts causing someone to be unreasonably suspicious of other people), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Minimum Data Set (MDS, an assessment tool) dated 6/19/17, indicated the resident had severely impaired cognitive skills for daily decision making. During an observation on 8/15/17 at 7:54 a.m. and 8/17/17 at 9:10 a.m., Resident 30 was observed in his bed with both arms and hands covered with long socks. During an interview on 8/17/17 at 9:10 a.m. with LVN K, who was present during this observation, she stated the purpose of the socks was to keep Resident 30 from scratching himself. During an observation in the assisted dining area on 8/17/17 at 11:36 a.m., Resident 30 was observed in a reclining wheelchair with socks covering both his arms and hands. In a concurrent interview with the activity assistant (AA), she stated Resident 30 swings and flings his arms a lot and the the purpose of the socks is "to protect his arms and hands". She also stated Resident 30 was in a reclining wheelchair and away from the table because he would "jump out from the chair usually kicking and his hands flinging". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 23 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 30's clinical record, and interview with LVN K on 8/17/17 at 12:36 p.m., she validated no physician's order, care plan, informed consent, IDT note, and documentation that the physician was notified about the use of socks on both arms/hands was in Resident 30's clinical record. This was also confirmed by registered nurse C (RN C) who joined the interview at 1:10 p.m. Both LVN K and RN C showed the monitoring on the point click care (PCC, a computerized medical record), done by certified nursing assistants under Tasks: "Gloves to hands to minimize self-injury caused by scratching". RN C stated the use of gloves or socks on Resident 30's arms/hands should be included in the care plan interventions as it is part of tasks. RN C could not remember when the facility started applying the socks to Resident 30's arms and hands. During an interview on 8/17/17, at 4:15 p.m., the social service assistant (SSA) stated the former director of nursing was looking into ordering Resident 30 therapeutic hand gloves. The SSA reviewed Resident 30's clinical record and validated there was no IDT note on the use of socks/gloves. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. Review of facility policy and procedure, "Care Plan, Comprehensive", dated Jan 2017 indicated: It is the policy of this facility to develop, in conjunction with the resident and/or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 24 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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. Care plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. Review of the facility policy titled, "Operating Standard Guideline Interdisciplinary Walking Rounds" (IDT WR), dated 2017, indicated: Walking rounds are completed on a regularly scheduled basis to manage new admission transitions of care and to mitigate unnecessary transfers related to changes of condition; the process is completed via IDT face -to-face engagement with the resident to determine necessary interventions, discuss preferences and to create care and discharge plans; and there are four types of IDT Walking Rounds including Significant Occurrences and Clinical Change of Condition.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 09/19/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 25 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure adequate assistance to prevent accident and injury for one of 20 sampled residents (Resident 8). The facility failed to assist the resident during activities of daily living (ADLs, such as bed mobility, transfer, toileting, personal hygiene, and ambulation); failed to provide a mattress on the floor, and failed to implement interventions in response to Resident 8's frequent falls. These failures resulted in Resident 8's left forehead laceration (tear in skin) and acute right subdural hematoma (a collection of blood under the skull and outside the brain as a result of a blow to the head). Findings: Review of Resident 8's clinical record indicated he was admitted on 2/18/17 with diagnoses including falls, dementia (memory problem), dysphasia (communication disorder), Alzheimer's disease (progressive mental deterioration), muscle weakness, and lack of coordination. His Minimum Data Set (MDS, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 26 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment tool) dated 2/25/17, indicated the resident had a severely impaired cognition (mental process), and required assistance for bed mobility, transfer, ambulation, toileting, and personal hygiene. Resident 8's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) Fall Report of Incident indicated he had falls on 3/14/17, 3/16/17, 3/19/17, 4/6/17, 4/18/17, 4/27/17, 4/29/17, 5/7/17, 5/11/17, 5/12/17, 5/21/17, 5/29/17, 6/6/17, and 8/17/17 (total of 14 falls). Review of Resident 8's Fall Risk Assessment dated 3/20/17 indicated he had a score of 75. A score of 45 and higher represents a high risk for fall. Review of Resident 8's Self Care Deficit care plan dated 2/18/17 indicated the resident required assistance with ADLs related to confusion and weakness. Review of Resident 8's High Risk for Fall Care Plan related to history of falls, weakness, dementia, and lack of safety awareness, dated 2/18/17, indicated the resident used a bed or sensor pad alarm (to indicate if a resident is getting up from a bed). Review of Resident 8's Actual Fall Care Plan, dated 2/22/17, indicated use of a mattress on the floor