Pleasant Hills Community Living Center

Inspectors wroteBased on observation, record reviews, interviews and facility policy review, the facility failed to properly secure a wheelchair security device and prevent accidents for residents who depended on the facility van and staff for transfers to medical appointments for one (1) of three (3) sampled residents. Resident #1. Findings Included:Record review of the facility of the facility policy Accidents/Incidents (undated) revealed .Purpose: To assure that all persons who are involved in an incident or accident, or suspected to have had an incident or accident, are evaluated and receive treatment as indicated and are monitored for disposition of incident and accident .Record review of the incident report dated 1/08/26 for Resident #1 revealed the incident was described as . while in route to Dr. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of ten (10) sampled residents, Resident #9. On 11/28/25, at approximately 10:40 AM a member of the facility staff observed Resident #9 with a Rollator exit the facility behind a visiting nurse. Resident # 9 was outside unsupervised for approximately 22 minutes. At 11:02 AM Resident # 9 was located 0.4 miles away from the facility down a busy four lane street in the parking lot of a local funeral home. The temperature at the time was 51 degrees; the resident was dressed in a sweatshirt and jeans. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure Resident #1's right to be free from abuse when the facility failed to prevent repeated resident-to-resident physical aggression between Resident #1 and Resident #2. This resulted in Resident #1 sustaining periorbital edema and redness to the left eye, causing Resident #1 pain that required analgesic (pain) medication for two (2) of (30) sampled residents. Resident #1 and Resident #2.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure the resident's right to respectful, dignified care when they failed to apply the indwelling urine catheter collection bag cover, leaving the bag and its contents visible from the hallway for one (1) of three (3) residents with indwelling catheters (Resident #3).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide reasonable accommodation of resident needs and preferences by discontinuing the use of disposable premoistened cleansing cloths for four (4) of thirty (30) sampled residents. (Residents #8, # 9, #14, and #20). Residents and staff were informed that the premoistened disposable cloths could be provided for incontinent residents with wounds, due to their softer texture being less irritating to fragile, damaged, or healing skin. However, the facility failed to make the premoistened disposable cloths available.

Inspectors wroteBased on observations, interviews, record review and facility policy review the facility failed to provide a safe and comfortable environment for residents dependent on wheelchairs for mobility (Resident #28 and Resident #8) and failed to provide adequate clean linens for (Resident #9 and Resident #20) for four (4) of (30) sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of resident-on-resident physical abuse to the State Agency (SA) within the required timeframe for one (1) of four (4) reviewed allegations of abuse. Resident #1. Specifically, an allegation made on 6/09/25 that Resident #1 physically abused Resident #2 and was witnessed and reported by Certified Nursing Assistant (CNA) #5. This was investigated internally by the facility but not reported to the SA as required by federal regulations. Findings Included: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide personal hygiene, specifically fingernail and toenail care during Activities of Daily Living (ADL) care for two (2) of (29) residents reviewed: Resident #18 and Resident #28.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to evaluate and analyze hazards and risks and failed to assess a resident following a documented fall for one (1) of three (3) residents with documented falls: Resident #27.

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to safely and securely store medications for one (1) of thirty (30) sampled residents: Resident #8.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to assess the resident population and identify resources needed to provide necessary day-to-day care and services for residents. The facility failed to evaluate the overall number of facility staff and mechanical lifts needed to ensure sufficient staff and equipment were available to meet residents' needs based on residents' assessments for (30) of (30) sampled residents with the potential to affect all residents.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure medications were secured when a medication cart and treatment cart were left unlocked and unattended and failed to ensure medications were not left at a resident's bedside for two (2) of three (3) days of the survey.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights were followed related to respect and dignity when a Certified Nurse Aide (CNA) attempted to check a resident for incontinence in the hallway and against his wishes (Resident #7) and failed to have a privacy cover on a urinary drainage bag (Resident #79) for two (2) of 19 sampled residents.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to label and date enteral feeding bags for three (3) of four (4) observations for a resident with enteral feedings.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to revise a comprehensive care plan intervention when an order changed related to accuchecks for one (1) of 20 sampled residents. (Resident #62)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to conduct a safety smoking assessment for a resident to safeguard against the potential hazards for burns and/or fires. This concern was identified for one (1) of three (3) residents reviewed for accidents and hazards.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure indwelling catheter tubing was secured to prevent complications for one (1) of one (1) resident reviewed with an indwelling catheter.

Inspectors wroteBased on facility policy review, record review and interviews the facility failed to ensure that residents were treated and spoken to in a dignified and respectful manner for two (2) of four (4) sampled residents. Resident #1 and Resident #2.

Inspectors wroteBased on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who was a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 kicked open an entrance door and exited the facility. He was last observed by facility staff to be in his room in bed at 1:15 AM on 3/9/2024. The facility staff were unaware of Resident #1's absence until 3:15 AM when a staff member entered his room and noted he was not in bed. Resident #1 was located in a neighboring town by the police department at 9:09 AM, approximately 12 miles from the facility. Resident #1 had been off the facility grounds and unsupervised for approximately six (6) to eight (8) hours. [...]

Inspectors wroteBased on interviews and record review, the facility failed to treat residents with dignity and respect by failing to consistently ensure call lights were answered in a timely manner for three (3) of 31 sampled residents (Residents #1, 32, and 45) and one (1) unsampled resident (Resident #80).

Inspectors wroteBased on observation, record review, and facility's policy review, the facility failed to obtain an informed consent for the use of bed rails for seven (7) of eighteen residents reviewed for bedrails. (Resident's #1, #14, #24, #31, #45, #81, and #142)

Inspectors wroteBased on interviews, record review, facility investigation, and facility policy review, the facility failed to treat a resident with respect and dignity during care for one (1) of four (4) residents reviewed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to have staff to provide care to meet the needs of the residents for two (2) of 19 sampled residents. Resident #8 and Resident #41. Findings Include: The State Agency (SA) received a complaint, MS #22934, which alleged the facility did not have enough staff on the night shift to provide incontinent care for the residents. Review of the facility's policy, Staffing, dated 10/2022, revealed, .Our facility provides sufficient numbers of staff .to provide care and services for all residents in accordance with resident care plans and the facility assessment . A record review of the Facility Assessment, undated, revealed .B.1. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to have a Registered Nurse (RN) for eight (8) consecutive hours a day for eight (8) of 60 days reviewed. 5/6/23, 5/20/23, 5/21/23, 5/27/23, 5/28/23, 6/4/23, 6/10/23, 6/24/23