Inspection Reports for
Pleasant Hill Post Acute

The facility was generally found to be in compliance with safety and sanitary standards, including fire clearance, hot water temperature, and hygiene supplies. However, a deficiency was cited for using a storage room as a caregiver bedroom without proper permits or approvals.

The facility was generally compliant with safety and sanitation standards, including fire clearance, water temperature, and hygiene supplies. However, a deficiency was cited for the unauthorized alteration of a storage room into a caregiver bedroom without proper permits.

The facility was found deficient for failing to provide a resident timely access to requested medical records, causing undue concern and anxiety. Additionally, the facility administered an unnecessary anticoagulant medication to a resident, posing a significant health risk.

The facility was found deficient in multiple areas including failure to inform residents about advance directives, late completion of Minimum Data Set (MDS) assessments, failure to label enteral feeding and IV tubing, inadequate individualized activity programs, medication errors including failure to check vital signs and unauthorized medication administration, unsafe food storage and preparation practices, infection control lapses including open doors for COVID-19 positive residents and inadequate hand hygiene, unlabeled oxygen tubing, insufficient room space per resident, and ineffective call bell system response.

The facility was found deficient in timely completion of admission and discharge Minimum Data Set (MDS) assessments, medication administration errors with a 13.79% error rate, unsafe food storage practices including moldy food and dented cans, and failure to provide the required minimum living space per resident in multiple rooms.

The inspection found multiple deficiencies including unsecured knives and matches accessible to residents with dementia, lack of criminal record clearance for a private caregiver, absence of valid CPR/First Aid training for staff, missing dementia care training for staff, lack of current annual medical assessment for a resident with dementia, and unsafe yard conditions with clutter. Some deficiencies were corrected during the visit, while others required follow-up.

The complaint investigation was substantiated for staff not having the required training to meet resident needs. Other allegations regarding feeding procedures, ambulating assistance, and medication assistance were unsubstantiated.

The investigation substantiated the allegation that staff failed to complete the required annual training, posing a potential health and safety risk. However, allegations related to feeding procedures, ambulating assistance, and medication assistance were found to be unsubstantiated due to lack of preponderance of evidence.

The visit was triggered by a priority 1 complaint. A civil penalty of $250 was assessed for a repeat violation related to unlocked cleaning supplies and scissors.

The inspection found several deficiencies including unlocked cleaning supplies and scissors accessible to clients, furniture polish stored next to food supplies, a loose air vent, missing toilet seat in room #3, dirty shower floor, and a gate latch in disrepair. Some deficiencies were corrected during inspection, while others required a plan of correction.

The visit was triggered by a priority 1 complaint. The report does not explicitly state the substantiation status.

The inspection found multiple deficiencies including unlocked cleaning supplies and scissors accessible to residents, furniture polish stored next to food supplies, and maintenance issues such as a loose air vent, missing toilet seat, dirty shower floor, and a gate latch in disrepair. These deficiencies pose immediate and potential health and safety risks to persons in care.

The facility failed to perform Annual Performance Evaluations for two Certified Nursing Assistants, which could allow problematic staff to remain employed. Additionally, the facility failed to ensure food was stored under sanitary conditions, with multiple undated food items found in the freezer, refrigerator, and dry storage room, posing a risk for food-borne illness.

The facility was generally compliant with infection control and safety practices, including staff vaccination and PPE use, but two deficiencies were cited related to storage space and food service cleanliness, both corrected or with plans of correction.

The facility was found to have generally good infection control practices with all staff and residents fully vaccinated and proper PPE use. Two deficiencies were cited: one Type A deficiency related to unsafe storage in a kitchen drawer and one Type B deficiency related to food contamination in a refrigerator, both corrected or with plans of correction.

The visit was related to complaint findings (15-AS-20201028095918) concerning the use of monitors on residents.

The licensee was found not in compliance with California Code of Regulation, Title 22, Section 87468.1(a)(3) regarding residents' personal rights due to the use of monitors on residents without proper justification. The administrator agreed to remove the monitors during the visit, and the deficiency was cleared.

Complaint findings (15-AS-20201028095918) were delivered during the visit. The deficiency was substantiated based on observation of noncompliance with personal rights regulations.

The Licensing Program Analyst observed four monitors used to monitor residents in their bedrooms, with one of five residents identified as fall risk. A deficiency was cited for failure to comply with personal rights regulations, posing a potential health and safety risk.