Other·June 13, 2018

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 investigation of an abbreviated survey regarding a complaint conducted on 6/8/18. For Complaint CA00588915 regarding Quality of Care/Treatment, the Department did substantiate a Federal deficiency (see F 689). The deficiency had a scope and severity of "G". A Class "B" Citation was issued. Inspection was limited to the complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 32892, Health Facilities Evaluator Nurse.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (1) while 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: BD5811 Facility ID: CA070000048 If continuation sheet 1 of 4 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 06/08/2018 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 smoking. This failure resulted in Resident 1 sustaining second degree (partial thickness burns that affect the epidermis and the dermis [lower layer of skin] that cause pain, redness, swelling, and blistering) burn wounds on his face and left hand. Findings: Resident 1 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension (persistent elevation of blood pressure), and heart failure ( inability of the heart to pump adequate blood to the body). His minimum data set (MDS-an assessment tool), dated 3/5/18, indicated he had no cognitive impairment. There was a physician's order dated 4/18/18, to administer oxygen 2-4 liters per minute via nasal cannula (plastic tubing that delivers oxygen) to keep oxygen saturations above 90%. During an interview with Resident 1 on 5/30/18 at 2:50 p.m., he stated certified nursing assistant A (CNA A) accompanied him during a smoke break on 4/29/18 around 10 a.m.. He stated he was sitting in his wheelchair with a portable oxygen container located at the back of his wheelchair. Resident 1 stated CNA A lit up his cigarette. During an interview with CNA A on 5/30/18 at 2:57 p.m., he stated he accompanied Resident 1 during a smoking break on 4/29/18 around 10:00 a.m. Resident 1 was sitting in his wheelchair with a portable oxygen container located at the back of the wheelchair. He stated Resident 1 was smoking and suddenly complained of being lightheaded. CNA A handed the nasal cannula to Resident 1 which started the ignition. CNA A stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BD5811 Facility ID: CA070000048 If continuation sheet 2 of 4 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 06/08/2018 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 immediately applied wet towels to Resident 1's face. He stated Resident 1 suffered minor burns in his nostrils. Review of Resident 1's nurse's progress notes dated 4/29/18, indicated Resident 1 had burns on both nostrils, left hand middle finger, neck, and eyebrows. Nurse's progress notes, dated, 4/30/18 revealed a blister on his left middle finger measuring 2 x 2 x .0.1 cm (centimeters, unit of measurement) During an interview with treatment nurse B (TN B), on 6/5/18 at 8:51 a.m., he stated Resident 1 suffered multiple burn injuries including blisters on his left middle finger. TN B further stated Resident 1 was referred to the wound doctor (WD). During an interview with the WD, on 6/6/18 at 3:04 p.m., he stated Resident 1 had second degree burns on his face and hand. Review of Resident 1's Wound Care Specialist Evaluation, dated 5/2/18, indicated Resident 1 had second degree burn wounds on his face and left hand from cigarette/oxygen combustion. The burn wound on his face measured 2.5 x 5.5 cm and the burn wound on his left hand measured 1.5 x 2.5 x 0.1 cm. During an interview with medical director (MD) on 6/5/18 at 12:03 p.m., he stated Resident 1 suffered burns on his nostrils, nasal area, clavicle area, and left middle finger. He further stated he had informed facility staff not to allow residents to smoke while on oxygen during a smoke break. Review of the facility's policy dated 2/2018, "Smoking Policy", indicated to monitor and evaluate residents for safety related to smoking. It further indicated "portable oxygen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BD5811 Facility ID: CA070000048 If continuation sheet 3 of 4 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 06/08/2018 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 tanks and/or other oxygen delivery systems are NEVER allowed in designated smoking areas, even if oxygen is turned off." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BD5811 Facility ID: CA070000048 If continuation sheet 4 of 4