and sensor pad alarm in bed. Review of Resident 8's SBAR Fall Report of Incident, dated 5/13/17, indicated the resident had an unwitnessed fall from his bed when he tried to ambulate with no assistance. Resident 8 was found on the floor next to his bed with no mattress on the floor. The intervention to prevent falls was to place a mattress on the floor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 27 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 8's SBAR Fall Report of Incident 5/21/17 indicated the resident had an unwitnessed fall from his bed when he tried to get up with no assistance. Resident 8 was found on the floor with a laceration to his forehead and was later transferred to the acute hospital. There was no documentation the mattress on the floor was in place. The intervention was to place a sensor pad alarm and mattress on the floor. During an interview with licensed vocational nurse H (LVN H) on 8/17/17 at 9:40 a.m., LVN H acknowledged Resident 8 had no mattress on the floor when he fell on 5/21/17. LVN H stated the resident was found on the floor next to his bed, hit his head, and there was blood on the floor. A review of the consulting physician notes from the acute hospital dated 5/21/17 indicated Resident 8 fell and struck his head on a hard surface resulting in closed head injury with left frontal laceration. Review of Resident 8's Acute Hospital Chart Print Report dated 5/24/17 indicated the resident had left forehead stitches and a diagnosis of acute right subdural hematoma. Resident 8 was admitted to the intensive care unit (ICU) for close neurological surveillance (observe and monitor the patient's condition). During an observation on 8/16/17 at 8:25 a.m., Resident 8 was lying on his bed sleeping with the sensor pad alarm, but the cord was not connected to the machine. During an observation and interview with certified nurse assistant I (CNA I) on 8/17/17 at 9:25 a.m., she confirmed the sensor pad alarm cord was not connected to the machine. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 28 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated the sensor pad alarm would not work if the cord was not connected. CNA I acknowledged the sensor pad alarm should have been connected to the machine to work. During an observation on 8/16/17 at 8:26 a.m. and 8/18/17 at 8:02 a.m., Resident 8 was sleeping on his bed with the floor mattress folded and placed on the side of the bedside table. During an observation and interview with the director of staff development (DSD) on 8/18/17 at 8:10 a.m., Resident 8 was sleeping on his bed and there was no mattress on the floor. The DSD stated the resident should have a mattress on the floor to prevent injury, especially because he had previously hit his head on the floor during a fall. During an interview and record review with the director of nursing (DON) on 8/18/17 at 11:35 a.m., she stated Resident 8 was a high risk for falls and required assistance during his ADLs. She stated the fall care plan intervention should have been implemented to prevent falls. The DON confirmed the mattress on the floor should have been in place to prevent injury. Review of the facility's 8/2014 policy, "Fall Management", indicated nursing staff and interdisciplinary team (IDT, team members from different department involved in a resident's care) will evaluate the risk factors, provide interventions to minimize the risk, injury, and occurrences; review, revise, evaluate care plan effectiveness to minimize falls, and injuries.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 (b)(2) Foot care. To ensure that residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 29 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 30 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents’ goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide needed respiratory care for one nonsampled resident (27) when Resident 27's oxygen tank was empty while in use. This failure could potentially affect the care and safety of the resident. Findings: Review of Resident 27's clinical record indicated he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, is a lung disease that causes coughing, wheezing, and shortness of breath).The Minimum Data Set (MDS, an assessment tool) dated 6/14/17 indicated Resident 27 had a BIMS (Brief interview of mental status) score of 15 (ranging from 13 to 15, 15 being cognitively intact). Resident 27's Physician Order dated 8/21/17 indicated oxygen at 4LPM (liters per minute) via NC (nasal cannula, tubing inserted into the nostrils) continuous to keep 02 (oxygen level) above 90% every shift. During an observation on 8/16/17 at 8:20 a.m., Resident 27 was in bed with the NC attached to a portable oxygen tank. The pressure gauge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 31 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (accurately monitors pressure levels of oxygen) hand indicator was pointed to a red mark. During a concurrent interview with Resident 27, he indicated that he could not feel the air coming out from the nasal cannula but could breath fine. He stated that he needed oxygen at all times. During an interview with nurse supervisor A (NS A) in the presence of the director of nursing (DON) on 8/16/17 at 8:30 a.m., NS A confirmed the above observation. She stated the red indicator on the oxygen tank meant it was empty and needed to be replaced. The DON indicated that staff should be checking the oxygen condition during nursing rounds to see if it's functional. A review of the facility's 2012 "Oxygen Use" policy indicated routine equipment inspection and maintenance should be performed based on manufacturer's recommendations.

