Pleasanton South Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for one (1) of three (3) staff (MA A) observed for confidentiality of records. The facility failed to ensure MA A locked her computer on the medication cart, which exposed Resident #1's electronic medication administration record, so the resident's information could be seen and/or accessed by someone walking by on 06/18/2026 at 12:36 p.m. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for two (2) of two (2) days (06/17/2026 and 06/18/2026) reviewed for posting of required information. 1. The facility failed to post the correct date on the required current nurse staffing and census information on 06/17/2026. 2. The facility failed to post the required current nurse staffing and census information at the beginning of each shift on 06/18/2026. These failures could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen in that: 1. A 40-ounce package of honey ham was undated. 2. A 32-ounce container of liquid eggs was undated. 3. A clear carafe of yellow liquid was uncovered, unlabeled, and undated. 4. A 6-ounce container of raspberries was undated. 5. An open 16-ounce can of energy drink was on the table where residents' food was prepared. 6. The plate warmer was not plugged-in during lunch service. 7. A 1 pound block of margarine was undated. 8. A tray of approximately 24 cups of liquid was unlabeled and undated. 9. Two 3-quart containers of apple juice were undated. 10. A 5-pound container of sour cream was undated. 11. A tray of approximately 24 cups of milk was unlabeled and undated. 12. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 6 of 7 residents (Resident #7, Resident #10, Resident #47, Resident #53, Resident #54, and Resident #63) who were reviewed for resident assessments. 1. The facility failed to document Resident #7's use of anticoagulant medication on the quarterly MDS (Minimum Data Set) assessment. 2. The facility failed to document Resident #10's use of scheduled (routine) pain medication on the admission MDS assessment.3. The facility failed to document Resident #47's use of hypoglycemic medication and lack of use of scheduled pain medication on the quarterly MDS assessment.4. The facility failed to document Resident #53's lack of use of PRN (as needed) pain medication on the quarterly MDS assessment. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible for two (Hall E and Hall F) of four resident hallways, in that: Supply closets on resident Hall E and Hall F were open and unlocked and contained potentially hazardous materials. This deficient practice could result in residents coming into contact with, and being harmed by, hazardous materials.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records for each resident that were complete and accurately documented for 2 (Resident #27 and Resident #28) of 25 residents reviewed for clinical records, in that: Resident #27's diagnoses of Adjustment Disorder Unspecified and Other Specified Persistent Mood Disorders were not included on his list of diagnoses. Residents #28's diagnoses of Pain, Bilateral Cataracts, Poor Visual Acuity, and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct were not included on his list of diagnoses. This failure could result in inadequate care due to incomplete and inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents could call for staff assistance for 1 (Resident # 60) of 25 residents reviewed in that: Resident #60's call light was out of reach under the resident's bed. This deficient practice could result in delay of needed care and assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 6 residents (Resident's #5 and #6) reviewed for clinical records. The facility failed to document Resident #6's and Resident #5's death, pronouncement of death, and details of notifications. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interview and record review, the facility failed to notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #6) of six residents reviewed for notification of changes. The facility failed to notify Resident #6's family when she expired (died) on [DATE]. This failure could place residents at risk of their family/RP not being aware of the residents' condition.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services was agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide routine drugs and biologicals to its residents or obtain them under an agreement and failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 7 residents (Residents #44, #51, and #52) reviewed for pharmacy services. 1. Resident #44 was administered her ordered supplement and shared it with Resident #52 while the nurse was not present. 2. Resident #51 did not receive her ordered doses of Velphoro (A medication used for people receiving dialysis to bind phosphates in the blood for excretion to prevent excess build up, the chewable tablets are 500mg) from 8/26/24 to 8/30/24, 9/3/24, and 9/4/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 5 residents (Resident #25) reviewed for pharmacy services. Resident #25's tube feeding bag was not labeled with the correct date, did not have the resident's name, time hung, or date and time to be taken down. This failure could put residents at risk of not receiving the correct tube feeding and could result in decreased continuity of care, and a general decline in health.

Inspectors wroteBased on interview and record review the facility failed to provide a minimum of 80 square feet per resident in 43 of 43 resident rooms (A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E2 through E4, E6 through E8, and F1 through F8) reviewed for minimum for square footage per resident, in that: Resident rooms A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E6 through E8, and F1 through F8 did not have a minimum of 80 square feet per resident. This deficient practice could affect residents residing in rooms due to the reduced living space for the residents and could pose problems in the residents' activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to exit the facility without staff knowing on 08/13/2024. Staff were unaware that Resident #1 had walked out of the facility until they received a call from local police informing them Resident #1 was with the Police at a restaurant located .3 miles from the facility. An IJ was identified on 08/27/2024. The IJ template was provided to the facility on [DATE] at 06:45 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #2) reviewed for infection control. CNA-AB failed to follow EBP by not wearing a gown while providing incontinent care for Resident #2 on 08/27/2024 This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 25 residents (Resident #20) reviewed for administration. The facility failed to ensure all staff providing direct care to residents in the facility identify themselves by name and job title. This failure could affect resident in the facility by placing them at risk of not having needs met.

Inspectors wroteBased on interview and record review the facility filed to ensure 1(NA A) of 3 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA A was certifed within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #61) of 29 residents reviewed for CPR, in that; Resident #61 was discovered unresponsive, assessed as full code, and provided CPR for 9 minutes without the use of an available an AED prior to 911 EMS's arrival at the resident's side. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 11:05 am. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because the facility is still monitoring their effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 3 of 29 (Resident #61) residents reviewed for CPR care and 2 of 21 nurses (LVN A and RN C) reviewed for competencies and skill sets for CPR care to include an AED, in that; The facility failed to ensure all nursing staff had competent skills in performing actual CPR, to include using the AED, as a result of Resident #61 being found unresponsive on [DATE] and the responding nurse staff (LVN A and RN C) not using the AED during the actual CPR process for this resident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:10 pm. [...]

