Pleasant Hill Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-3, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow state Title 22 regulations and ensure a qualified social services director was qualified to supervise and direct the social services department for all 47 residents when the facility's previous social services director of 14 months did not have the educational qualifications, and the current social services director did not have two years of social work experience required for the position. The failure had the potential for all residents to receive inadequate social services and discharge planning care. During a concurrent interview and record review on 8/12/25, at 11:17 a.m., with Operations Manager (OM), OM stated they were acting as the social services director because the previous social services director departed. OM stated they had been acting as the SSD for approximately two weeks. [...]

Inspectors wroteBased on interview and record review, for six of 47 sampled residents (Resident 2, 4, 9, 16, 64, and 68), the facility failed to inform and provide information to the resident and/or resident representatives, the option to formulate an Advance Directive (AD, a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity). This deficient practice had the potential to result in delayed treatment directions to healthcare providers regarding residents' medical care. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to meet professional standards of quality for three of three sampled residents (Residents 64, 34, and 67) when the following were observed:1. Resident 64's Fiber source enteral feeding bag (food given through a feeding tube) and tubing were not labeled.2. Resident 34's Intravenous (IV - small flexible tube used to deliver medicine/fluids into a person's vein) secured by tegaderm (clear, waterproof medical device to secure IV line to a person's skin) was not labeled.3. Resident 67's IV line and tubing was not labeled. This failure had the potential to negatively impact the delivery of care services provided to Residents 64, 34 and 67.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was below five percent (%) when:1. Licensed Vocational Nurse (LVN) 2 administered three antihypertensive (medication to treat high blood pressure) medications to Resident 72 without checking vital signs prior to administering the medications.2. LVN 1 administered topical medication to Resident 45 without doctor's order. These deficient practices placed Residents 72 and 45 at risk of developing complications and adverse reaction related to error in medication administration. 1. During concurrent medication administration observation and interview on 8/14/25, at 9:18 a.m. with LVN 2, LVN 2 was doing morning medication pass. LVN 2 administered Bumetanide 2mg 1 tablet, Carvedilol 6.25mg 1 tablet, and Losartan 100mg 1 tablet by mouth to Resident 72 without checking vital signs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident of 27 (Resident 72) sampled residents observed during medication administration pass was free from significant medication error when Licensed Vocational Nurse (LVN) 2 administered the following medications without checking Resident 72's vital signs (clinical measurements that tells the state of essential body functions).1. Bumetanide (a powerful water-pill that can lower blood pressure) 2 milligrams (mg - unit of measurement)2. Carvedilol (antihypertensive - medication to treat high blood pressure)3. Losartan (antihypertensive- to treat high blood pressure)This deficient practice had the potential for dangerous drop in blood pressure, possible for stroke and increased risk of death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when:1. Two dietary staff members did not have their hair fully covered with a hairnet. 2. Plate covers and plate bases used were worn out and damaged. 3. A ladle spoon was found stored dirty and in poor condition. 4. Kitchen storage cabinet doors for storing food and cooking equipment were either missing or in poor condition. These failures had the potential to result in contamination of food and foodborne illness for 46 residents who received food from the kitchen out of a facility census of 47. 1. During a concurrent observation and interview on 8/13/25, at 12:40 p.m., with [NAME] 1 and Dietary Aide 1, both dietary staff members did not have their hair fully secured with a hairnet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food items brought from outside and stored in the residents' refrigerator located in the Conference Room, were labeled and stored appropriately for one of 47 sampled residents (Resident 19). These failures had the potential to cause food contamination and foodborne illnesses. A review of Resident 19's admission Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 6/13/25, indicated resident was admitted to the facility on [DATE], with a therapeutic diet (a meal plan) order. During a concurrent observation, interview, and record review, on 8/13/25, at 3:15 p.m., with the Infection Preventionist (IP) and Dietary manager (DM), in the conference room, contents of the facility's refrigerator and freezer designated for residents' food brought from outside were checked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when following were noted:1. Doors of four out of five sampled rooms designated for COVID-19 (a disease caused by coronavirus that spreads through the air when an infected person coughs, sneezes, or talks. It can cause fever, cough, tiredness, and trouble breathing, and can be more serious in older adults or people with health problems) residents were left open.2. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after touching resident care areas and prior to serving food to Resident 51.3. Resident 57 did not have hand hygiene supplies readily available and within easy reach, to clean his hands after coughing up phlegm (yellow thick mucus).4. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the tracking entry Minimum Data Set (MDS - a federally mandated assessment tool) within seven calendar days after re-entry for one of 47 sampled residents (Resident 64). [...]

