Pacific Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Pacific Hills Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when:1. Staff incorrectly tested the Quaternary sanitizer solution; and,2. Staff performed incorrect thermometer calibration These failures had the potential to negatively impact the nutrition and health status of the facility's 95 residents.Findings:1. During a concurrent observation and interview on 12/4/25, at 9:30 a.m., with Dietary Aide (DA) K, in the kitchen, DA K demonstrated testing of the strength of the quaternary (chemicals used in cleaners because of their antiviral and antibacterial properties) sanitizing solution in the red bucket by immersing a chemistry test strip into a red bucket filled with the… […]

• No harm, potential for more than minimal, patternF553May 18, 2026

  Based on interview, and record review, the facility failed to ensure to schedule, conduct, and document interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) care conference with resident/resident's representative (RP, an individual chosen by resident to act on behalf of resident for day today and healthcare decision making for resident) for four out of four sampled residents (Resident 1, 2, 3, and 4) when:There was no documentation for initial and quarterly IDT care conference for Resident 1;There was no documentation for initial IDT care conference for Resident 2; There was no documentation for quarterly IDT care conferences for Resident 3;There was no documentation for quarterly IDT care… […]

• No harm, potential for more than minimal, patternF578Dec 5, 2025

  Based on interview and record review, the facility failed to ensure their policy and procedures (P&P) for advance directives (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) were followed for five of nine sample residents (Residents 1, 23, 123, 57, and 97) when there was lack of evidence advance directives were discussed and/or carried out with them. […]

• No harm, potential for more than minimal, patternF761Dec 5, 2025

  Based on observation, interview, and policy review, the facility failed to ensure medications were stored and labeled appropriately when medications were found past their discard date in Station 3 and Station 4 medication carts. This failure resulted in expired medications being administered to the residents.Findings:1. On 12/1/25, at 11:05 a.m., during an observation of Station 3 medication cart with licensed vocational nurse F (LVN F), one Artificial Tears (eye drops used to lubricate dry eyes) bottle for the resident in room [ROOM NUMBER]B was labeled as opened on 9/25/25 and one Refresh Tears (lubricant eye drops) bottle for the resident in room [ROOM NUMBER]A was labeled opened on 10/16/25 were found in active use areas within the medication cart. 2. […]

• No harm, potential for more than minimal, patternF684May 10, 2024

  Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) received the necessary care and services when: 1a. The interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) did not develop a change in condition plan of care (POC) for Resident 1; 1b. There was no close monitoring of Resident 1 for signs and symptoms of hypoglycemia (low blood sugar level) and no documentation of hypoglycemia protocol in Resident 1's clinical record; and 1c. […]