Other·January 24, 2019

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 standard abbreviated survey regarding investigation of an entity reported incident conducted on 1/17/19. For Entity Reported Incident CA00610378 regarding Quality of Care, federal deficiencies were identified (see F684 and 690). A federal deficiency was identified for a violation unrelated to the entity reported incident (see

F758). A "G" level deficiency was identified for F690. A Class "B" citation was also issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 32276, Health Facilities Evaluator Nurse.

F684 SS=D Quality of Care CFR(s): 483.25

F684 § 483.25 Quality of care Quality of care is a fundamental principle that 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: JP2W11 Facility ID: CA070000048 If continuation sheet 1 of 12 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 01/17/2019 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 applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow thier policy and procedure for congestive heart failure (CHF, occurs when your heart muscle doesn't pump blood as well as it should, and blood and other fluids can back up inside the lungs, abdomen, liver, and lower body) for one of four sampled residents (Resident 1). This failure had the potential for unmet care needs and worsening health conditions. Findings: During a review of the clinical record for Resident 1, the Order Review Report dated 11/13/18, indicated "CHF PROTOCOL: daily weight before breakfast. Notify MD (medical doctor) if 2 lb over admission weight or 3 over admission weight in 4 days every shift [sic]...fill out CHF SHEET on binder every shift." The Weights and Vitals Summary indicated Resident 1's weights as: 10/23/18 136.8 lbs 10/24/18 patient refused 10/25/18 149.2 lbs (12.4 lb difference since admission) 10/26/18 145.2 lbs 10/27/18 143.4 lbs 10/28/18 N/A (non-applicable) 10/29/18 150.2 lbs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 2 of 12 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 01/17/2019 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 There was no documentation that the MD was notified of Resident 1's 12.4 lb weight gain in two days. There was no documentation of a CHF care plan. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and verified the 12.4 lb weight gain in two days. LN A was unable to find documentation the MD was notified of the weight gain or a care plan. She stated the CHF and weight gain should have a care plan. During a review of the clinical record for Resident 1, there was no documentation of intake and output monitoring (measuring fluid which goes into and out of the body for fluid balance). During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of intake and output monitoring. The facility's policy and procedure, "Heart Failure Clinical Protocol Standard" dated 10/2015, indicated "To promote safe and effective care for [residents] with heart failure... 4. The HF (heart failure) protocol includes: c. Intake and Output monitoring every shift... d. Weigh HF [residents] DAILY prior to breakfast and post-voiding (urinating), when possible. (Daily weights are documented in the EMR (electronic health record). Notify attending physician for weight gain of [great than or equal to] 2 lbs (pounds) in one day or [greater than or equal to] 5 lbs in 3 days.)

