Pacific Hills Post Acute: Hospice Care Coordination Failure - CA
That was the finding from a May 2027 complaint inspection at the Morgan Hill skilled nursing facility. Inspectors cited the home for failing to ensure care coordination for a resident entering hospice, a lapse that regulators classified as causing minimal harm or the potential for actual harm. Few residents were affected, according to the report.
The care coordination document at the center of the finding is the kind of paperwork that, when it works, tells everyone involved in a dying person's care exactly who is responsible for what. When it doesn't exist, or when no one has checked whether it exists, the result is a gap between two sets of caregivers, each of whom may assume the other has handled something they haven't.
That appears to be what happened here.
When inspectors interviewed the facility's administrator, the administrator said the hospice provider should have completed the coordination documentation and reviewed it with the resident and facility staff before Resident 1 was admitted to hospice. In other words, the administrator's position was that the responsibility belonged to the hospice agency.
The hospice agency's contract with Pacific Hills Post Acute told a more complicated story.
The facility's own signed agreement with the hospice provider, titled Nursing Facility Service Agreement, stated under a section on coordination of care that the facility was required to coordinate with the hospice provider in developing a plan of care for each hospice patient. The contract acknowledged that the hospice agency retains primary responsibility for developing the plan, but it did not let the facility off the hook for participating in that process.
The facility's internal policy on its hospice program said much the same thing. That policy, reviewed by inspectors, stated that hospice providers contracting with the facility must have a written agreement outlining the responsibilities of both parties in detail, and that the facility was expected to collaborate with the hospice representative and coordinate staff participation in the hospice care planning process.
The facility's own policy said it should have verified that the coordination document was completed. The administrator said it was the hospice provider's job. The document, inspectors found, had not been confirmed as complete when Resident 1 was moved into hospice care.
What that meant in practice for Resident 1 is not fully detailed in the inspection report. The citation covers a single resident and is graded at the lower end of the harm scale. But the coordination document that went unverified is not a bureaucratic formality. For a person entering hospice, the plan of care is the agreement that governs pain management, comfort measures, family communication, and the division of responsibility between the nursing home's staff and the hospice team. Without a confirmed, shared plan, caregivers on both sides are working without a common map.
The administrator's response to inspectors pointed outward, toward the hospice provider. The facility's own signed contract pointed back.
Pacific Hills Post Acute's hospice policy required the facility to ensure that coordination happened. The contract required the facility to participate in developing the plan. Neither document gave the facility the option of waiting to see whether the hospice agency had handled it.
Resident 1 was admitted to hospice care in that gap.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacific Hills Post Acute from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
PACIFIC HILLS POST ACUTE in MORGAN HILL, CA was cited for violations during a health inspection on May 27, 2026.
That was the finding from a May 2027 complaint inspection at the Morgan Hill skilled nursing facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.