Pleasant Hill Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF755Jul 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF836Jul 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF578Aug 15, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF658Aug 15, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF759Aug 15, 2025

  Based 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. […]