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 32 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 3 of 20 sampled residents (8, 12, and 17) were free from unnecessary drugs when: 1) The facility did not monitor the target behavior for the use of Nuedexta (medication to treat pseudobulbar affect, PBA, a specific condition of sudden, frequent laughing and/or crying episodes) on Resident 17; two licensed nurses were unable to identify the indication and target behaviors for Nuedexta; two licensed nurses and the director of nursing (DON) did not find any care plan and target behavior monitoring for the use of Nuedexta for Resident 17 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 33 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2) The facility did not identify the behavior and side effects for the use of alprazolam (antianxiety medication) for Resident 12 3) The facility did not monitor the target behaviors for the use of Depakote (an anticonvulsant medication) for Residents 8 This failure had the potential to result in unnecessary medication for the residents. Findings: 1. Resident 17 was admitted on 8/2/17 with diagnoses including insomnia (inability to sleep), obstructive sleep apnea (the airway collapses or becomes blocked during sleep), bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), history of venous thrombosis (formation or presence of a blood clot in a blood vessel) and embolism (obstruction in a blood vessel due to a blood clot or foreign matter), anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected), hypertension (high blood pressure). On 8/16/17, a review of Resident 17's clinical record indicated a physician order with start date of 8/2/17 for, "Nuedexta Capsule 20-10 mg (mg, unit of measurement) Give 1 capsule by mouth two times a day for neurological disorder due to multiple CVAs". (Cerebrovascular Accidents-the medical term for a stroke. A stroke is when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel.). There was no documented evidence in the medical record that the facility monitored target behaviors and had a care plan specific to Nuedexta for Resident 17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 34 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with licensed vocational nurse F (LVN F) on 8/17/17 at 1:30 p.m., he stated he could not remember what the indication was for Nuedexta, and he was not familiar with the drug. LVN F checked the doctor's order on the computer, he quoted the order for Resident 17 was for, "neurological disorder for multiple CVAs". LVN F could not state the target behaviors monitored for Nuedexta, and he confirmed there was no target behaviors monitored for the use of Nuedexta for Resident 17. During an interview with registered nurse G (RN G) on 8/17/17 at 3:40 p.m., she stated Nuedexta is a, "psych medication". She could not state the indication and target behaviors for Nuedexta. RN G could not show any care plan or target behavior monitoring on Nuedexta for Resident 17. In a concurrent interview with the DON, she reviewed Resident 17's medical record and stated she could not find a care plan and target behavior monitoring on Nuedexta for Resident 17. During an interview with registered nurse J (RN J) on 8/18/17 at 9:20 a.m., she stated if the resident had been there two weeks, a care plan should have been initiated. According to http://www.avanir.com/nuedexta (website for Nuedexta), Nuedexta is approved for the treatment of PseudoBulbar Affect (PBA). PBA is a medical condition that causes involuntary, sudden, and frequent episodes of crying and/or laughing in people living with certain neurologic conditions or brain injury. PBA episodes are typically exaggerated or don't match how the person feels. PBA is distinct and different from other types of emotional changes caused by neurologic disease or injury. Nuedexta is not an antidepressant, an antipsychotic, anxiolytic, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 35 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sedative hypnotic drug. The facility policy and procedure, "Care Plan, Interim", dated 2008, indicated: Interim care plans may be used upon admission following completion of the Admission Nursing Assessment; Purpose: To establish a preliminary plan of care to address actual or potential issues upon admission through completion of the initial comprehensive assessment. 