Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Hills Post Acute during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions experienced a change of condition due to a broken tooth, but the facility did not develop or implement a care plan to address this issue. Despite facility policies requiring care plans for acute changes, no interventions or monitoring were documented for the dental problem, as confirmed by the DON.
A facility failed to follow up on psychiatric recommendations for a resident with schizophrenia, delaying a new treatment plan by three weeks. The resident had been involved in altercations, prompting a psychiatric evaluation that recommended medication adjustments. The facility lacked a procedure to ensure timely access to these recommendations, which were available on an online portal.
The facility failed to report the results of abuse investigations to CDPH within the required five working days for two residents. In one case, a verbal abuse allegation was not reported on time, and in another, a psychological abuse allegation was faxed ten days after the facility was aware of it. The administrator could not verify the timely submission of these reports, contrary to the facility's policy.
The facility failed to follow its P&P on abuse reporting for two residents by not providing a thorough summary of findings, including interview information, to CDPH. The facility determined the abuse allegations were unsubstantiated but did not include specific evidence in the reports. The Administrator denied surveyor requests for investigative documents, citing them as protected.
A resident's MDS assessment inaccurately coded an antiplatelet medication as an anticoagulant, despite the resident's medical records indicating the use of clopidogrel bisulfate for blood clot prevention. The MDS Director confirmed the error, and the Administrator expected accurate coding, revealing a failure to follow CMS guidelines.
The facility failed to ensure a resident received necessary care and services, including developing a change in condition plan, monitoring for hypoglycemia, and following a post-op appointment order. The interdisciplinary team did not address the resident's cognitive decline, and there was no documentation of hypoglycemia protocol or post-op follow-up.
The facility failed to assess, notify the physician and responsible party, and document a pressure injury on the bilateral buttocks of a resident with type 2 diabetes and dementia, despite a physician's order for treatment. Interviews confirmed the lack of documentation and notification, contrary to the facility's policies.
Failure to Develop and Implement Care Plan for Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan for a resident who experienced a change of condition due to a broken tooth. The resident, who had a medical history including palliative care, alcoholic cirrhosis of the liver with ascites, and type 2 diabetes mellitus with complications, was observed to be alert, oriented, and comfortable. The resident confirmed that the broken tooth had already been extracted. However, review of the care plans revealed that no care plan was created at the time of the change of condition to address the broken tooth, including necessary interventions and monitoring. Interviews with the DON confirmed that a care plan should have been initiated for the resident's broken tooth to ensure proper monitoring, interventions, and follow-up, but this was not done. Review of facility policies indicated that both episodic and comprehensive care plans are required for acute changes in condition, with measurable goals and timeframes. Despite these policies, the facility did not create or implement a care plan for the resident's dental issue, resulting in a failure to address the resident's needs as required.
Failure to Implement Timely Psychiatric Recommendations
Penalty
Summary
The facility failed to implement a procedure to ensure timely follow-up on psychiatric recommendations for a resident diagnosed with schizophrenia. This deficiency was identified when the facility did not act on the psychiatry recommendations for the resident after a psychiatric evaluation was completed. The delay in implementing the new treatment plan lasted three weeks, which could have negatively impacted the resident's behavior and the safety of other residents. The resident had been involved in altercations with other patients, prompting a psychiatric evaluation to consider medication adjustments. The psychiatric evaluation recommended increasing the resident's Mirtazapine dosage and considering the addition of Depakote for irritability and aggression. However, the facility did not access these recommendations promptly due to the absence of a procedure for following up on external psychiatric referrals. The Social Services Director acknowledged the lack of a procedure and only became aware of the recommendations weeks later. The Nurse Practitioner confirmed that the evaluation and recommendations were uploaded to an online portal accessible to the facility staff, but the facility did not review them until much later.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of its abuse investigations to the California Department of Public Health (CDPH) within the required five working days for two residents. In the first case, a verbal abuse allegation involving a staff member and a resident was reported to the facility, but there was no documented evidence that the investigation results were sent to CDPH within the stipulated timeframe. The incident was reported to the facility on May 27, 2024, and the investigation was completed by June 4, 2024, but the facility administrator could not provide evidence of timely submission to CDPH. In the second case, a psychological abuse allegation was made against a staff member involving another resident. The facility determined the allegation to be unsubstantiated, but the report was faxed to CDPH ten days after the facility became aware of the incident, exceeding the five-day requirement. The administrator was unable to verify the exact date the report was sent, and there was no documented evidence to confirm the timely submission. The facility's policy requires that such investigations be reported in accordance with federal and state regulations, which was not adhered to in these instances.
