Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant Hill Post Acute during CMS and state inspections, most recent first.
Six residents with complex medical conditions were not informed of or offered the option to formulate an Advance Directive upon admission or re-admission. Record reviews and staff interviews confirmed that these residents had no ADs on file and were not given the opportunity to establish one, despite facility policy requiring this process.
Three residents receiving enteral feeding or IV therapy did not have their feeding bags, IV lines, or tubing labeled with the required date and time, as confirmed by nursing staff and facility policy. This failure to follow professional standards was observed during care for residents with conditions such as malnutrition, dysphagia, and metabolic encephalopathy.
Two residents experienced medication administration errors when an LPN gave antihypertensive medications without checking vital signs and another LPN applied a topical pain reliever without a physician's order. Both actions were contrary to facility policy and were confirmed by the DON during interviews and record reviews.
A nurse administered Bumetanide, Carvedilol, and Losartan to a resident with hypertension and heart failure without checking vital signs as required by physician orders and facility policy. The nurse relied on earlier vitals taken by a CNA and did not verify their accuracy or obtain a current blood pressure reading, resulting in a significant medication error.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident's food items brought in by family or visitors were found in a designated refrigerator without required labeling, such as received date, open date, or use-by date, and some items were removed from original packaging. Staff interviews confirmed that facility policy requires such labeling and regular checks, but these procedures were not followed, resulting in improper storage of the resident's food.
During a COVID-19 outbreak, the facility did not keep doors closed for rooms under enhanced airborne precautions, staff failed to perform required hand hygiene before serving food to a resident, a resident with COVID-19 did not have hand hygiene supplies within reach after coughing up phlegm, and oxygen tubing for a resident was found unlabeled and on the floor, contrary to facility policy.
A resident who was cognitively intact requested copies of medical records and the contact information for a former facility physician. Despite submitting a written request and following up multiple times, the records were not provided within the required two-business-day timeframe, and the resident experienced undue concern and anxiety due to the delay. The facility delayed the request while consulting with its legal team and ultimately did not provide the physician's contact information, as the physician had retired.
A deficiency was found when a resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without proper justification documented in the medical record.
A resident with multiple complex medical conditions was re-admitted, but the required MDS tracking entry assessment was not completed within the federally mandated seven-day timeframe. The delay was acknowledged by the MDS Coordinator and was not in accordance with facility policy, potentially impacting timely care planning and delivery.
A resident with multiple complex diagnoses did not have quarterly MDS assessments completed and transmitted within the required timeframe. The MDS Coordinator confirmed the delay, which was not in compliance with federal regulations and facility policy.
A resident in isolation did not receive a thorough activities assessment or an individualized activities program, despite being able to communicate personal interests such as music and news. The AD left key assessment sections blank, offered only limited in-room activities, and inaccurately documented participation. The resident expressed frustration and isolation, and the care team was not informed of the lack of engagement, resulting in no alternative interventions.
A resident quarantined for COVID-19 experienced repeated delays in staff response to a standalone wireless call bell that was not integrated with the facility's monitoring system. The call bell did not provide a visual signal or allow tracking of response times, leading to multiple instances where the resident waited 10 to 25 minutes or more for assistance, sometimes resorting to using a personal phone to call for help. Staff interviews confirmed inconsistent awareness and response to the call bell, in violation of facility policy requiring prompt attention to resident calls.
The facility did not provide the required minimum of 80 square feet per resident in several multiple occupancy rooms, with some rooms offering as little as 49.5 to 70 square feet per resident. Despite this, interviews and observations indicated that space was adequate for belongings and care, and no complaints were reported.
The facility failed to complete comprehensive Admission MDS assessments within 14 days for three residents, resulting in delayed care planning. The MDS Coordinator and DON acknowledged the delays, and the Administrator did not recall any issues with late entries for December 2023.
The facility failed to complete the MDS discharge assessments for three residents within the required 14 days from their discharge date. The MDS Coordinator acknowledged the late entries and the lack of a facility protocol on MDSC policies. This delay resulted in an inaccurate reflection of the resident census, potentially affecting census tracking and staffing ratios.
The facility failed to maintain safe and sanitary food storage conditions, including moldy bread, a dented can of applesauce, and unsealed food items. The RD acknowledged these issues, which were against the facility's policies.
The facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed. A resident did not receive the correct eye drop and Vitamin C dosage, while another resident's Vitamin D3 dosage was not verified with the physician. These errors were acknowledged by the LVN and the DON.
