Pleasant Hills Community Living Center

In the surveyor’s words

From the most serious findings on record at Pleasant Hills Community Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 4, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 21, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF657Oct 28, 2022

  Based on interviews, record review, and facility policy review the facility failed to revise a fall care plan following a fall with a major injury and two (2) additional falls for one (1) of three (3) residents reviewed for falls, Resident #6. The facility's failure to have a communication system in place with the interdisciplinary team and a system in place to ensure compliance of revising care plans with appropriate interventions following a fall placed this resident and other residents at risk for a fall in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF689Oct 28, 2022

  Based on observation, interviews, record review, and facility policy review the facility failed to put in place appropriate interventions to prevent an incident of an unwitnessed fall on 08/02/2022 that resulted in a closed non-displaced fracture of the head of left radius for Resident #6, one (1) of three (3) residents reviewed for falls. A fall risk assessment was completed after admission to the facility on [DATE], which indicated Resident #6 was at high risk for falls. Resident #6 had an unwitnessed fall on 08/02/2022. Resident # 6 was found to be laying on the floor beneath the bedside table. She was sent to the local hospital for further evaluation. X-rays completed at the hospital revealed a closed nondisplaced fracture of head of left radius. […]

• Actual harm, isolatedF689Feb 23, 2026

  Based 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. […]