2. Review of Resident 12's clinical record indicated she was admitted to the facility with diagnoses including anxiety disorder (the reaction to situations perceived as stressful or dangerous). A review of the physician's orders on 8/15/17 indicated to give alprazolam tablet (used to treat anxiety disorders) 0.25 milligram (mg, a unit measurement) every twenty-four hours as needed for anxiety . Review of Resident 12's medication administration record (MAR) indicated that alprazolam was given on 8/2, 8/3, 8/8, 8/9, 8/12, and 8/14/17. During an interview and record review with nursing supervisor A (NS A) on 8/17/17 at 7:45 a.m., she indicated there should be a description of Resident 12's behavior whenever alprazolam medication was given as this was an as needed medication, and documentation for effectiveness under order administration notes. On 8/16/16, alprazolam 0.25 mg was given at 19:28 with Resident 12's behavior described as increased agitation, kicking staff and throwing away clothes. NS A confirmed that on 8/2, 8/3, 8/8, 8/9, 8/12, and 8/14/17 there were no identified behaviors documented, and no side effects monitoring was done. She stated there should be an order for side effects FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 36 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE monitoring for psychotropic medications. 3. Review of Resident 8's clinical record indicated he was admitted on 2/18/17 with diagnoses including delirium (a mental disturbance characterized by confused thinking and disrupted attention) and dementia (memory problem). His Minimum Data Set (MDS, an assessment tool), dated 2/25/17, indicated the resident had severely impaired cognition (mental process). There was no documentation for specific behavior monitoring for delirium. Review of Resident 8's physician's order dated 7/9/17 indicated Depakote 125 mg by mouth two times daily for delirium. Review of Residents 8's potential behavior disturbance care plan, dated 3/27/17 indicated it was related to delirium as evidenced by picking at things which were not present, talking to people that were not present, heading in the direction of objects or things that are not present, placing the resident at increased risk for fall with injury. During an interview with the pharmacy consultant on 8/16/17 at 4:30 a.m., he stated Resident 8 should have specific behavior monitoring for the use of Depakote. He also stated the specific behavior should have been monitored, which could potentially endanger the safety of the resident related to a fall. During an interview with the director of nursing (DON) on 8/18/17 at 11:50 a.m., she acknowledged Resident 8's Depakote should include specific behaviors to be monitored for. Review of the facility's 2/2017, "Psychotropic Medication Management", indicated psychoactive medications are prescribed, the clinical record should reflect the diagnosis, and specific condition, or targeted behavior being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 37 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treated. The effectiveness of medications and non-drug approaches should be regularly documented. Observed, specific behaviors, effectiveness of non-drug approaches, and monitoring of medication are to documented.