Failure to Provide Thorough Abuse Investigation Summary
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding Alleged or Suspected Abuse and Crime Reporting for two residents. For both residents, the facility did not provide a thorough summary of findings, including information obtained from interviews, to the California Department of Public Health (CDPH) upon request. This deficiency was identified during a review of the mandated abuse allegation reporting forms (SOC 341) and the Verification of Incident Investigation reports for both residents. The reports indicated that the facility determined the abuse allegations were unsubstantiated but did not include specific evidence or details from interviews or medical record reviews. During an interview, the facility's Administrator stated that she could not provide the investigative interviews, follow-up actions, or any other evidence of a thorough investigation for the abuse allegations, citing them as protected documents. Despite two requests from the surveyor for the investigative documents, the Administrator denied access both times. The facility's P&P clearly states that a Verification of Incident Investigation should include a brief description of the incident, a thorough summary of findings, follow-up actions, and notifications, which can be provided to federal or state survey agencies upon request.
Inaccurate MDS Assessment for Medication Classification
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, resulting in a discrepancy in medication classification. The resident, who was admitted with a medical history of congestive heart failure, peripheral vascular disease, and hypertension, was receiving clopidogrel bisulfate, an antiplatelet medication, for blood clot prevention. However, the MDS assessment incorrectly coded the resident as having received an anticoagulant medication during the seven-day look-back period. The error was identified during a review of the resident's medical records and confirmed through interviews with the MDS Director and the Administrator. The MDS Director acknowledged that clopidogrel bisulfate is an antiplatelet medication and should have been coded as such. The Administrator expressed an expectation for MDS assessments to be accurately coded, highlighting the facility's failure to adhere to the coding instructions outlined in the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to ensure that Resident 1 received the necessary care and services, leading to several deficiencies. The interdisciplinary team (IDT) did not develop a change in condition plan of care for Resident 1 despite a noticeable decline in cognition and other health issues. The IDT did not address Resident 1's decline in cognition, and there was no plan of care developed. This was confirmed by the Director of Nursing (DON), Certified Nursing Assistant (CNA), and other staff members who acknowledged the lack of a comprehensive plan to address the resident's condition changes. Additionally, the facility did not closely monitor Resident 1 for signs and symptoms of hypoglycemia, nor was there documentation of a hypoglycemia protocol in the resident's clinical record. Despite multiple instances of critical low blood sugar levels, there were no documented assessments, repeat blood sugar checks, or interventions performed to address these critical levels. Interviews with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurses (LVNs) confirmed that the necessary steps to manage hypoglycemia were not taken. Furthermore, the facility failed to follow Resident 1's physician order for a post-operative follow-up with the surgeon. The DON confirmed that the post-op appointment was not followed as ordered, and there was no documentation indicating that Resident 1 attended the appointment. The order was not properly transcribed to the Medication Administration Record (MAR), and the social services department did not receive the appointment information to set up transportation. This oversight was acknowledged by the DON and other staff members involved.
Failure to Document and Notify Pressure Injury
Penalty
Summary
The facility failed to properly assess, notify the physician and responsible party, and document a pressure injury on the bilateral buttocks of a resident. The resident, who was admitted with diagnoses including type 2 diabetes and dementia, was identified as being at moderate risk for pressure sores upon admission and later assessed as high risk. Despite a physician's order to clean and treat the buttocks area, there was no documentation of the pressure injury assessment, measurements, or notifications to the physician or responsible party on the specified date. During interviews, the licensed vocational nurse confirmed the lack of documentation and notification regarding the pressure injury. The Director of Nursing also acknowledged the absence of proper assessment and documentation, stating that the nursing staff should have performed these actions. The facility's policies and procedures require documentation of assessment findings and communication with the physician and responsible party, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Morgan Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgan Hill Healthcare Center | 0.2 mi | — | 1 | 0 |
| Gilroy Healthcare Center | 8.8 mi | — | 2 | 0 |
| Manresa Healthcare Center | 15.2 mi | — | 12 | 0 |
| Watsonville Nursing Center | 15.4 mi | — | 12 | 0 |
| Watsonville Post Acute Center | 15.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.