Inspectors wroteBased on interview and record review the facility must inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of, Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 4 of 5 (Residents #42, #3, #59, #38) residents reviewed for NOMC (Notice of Medicare Non-Coverage) services in that: 1 Resident #42 was discharged from therapy services on 04/7/2023 and did not receive/documentation of the cost if he would resume therapy. 2. Resident #3 was discharged from therapy services on 07/14/2023, and did not receive/documentation of the cost if she would resume therapy 3. Resident #59 was discharged from therapy services on 07/18/2023 and did not receive/documentation of the cost if he would resume therapy 4. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to support resident rights to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 29 residents (Resident #1) and 5 of 8 months (January, February, March, April, May, June, July, August) reviewed for grievances, in that; 1. RN R did not initiate a grievance report on behalf of Resident #1 when Resident #1 reported mistreatment by CNA V. 2. The facility did not document and resolve grievances for residents for the months of April, May, June, July, August 2023. [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 5 (NA AC, LVN I, Housekeeper AD) new staff hired within the last 4 months review, in that: 1. NA AC did not have her EMR/NAR checked before the hire date. 2. LVN I did not have her EMR/NAR checked before the hire date. 3. Housekeeper AD did not have her EMR/NAR checked before the hire date. This could place residents safety at risk of abuse, neglect, exploitation or misappropriation due to staff not being fully screened to determine employment eligibility.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 1 facility's reviewed for abuse, neglect, exploitation, and/or mistreatment allegations, for 1 of 8 residents (Resident #1) reviewed for reporting mistreatment, in that: 1. The facility experienced a faulty heating ventilation air conditioning [HVAC] system for the A-hall on June 26, 2023, and did not report the allegation of neglect for physical environment to the state agency. 2. RN R did not report on behalf of Resident #1 an allegation of mistreatment by CNA V. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 33 (Resident #46, #10, and #1) residents reviewed, in that: 1. Resident #46's care plan did not address that they were was PASRR positive. 2. The facility failed to ensure Resident #10's care plan was updated to pureed diet. 3. The facility failed to revise a comprehensive care plan for Resident #1's needs for durable medical equipment. These deficient practices could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. The facility error was 8% based on 2 errors out of 25 opportunities for 2 of 6 residents (Resident #33 and #267) reviewed for medication administration: 1. LVN F administered Carafate [a medication used to treat and prevent ulcers in the intestines] to Resident #33 and did not follow the physicians order to administer the medication by itself at least 2 hours away from other medications. 2. MA W crushed and administered metoprolol extended release [a medication which lowers blood pressure and should not be crushed] to Resident #267. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 4 of 6 (Residents #35, #20, #2, and #53) residents reviewed for dietary services in that: The kitchen ordered unpasteurized eggs and Residents #35, #20, #2, and #53 were served soft yolks for breakfast: This failure could affect residents that was served over easy eggs and could place them at risk for food borne illnesses. 1. Record review of Resident # 35's admission record dated 8/4/2023 revealed he was admitted to the facility on [DATE] with diagnoses of muscle weakness, cellulitis (common, potentially serious bacterial skin infection.), insomnia, kidney failure, and history of falls. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 (Resident #13) residents reviewed in that: Resident #13's call light was not within reach while he was in bed. This could affect residents who used their call light or desired to use the call light and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 11 residents (Resident #24) reviewed for advanced directives, in that: The facility failed to ensure Resident 24's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was executed correctly. This failure could place residents at-risk for residents' rights not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #54) reviewed for respiratory care, in that: The facility failed to ensure Resident #54's oxygen order included liter parameters This deficient practice could place residents who received oxygen therapy at risk for incorrect oxygen support being delivered and an increase in respiratory complications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 1 of 6 residents (Resident #267) reviewed for medication administration, in that: MA W crushed and administered metoprolol extended release [a medication which lowers blood pressure and should not be crushed] to Resident #267. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 1 Resident(s) (Resident #61) reviewed for accurate medical records, in that: LVN A and RN C failed to document the details of CPR care provided for Resident #61. This failure could place residents at risk for harm by inaccurate records.

Inspectors wroteBased on interviews and record reviews the facility failed to establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events for 1 of 1 Resident(s) reviewed (Resident #61) for an adverse CPR event, in that: The DON did not report Resident #61's CPR event for QAPI review. This failure could place residents at risk for adverse health outcome by denying the QAPI committee the data for review.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 1 facility in that: Resident # #39 was sitting outside on his wheelchair and a live wasp was near him, the wasp were above him under the roof soffit had holes. The facility had 7 live wasp and 7 nests in water puddles and the roof soffits had holes with wasp and wasp nest. This could effect residents sitting outside the facility and could result in residents being stung

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Nurse Staffing Information. Data requirements. The facility must post the following information on a daily basis: Resident census for 2 of 2 days in that: The nurse staffing postings for 2 days did not have a census and the 18 months ([DATE]-August 3, 2023) of nurse staffing posting did not have a census. This could result in family and residents not being aware of the census for the day.

Inspectors wroteBased on interview and record review the facility failed to provide a minimum of 80 square feet per resident in 43 of 44 resident rooms (A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E8, and F2 through F8) reviewed for minimum for square footage per resident, in that: Resident rooms A2 through A8, A10, B3 through B11, C2 through C5, C7, C9, C10, D2 through D7, E3 through E8, and F2 through F8 did not have a minimum of 80 square feet per resident. This deficient practice could affect residents residing in rooms due to the reduced living space for the residents and could pose problems in the residents' activities of daily living.