F332 SS=D FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1)

F332 (f) Medication Errors. The facility must ensure that its(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility had an 8% medication error rate when two medication errors during 25 opportunities were observed during the medication passes for two non-sampled residents (23 and 24). For Resident 23, the licensed nurse administered Calcium 500 milligrams (mg, unit of measurement) instead of Calcium 600 mg. Resident 24, had an order of Effexor XR (medication used to treat depression) 150 mg, two capsules, and the licensed nurse prepared and was about to administer Effexor XR 150 mg, one capsule. These failures had the potential to jeopardize the residents' health. Findings: 1. During a medication pass observation with licensed vocational nurse K (LVN K), on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 38 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8/16/17, at 9:45 a.m., LVN K took one tablet of Calcium 500 mg with Vitamin D 200 international unit (IU, unit of measurement) from the bottle. LVN K administered the Calcium with Vitamin D tablet and other medications to Resident 23. Medication reconciliation on 8/16/17 indicated Resident 23 had an order of Calcium 600 mg with Vitamin D 200 IU. During a concurrent interview with LVN K, she acknowledged she administered Calcium 500 mg instead of Calcium 600 mg. LVN K stated she would notify the physician about the medication error. 2. During a medication pass observation with licensed vocational nurse M (LVN M) on 8/16/17 at 8:35 a.m., LVN M popped one capsule of Effexor from Resident 24's bubble pack card and placed it on top of the medication cart. The Effexor bubble pack card indicated to give two capsules. LVN M locked the computer and the medication cart. LVN M took the medication cup on the top of the cart and was ready to administer the medication. Review of Resident 24's Physician Order, dated 8/2017, indicated Effexor XR capsule 150 mg, two capsules, daily for depression. During a concurrent interview with LVN M on 8/16/17 she acknowledged she was about to give the Effexor one capsule. LVN M stated she overlooked the medication administration record and missed the dosage order. Review of the facility's policy and procedure titled, "General Dose Preparation and Medication Administration", dated 1/1/13, indicated verify each time a medication is administered that it is the correct medication, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 39 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the correct dose, at the correct rate, and for the correct resident.

F371 SS=D FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain food sanitary practices when two containers of expired yogurt and one bowl of undated spoiled fruit were found in Resident 2's bedside refrigerator. This failure had the potential to cause food-borne illnesses to Resident 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 40 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: During an observation on 8/15/17 at 8:25 a.m., in Resident 2's room, two containers of yogurt with expiration dates of 5/20/17 and 6/11/17, and one undated spoiled bowl of fruit with three black spots in it were found inside Resident 2's bedside refrigerator. In a concurrent interview with registered nurse C (RN C), she stated, "I will throw them away and tell the nurse so they know". RN C also stated "usually we have to date (the food) when placed in the refrigerator and when opened". RN C stated expired and spoiled food could lead to food poisoning. During an interview with LVN D on 8/15/17 at 8:31 a.m., he confirmed the yogurt was expired and the undated fruit bowl was spoiled with 3 black spots in it. LVN D stated Resident 2's brother usually brought her food; the certified nursing assistant would take out food from the refrigerator and give it to Resident 2 who can feed herself; and that housekeeping checked the refrigerator but he was not sure how often. Review of the facility policy titled, "Personal Food Storage", with effective date 09/14 indicated: Food or beverage brought in from an outside source for storage in facility pantries, refrigeration units, or personal room refrigerator units will be monitored for food safety; 3. Food and beverage items in facility pantry refrigerators will be labeled and dated and/or follow expiration dates; 4. Designated facility staff will be assigned to monitor individual room storage and refrigeration units for food and beverage disposal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 41 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F425 PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one emergency medication kit (e-kit) was replaced within 72 hours after being used. This failure had the potential to delay treatment during an emergency situation. Findings: During an observation of the medication room on 8/16/17 at 10:50 a.m., accompanied by nursing supervisor A (NS A), the e-kit for intravenous solutions (IV solutions, fluids administered into a vein) antibiotic was inspected. The label on the e-kit container indicated it was to contain one vial (small container) of