Inspectors wroteBased on interview and record review, for one of 47 sampled residents (Resident 64), the facility failed to complete the quarterly Minimum Data Set (MDS - a federally mandated assessment tool) assessments. This failure had the potential to result in the delayed assessment of resident needs, goals of care and inability to monitor each resident's progress over time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three residents (Resident 57) received a thorough assessment and individualized activities program designed to meet his interests for almost two weeks. This failure resulted in Resident 57 feeling frustrated and placed him at risk for isolation. During a review of Resident 57's admission Record printed on 8/14/25, the record indicates Resident 57 was admitted to the facility on [DATE]. During a review of Resident 57's Minimum Data Set (MDS-federally mandated resident assessment tool) assessment dated [DATE], the assessment indicated Resident 57 was able to understand others and was able to make himself understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident 57's call bell was answered in a timely manner. Resident 57's call system consisted of a standalone call bell, not connected to the call light monitoring panel situated at the nursing station. The call bell did not activate a visual signal outside the room and did not allow tracking of response times. Staff did not respond to Resident 57's call promptly on multiple occasions. This failure resulted in Resident 57 feeling frustrated and placed him at risk for unmet care needs while he was already quarantined for COVID-19 infection. During a review of Resident 57's admission Record printed on 8/14/25, the record indicated Resident 57 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide at least 80 square feet for each resident in multiple resident bedrooms: Rooms 14, 15, 12, 16, 17, 18, 19, 20, 21, and 22. This failure had the potential to result in a lack of sufficient space for facility staff to provide proper care and increased the risk of not having enough room to store resident belongings at their bedside. During random interviews and observations of care and services from 8/12/25 to 8/15/25, there were adequate space for residents' belongings and for caregivers to provide care in all of the rooms listed. There were no complaints from residents or staff regarding the room space. [...]

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 63), the facility failed to ensure Resident 63 was allowed to obtain a copy of his requested medical records within the required time frame. This failure resulted in Resident 63's undue concern and anxiety pertaining to obtaining the requested medical records and contact number of his former physician. A review of Resident 63's admission Record, printed on 8/14/24, indicated that resident was admitted to the facility on [DATE] and discharged to home upon completion of care on 4/16/23. A review of Resident 63's admission Minimum Data Set (MDS, a resident assessment tool used to provide care) dated 3/15/23, indicated resident was understood, able to understand others, and had a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 68) was not given unnecessary anticoagulant (a prescription medication and powerful blood thinner) medication without a doctor's order. This failure resulted in Resident 68 to receive anticoagulant medication unnecessarily and posed a significant health risk, potentially leading to serious and life-threatening outcome. During a review of Resident 68's admission record, printed on 8/15/25, indicated Resident 68 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 68's Minimum Data Set (a federally mandated assessment tool) dated 5/11/25, indicated Resident 68 had multiple diagnoses that included Cerebrovascular Accident (CVA or stroke, where blood vessels in the brain suddenly ruptures and bleeds into the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment was completed within 14 calendar days of admission date for three of three sampled residents (Resident 45, Resident 313, Resident 317). This deficient practice resulted in delayed completion of admission assessment and had the potential to result in Resident 45, 313, and 317 not receiving the appropriate care and services needed based on their health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents' (Resident 45, 315 and 316)'s Minimum Data Set (MDS, an assessment tool used to guide resident care) discharge assessments were completed within 14 days from their discharge date from the facility. This deficient practice has the potential to result in inaccurate census of the facility that may interfere with accurate planning for safe staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under safe and sanitary conditions when: - moldy and unusable foods were not discarded. - dented can was stored. - food items in dry storage room were not sealed. These failures placed the facility's 45 residents who received food from the kitchen at risk of foodborne illness. During initial observation of the kitchen on 5/13/24 at 9:43 a.m. accompanied by Registered Dietician (RD), showed the following: (a) opened bag with 16 moldy and unusable French bread were stored in the dry storage room labeled with received by 5/8/24 and used by 5/10/24 (b) dented can of six ounce of unsweetened applesauce was stored with remaining stock in dry storage room (c) opened box of hashbrown was not sealed (d) opened box of brown rice was not sealed. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed during medication administration for two of four sampled residents (Resident 165 and 264). Resident 165 did not receive an eye drop and an oral medication according to the physician's order. Resident 264's medication did not have a prescribed dosage for cholecalciferol (used to treat or prevent vitamin D deficiency). These failures resulted in medication not given in accordance with the prescriber's orders, which may negatively affect the resident's health.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide at least 80 square (sq) feet (ft) of living space per resident for 24 residents who occupied the following multiple resident bedrooms: Rooms 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and a lack of sufficient space for residents to have personal belongings at the bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored under sanitary conditions when multiple undated food items were stored in the freezer, refrigerator and the dry storage room. This deficient practice had the potential of putting residents at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to perform Annual Performance Evaluations for two of two Certified Nursing Assistants (CNAs), CNA 1 and CNA 2. This failure had the potential for the facility to employ problematic staff.