F690 SS=G Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F690 Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 3 of 12 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 01/17/2019 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 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that one out of four sampled residents (Resident 1), who was admitted to the facility with an indwelling urinary catheter (tube inserted into the bladder to drain urine) received appropriate care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 4 of 12 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 01/17/2019 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 services to prevent and to promptly treat urinary tract infection (UTI, an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) as indicated in the facility's policy and procedure by failing to: 1. Appropriately assess and document Resident 1's urine color, character, and output (amount of urine a resident excretes). 2. Initiate a care plan for indwelling urinary catheter care and assessment, and 3. Remove the indwelling urinary catheter per the medical doctor's (MD's) orders. These failures resulted in a delay of care for Resident 1 who was transferred on 10/30/18 via 911 (emergency services) to a general acute care hospital (GACH) and subsequently admitted with a diagnosis of severe sepsis (an overwhelming and life-threatening immune response to infection) with acute organ (kidney) dysfunction due to UTI. Resident 1 was a 73-year-old male who was admitted to the facility on 10/22/18 for rehabilitation after a CVA (cerebrovascular accident or stroke-when blood flow to a part of the brain stops). Resident 1 had a history of hyperlipidemia (high cholesterol), degenerative disk disease (back or neck pain caused by wear-and-tear on a spinal disc), atrial fibrillation (irregular and often rapid heart rate), hypertension (high blood pressure), dementia (loss of mental ability severe enough to interfere with normal activities of daily living), and congestive heart failure (the heart's function as a pump is inadequate to meet the body's needs). Resident 1 had an indwelling urinary catheter in place on admission to the facility due to neurogenic bladder (a condition in which problems with the nervous system affect the bladder and urination). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 5 of 12 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 01/17/2019 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 the clinical record for Resident 1, the Order Review Report indicated on 10/22/18, the MD ordered to continue the indwelling urinary catheter every shift for two days, may re-insert indwelling urinary catheter as needed for malfunction (not working), and "Remove indwelling urinary catheter for voiding trial (to assess patients' ability to empty their bladder successfully following the removal of indwelling urinary catheter) in 2-3 days. Bladder scan (test to measure the amount of urine in the bladder) every 6 hours x [times] 4 days after indwelling urinary catheter is removed. Replace indwelling urinary catheter for post-void residual (urine left in the bladder) [greater than] 250 ml (milliliters, a unit of measurement) ...monitor". During a review of the clinical record, the Progress Notes dated 10/27/18 at 3:00 p.m., indicated the indwelling urinary catheter was draining. There was no description of the urine (color, character or amount). There was no other documentation that the nurse assessed the indwelling urinary catheter every shift. There was no documentation which indicated the indwelling urinary catheter was removed for a voiding trial per the MD's orders. There was no documentation of a bladder scan or monitoring after indwelling urinary catheter removal. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she stated the indwelling urinary catheter had been removed, but was reinserted for urine retention (inability to empty the bladder completely). She could not state when the catheter was removed or reinserted. She reviewed the clinical record for Resident 1 and was unable to find documentation the indwelling urinary catheter was removed, or the indwelling urinary catheter FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 6 of 12 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 01/17/2019 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 was reinserted due to urinary retention. During a review of the clinical record for Resident 1, there was no documentation of intake and output monitoring (measuring fluid which goes into and out of the body, for fluid balance) during Resident 1's eight-day admission. There was no documentation of a care plan for the indwelling urinary catheter. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of intake and output monitoring or a care plan for the indwelling urinary catheter. During an interview with the Director of Nursing (DON) on 12/21/18 at 10:45 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of an indwelling urinary catheter care plan, intake and output, indwelling urinary catheter monitoring/assessment, or indwelling urinary catheter removal and reinsertion. During a review of the clinical record for Resident 1, the Change in Condition Evaluation, dated 10/30/18 at 8:47 a.m., indicated Resident 1 had abdominal distention and did not have any urine output from his indwelling urinary catheter. "Resident is noted to be more confused, lethargic (a lowered level of consciousness marked by listlessness, drowsiness, and apathy), abnormal vs (vital signs), distended abdomen (when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion) (and) no urinary output with (catheter) in place ..." Resident 1's blood pressure was 76/56 (normal blood pressure is considered 120/60). His heart rate was 106 (normal heart rate ranges from 60 -100). Resident 1's temperature was 100.5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 7 of 12 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 01/17/2019 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 degrees Fahrenheit (normal body temperature ranges from 97 to 99 degrees Fahrenheit). During an interview with LN A on 12/21/18 at 10:45 a.m., she reviewed the clinical record for Resident 1 and verified he had a change in condition on 10/30/18 and was transferred to the GACH via ambulance. The facility's policy and procedure, "Catheter Care, Indwelling Catheter", indicated "Assessment Guidelines may include, but are not limited to ...Color, consistency, amount of urine ...Pain, burning, discomfort ...Hydration and fluid balance status ...Documentation Guidelines ...Date, time, procedure ...any unusual condition or change in condition ...Color, amount, consistency and odor of urine ...intake and output and evaluation of intake and output ...Care Plan Guidelines ...Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. The use of an indwelling catheter is an approach to a specific problem. Develop a care plan with the objective of removing the catheter when the problem is resolved, whenever possible." During a review of the GACH Discharge Summary Notes, dated 11/1/18, the Hospital Course and Significant Findings indicated, "Per admission H&P [history and physical]: 'Resident 1 is a 73-year-old man presenting from his SNF (skilled nursing facility) for urinary retention for the last few days. History obtained from chart review, SNF documentation, and (Resident 1's) wife as (resident) is currently nonverbal. Reportedly, (resident's) ...catheter stopped draining 2-3 days ago. (Resident 1) has also been shivering for the last 3 days. Also, after the catheter stopped draining, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 8 of 12 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 01/17/2019 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) started to appear uncomfortable, and he eventually developed abdomen distention (Resident 1) has reportedly been febrile (had a fever) at his SNF over the last 1-2 days. Blood pressure today at SNF, prior to arrival here was 76/56 (low blood pressure is less than 90/60). (Resident) has also been lethargic and somewhat confused over the past 1-2 days."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(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; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 9 of 12 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 01/17/2019 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 §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) when: 1. Two ordered psychotropic medications did not indicate resident specific behaviors, 2. Behavior monitoring was not done for two psychotropic medications and hours of sleep were not monitored for one psychotropic medication, 3. Care plans were not initiated for psychotropic medication use, and 4. Informed consent was not obtained for three psychotropic medications. These failures had the potential for unnecessary medication administration. Findings: During a review of the clinical record for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 10 of 12 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 01/17/2019 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 1, the Admission Record indicated Resident 1 was admitted to the facility on 10/22/18. The Order Review Report dated 11/13/18, indicated the medical doctor (MD) had ordered fluoxetine for depression, risperidal for dementia (decline in mental ability severe enough to interfere with daily life) as evidenced by delirium (abrupt change in the brain that causes mental confusion and emotional disruption), and trazadone for insomnia (inability to sleep). During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of the resident specific indication for the use of psychotropics. During a review of the Medication Administration Record (MAR) for Resident 1, there was no documentation of behavior monitoring for the fluoxetine or risperidal. There was no documentation of hours of sleep for the trazadone. There was no care plan for the medications, behaviors, or insomnia. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of monitoring for hours of sleep or behaviors. LN A was unable to find documentation of a care plan. She stated the care plan would identify which behaviors to monitor for the resident. She stated the behaviors would also be listed in the MD's order. She reviewed the clinical record and was unable to find documentation of behavior monitoring stating "It's not there". During a review of the clinical record for Resident 1, there was no documentation the MD obtained informed consent for the fluoxetine, risperidone, or trazadone. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 11 of 12 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 01/17/2019 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 Progress Notes, dated 10/22/18, indicated "Verbal consent received from wife... for psychotherapeutic drugs, Trazadone, Risperdal, and Fluoxetine." The note was signed by the nurse. The note did not indicate the prescriber obtained informed consent, discussed possible side effects or the medication dosages. During an interview with Licensed Nurse A (LN A) on 11/13/18 at 11:10 a.m., she reviewed the clinical record for Resident 1 and was unable to find documentation of informed consent. She stated "It's not there". The facility's policy and procedure, "Psychotropic Medication Management" dated 11/17, indicated "1. Newly admitted residents receiving psychoactive medications are evaluated through a comprehensive assessment process to determine historical usage and confirm appropriate indications and clinical necessity... 3. When psychoactive medications are prescribed, the clinical record should reflect the diagnosis and specific condition, or targeted behavior being treated... 7. Informed Consent for psychoactive medications must be verified prior to use. 8. Care plans should be updated to reflect behavior(s) causing functional, emotional, or safety impairment, non-drug interventions to alleviate conditions, and potential side effects of psychotropic medications. Effectiveness of medications and non-drug approaches should be regularly documented. 9. Observed of reported behaviors, effectiveness of non-drug approaches, and monitoring of medication side effects are documented in the EHR (electronic health record)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JP2W11 Facility ID: CA070000048 If continuation sheet 12 of 12