Vancomycin (antibiotic, medication that treats infections) one gram (gm, unit of measurement) and one vial of Imipenem-Cilastatin (antibiotic, medication that treats bacterial infection) 500 milligram (mg, unit of measurement). These vials of antibiotics were not present inside the e-kit. There were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 42 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE written records inside the e-kit that the Imipenem-Cilastatin was taken out on 6/30/17 and Vancomycin was taken out on 7/12/17. NS A confirmed this observation. During an interview with the director of nursing (DON) on 8/18/17 at 11:15 a.m., she stated the e-kit should have been replaced as soon as it was opened. During an interview with the pharmacy consultant (PC) on 8/18/17 at 11:35 a.m., he stated e-kits must be replaced within 72 hours after the pharmacy receives a replacement request from the facility. Review of the facility's policy and procedure titled, "LTC Facility's Pharmacy Services and Procedure Manual", dated 1/3/17, indicated the facility should ensure that Emergency Medication Supplies remain in the nursing unit until either an item is withdrawn or one of it is about to expire. The facility should contact the pharmacy for a replacement. An Emergency Medication Supply is exchanged at the facility daily.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 43 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 44 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper infection prevention practices were followed for 6 non-sampled residents (25, 27, 28, 31, 33, and 34). For Resident 25, the nebulizer mask was unlabeled and exposed to air. For Residents 27, 28, and 31, the oxygen tubings were unlabeled and outdated. For Residents 33 and 34 when a nursing assistant did not wash hands in between food tray distribution. These practices had the potential to spread infection. Findings: 1. Review of Resident 25's Physician Order, dated 8/2017, indicated to give IpratropiumAlbuterol solution three milliliters (ml, unit of measurement) via nebulizer every eight hours for shortness of breath. Review of Resident 25's Medication Administration Record (MAR), dated 8/2017, indicated Ipratropium-Albuterol solution was given on 8/5 to 8/10/17 and 8/13/17. During the initial tour with the director of staff development (DSD) on 8/15/17 at 7:35 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 45 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 25's nebulizer mask was unlabeled and exposed to air. During a concurrent interview with the DSD, on 8/15/17, she stated Resident 25's nebulizer mask should be labeled and in the plastic bag. A review of the facility's 9/16, "Nebulized Medication/Hand Held Nebulizer " procedure indicated to change nebulizer set-up monthly and when visibly soiled. 2. Resident 27's Physician Order dated 8/21/17 indicated oxygen at 4LPM (liters per minute) via NC (nasal cannula, tubing inserted into the nostrils) continuous to keep 02 (oxygen level) above 90% every shift. During an observation on 8/15/17 at 7:45 a.m., Resident 27 was in bed with undated oxygen tubing wrapped around the bed side rail. During a concurrent interview with LVN E, she confirmed the above observation and stated it should have been dated. 3. Review of Resident 28's Physician Order on 8/16/17 indicated use oxygen prn (as needed) if 02 sat (is a measure of how much oxygen the blood is carrying) less than 90% every six hours. Change oxygen tubing monthly and as needed for when visibly soiled. Label and date tubing and plastic bag. During an observation on 8/15/17 at 7:40 a.m., Resident 28 had an oxygen concentrator (a device used to deliver oxygen) with oxygen tubing in a plastic bag. The plastic bag had a date of 1/18/17. There was a visible unclean area on the oxygen concentrator that licensed vocational nurse E (LVN E) started wiping. During a concurrent interview with LVN E, she confirmed the above observation and stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 46 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE oxygen tubing needed to be changed monthly. LVN E stated she was not sure if Resident 28 still needed oxygen. 4. During an observation on 8/15/17 at 8:04 a.m., Resident 31's oxygen concentrator was observed with undated oxygen tubing and an empty, undated humidifier bottle. During a concurrent interview with registered nurse C (RN C), she confirmed this observation and stated, "I don't see a date". Review of Resident 31's Physician Orders dated 6/10/17 indicated orders for: a) Oxygen at 2 LPM via NC PRN for SOB or to keep oxygen saturation greater than 90% as needed; b) Change oxygen tubing monthly and as needed when visibly soiled. And every night shift every 30 day(s) for SOB. The order and start dates were 6/10/17. Review of the Facility Policy on Oxygen use dated 2012 indicated: The O2 cannula or mask does not require scheduled changing when used on one resident. It should be changed when visibly soiled; if a disposable humidifier is used, it may be used until empty, there is no maintenance of the reservoir; and if reusable humidifier is used, it should be emptied rinsed, dried and refilled with sterile water daily. The person changing the water should label it with the date, time, and initials. During an interview with the director of nursing (DON) on 8/18/17 at 11:30 a.m., she stated if there is a physician order to change the tubing monthly, the physician's order had to be followed. 5. During tray distribution observation on 8/16/17 at 12:50 p.m., certified nursing assistant N (CNA N) was observed not performing hand hygiene. She went to the food cart, took and delivered a tray to Resident 8, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 47 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE placed the tray on Resident 8's table, opened the plate cover and assisted Resident 8 to open food items on the tray. CNA N then came out of Resident 8's room carrying the plate cover and placed it on top of the cart. She took another tray from the food cart and delivered the tray to Resident 33 without performing hand hygiene in between. CNA N placed the tray on Resident 33's table and assisted her to open food items. CNA N came out of Resident 33's room, did not perform hand hygiene, went to the food cart, took and delivered another tray to Resident 34. Resident 34's table looked cluttered. CNA N moved some items from the table including a container of wipes, did not perform hand hygiene and positioned the tray in front of Resident 34. CNA N opened the cellophane cover of a small yogurt plate for Resident 34. CNA N came out of Resident 34's room and was not observed performing hand hygiene. During an interview with CNA N on 8/16/17 at 1:10 p.m., she confirmed she did not perform hand hygiene between tray distribution and stated it can, "cause cross contamination". CNA N stated she did not use the hand sanitizer located inside the residents' rooms. Review of CNA N's employee file indicated her date of hire was 4/25/17. She attended inservices on Prevention and Control of Infection and Hand Hygiene on day 1 of her orientation. This was confirmed by the DSD. Review of the facility policy on Hand Hygiene dated 2012 indicated: Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene; the policy stated handwashing/hand hygiene is generally considered the most important single procedure, for preventing healthcare associated infections, and, Section II, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 48 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Waterless Handwashing Products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under "handwashing".

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 49 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure an accurate clinical record for three sampled residents (6, 10, and 17) and one non-sampled resident (30) when: 1) Resident 6's preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) required specialized services such as referral to a mental health authority) did not reflect a mental illness (MI) diagnosis. 2) Resident 10's updated PASRR was not uploaded timely to the point click care (PCC, a clinical record system) and the minimum data set (MDS, an assessment tool) did not reflect psychiatric/mood disorder diagnosis. 3) Resident 17's PASRR did not reflect the presence of a MI diagnosis and prescribed psychotropic medications. 4) Resident 30's PASRR Mental Illness Screen did not reflect an MI diagnosis. These had the potential to inaccurately reflect the clinical status necessary to meet and provide the needs of the residents. Findings: 1. Review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you ac; it causes feelings of sadness and/or a loss of interest in activities once enjoyed). Resident 6's physician's order for 8/1/17-8/31/17 indicated an order for Citalopram Hydrobromide (medication to treat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 50 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE depression) give 15 milligrams (mg, a unit of measure) by mouth one time a day for Depression with order date of 6/30/17. Resident 6's MDS dated 7/6/17, indicated, under Section I, Active Diagnosis indicated Depression. Review of Resident 6's PASRR completed 10/27/13, indicated, under Level I Evaluation, Section III Identifying Criteria for Mental Illness (MI) indicated an answer "No" for MI diagnosis. During an interview with registered nurse J (RN J) on 8/18/17 at 9:30 a.m., she stated she had to look on the PASRR website for an update. She returned at 11:50 a.m. without an updated PASRR for Resident 6. 2. Review of Resident 10's clinical record indicated he was admitted on 2/3/10 and readmitted on 3/7/17. Resident 10's physician order for 8/1/17-8/31/17 indicated diagnosis including anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected). Review of Resident 10's PASRR completed 2/3/10 indicated, under Level I Evaluation, Section III, Identifying Criteria for Mental Illness, indicated an answer "No" for MI diagnoses. During an interview with RN J on 8/18/17 at 9:30 a.m, she stated she had to look on the PASRR website for an update. RN J came back at 11:50 a.m. with a PASRR dated 3/9/17 with Section V -Mental Illness, Diagnosed Mental Illness reflecting a "Yes" answer. When RN J was asked why this PASRR was not in the PCC, she stated it had not been uploaded to the PCC yet. Review of Resident 10's MDS, dated 8/1/2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 51 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated, under Section I, Active Diagnoses, Psychiatric/Mood Disorder: no psychiatric/mood disorder checked. 3. Review of Resident 17's clinical record indicated he was admitted on 8/2/17. Resident 17's physician order for 8/2/17-8/31/17 indicated diagnoses including bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected) with medication orders for Alprazolam Tablet (medication used to treat anxiety) 0.5 milligrams (mg, a unit of measure) give 1 tablet by mouth at bedtime for anxiety; Buspirone HCL Tablet (medication used to treat anxiety disorder), give 7.5 mg by mouth two times a day for anxiety; and Latuda Tablet (medication used to treat mental/mood disorders such as depression associated with bipolar disorder) 60 mg give 1 tablet by mouth one time a day related to bipolar disorder, with order dates of 8/2/17. Resident 17's MDS dated 8/9/17, Section I - Active Diagnosis, Psychiatric/Mood Disorder included: Anxiety Disorder and Manic Depression. Review of Resident 17's PASRR dated 8/3/2017 indicated, under Section V Mental Illness: Diagnosed Mental Illness, Suspected Mental Illness and Psychotropic Medication, all left blank without answers. During an interview with RN J on 8/18/17, at 9:30 a.m., she stated that when the PASRR is completed and Section II, Item 16 {Is there a current (less than 18 months) PASRR on file for this resident with no significant change in condition} is answered Yes, it disables her to continue and answer the succeeding sections. She stated that in order for her to continue to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 52 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Section V - Mental Illness, there has to be a significant change of condition. 4) Review of Resident 30's clinical record indicated he was admitted on 12/31/15. Resident 30's physician orders for 8/1/178/31/17 indicated diagnoses including anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected), paranoid schizophrenia (a disease of disordered thoughts causing someone to be unreasonably suspicious of other people), and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) with medication orders for Lorazepam Tablet 0.5 mg by mouth in the evening for anxiety with order date of 8/3/16 and Lorazepam Tablet 1 mg give 1 tablet by mouth every 12 hours as needed for Anxiety manifested by (M/B) restless and fidgeting with order date of 12/31/15. His MDS dated 6/19/17 Section I, Active Diagnosis included Anxiety Disorder, Psychotic Disorder and Schizophrenia. Review of Resident 30's PASRR dated 1/4/16 indicated under Section I, Item 8: Physical diagnosis at time of transfer/admission: Dementia, Glaucoma, Schizophrenia. However, Section VII - Mental Illness Screen: Does the resident have or is suspected of having a mental illness, was left blank with no answers. During an interview with RN J on 8/18/17 at 9:30 a.m., she confirmed there were no answers on Section VII for mental illness, but said Section I - Item 8 has "Dementia, Glaucoma, Schizophrenia". The facility policy titled, "Guideline for Submitting a PASRR", dated Feb 2017 indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 53 of 54 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056037 (X3) DATE SURVEY COMPLETED 08/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC HILLS POST ACUTE 370 Noble Ct Morgan Hill, CA 95037 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A) PASRR screening: a "PASRR" screening is done on every admission that enters a Medicaid facility. A copy of this form must be kept in the medical chart. B) MDS vs PASRR: The MDS and PASRR form should reflect the same information, if a resident does not trigger on admission for any MI/ID (MI - Mental Illness, ID - Intellectual Disability), but does on the MDS, the facility should submit another PASRR. C) Mental Disorder - New information after admission: If a resident's record at the time of admission does not indicate a mental disorder and later information is provided stating that the resident does have a mental disorder a PASRR is to be submitted as a Resident Review because of a significant change in condition. D) Level II Screen: Suspected Mental Illness: If a resident is originally admitted and no referral is necessary at that time and has a change in mental status, medications, behaviors, then a PASRR must be completed to indicate these changes and must be referred to DSS (Department of Social Services) or DMH (Department of Mental Health) for Level 2 screen. List of diagnosis which would trigger a Level II Screen include schizophrenia delusional disorder, major depression and anxiety disorder. The facility policy titled, "Process for Scanning Documents into PointClickCare", dated February 2017, indicated to scan and attach the documents to the resident's electronic medical record as indicated: for PASRR, the frequency indicated is each time the form is completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VL6R11 Facility ID: CA070000048 If continuation sheet 54 of 54