The facility failed to provide at least 80 square feet of living space per resident for 24 residents in multiple rooms. Despite observations indicating sufficient space for care and no resident complaints, a record review confirmed that the rooms did not meet the required space per resident.
Failure to Inform and Offer Advance Directives to Residents Upon Admission
Penalty
Summary
Six residents were identified as not having been informed of, or provided with, the option to formulate an Advance Directive (AD) upon admission or re-admission to the facility. Record reviews for these residents revealed that their medical charts did not contain any documentation of an AD, nor evidence that they had been offered the opportunity to create one. Interviews with the Medical Records Director and Operations Manager confirmed that these residents had no ADs on file and had not been given the option to establish one during the admission process, contrary to facility policy. The residents affected had significant medical conditions, including hemiplegia, atrial fibrillation, diabetes mellitus, right lower leg fracture, COPD, chronic kidney disease, congestive heart failure, degenerative nervous system disease, acute and chronic respiratory failure, chronic lymphocytic leukemia, anoxic brain damage, breast cancer history, and traumatic subdural hemorrhage. The facility's policy required that the existence of an AD be determined prior to or upon admission by inquiring with the resident or their representative, but this process was not followed for the six residents in question.
Failure to Label Enteral Feeding and IV Lines According to Professional Standards
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents who required specialized nutritional and intravenous care. For one resident receiving enteral feeding due to malnutrition and dysphagia, the fiber source nutrition bag and tubing were not labeled with the date and time as required. The nursing supervisor confirmed that labeling was necessary for safety and infection control, and that the omission placed the resident at risk for complications. Facility policy required that enteral feeding bags and tubing be labeled with the date and time when prepared and administered. Two other residents receiving intravenous therapy also had deficiencies in labeling. One resident with dysphagia had an IV line secured with Tegaderm, but neither the dressing nor the IV tubing was labeled, making it unclear when the IV line was placed or changed. The Director of Nursing acknowledged that this failure could lead to infection and complications. Another resident with metabolic encephalopathy had a peripheral IV line and tubing that were also not labeled. The nursing supervisor stated that labeling with date and time was required to prevent infection. Facility policy specified that all IV tubing must be labeled with date, time, and initials.
Medication Administration Errors Due to Failure to Verify Orders and Vital Signs
Penalty
Summary
A deficiency occurred when a nurse administered three antihypertensive medications—Bumetanide, Carvedilol, and Losartan—to a resident with a history of hypertension, congestive heart failure, and a cardiac pacemaker without checking the resident's vital signs prior to administration. The nurse stated she relied on CNAs to check vital signs and did not verify them herself before giving the medications. The facility's policy required verification of vital signs before administering such medications, especially for residents with complex cardiac histories. In a separate incident, another nurse applied a topical pain reliever (Biofreeze gel) to a resident's knees without a physician's order. Upon review, the nurse confirmed there was no order for the medication and acknowledged the error. The resident had a history of immune system disorders, and the facility's policy specified that medications must be administered only as prescribed and after confirming there are no known allergies or contraindications. Both incidents were confirmed by the Director of Nursing during interviews and record reviews.
Failure to Check Vital Signs Before Administering Antihypertensive Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered Bumetanide, Carvedilol, and Losartan to a resident without checking the resident's vital signs prior to medication administration. The resident had a history of essential primary hypertension, congestive heart failure, and a cardiac pacemaker. The nurse relied on vital signs taken earlier in the morning by a Certified Nursing Assistant and did not verify their accuracy or obtain a recent blood pressure reading, despite physician orders specifying parameters for holding antihypertensive medications based on current systolic blood pressure and heart rate. The Director of Nursing confirmed that the medications were not administered in a safe manner, as the LVN did not follow the required parameters or check the resident's vital signs before giving the medications. The resident's care plan and the facility's medication administration policy both required adherence to these parameters and verification of vital signs prior to administration. The failure to check vital signs before administering these medications constituted a significant medication error.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Properly Label and Store Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure that food items brought in by family or visitors for a resident were properly labeled and stored according to facility policy. During an observation and review in the conference room refrigerator designated for residents' outside food, it was found that a resident's liquid food items, including a partially used carton of lactose-free milk and several plastic bags of single-packed creamers, were not labeled with required information such as received date, open date, use-by date, or expiration date. The milk carton only had an expiration date, and the creamers were removed from their original packaging and lacked any dating or labeling. Interviews with the Infection Preventionist (IP) and Dietary Manager (DM) confirmed that the facility's policy requires all food items brought in for residents to be labeled with the resident's name, the item, and a use-by date, and that perishable items should be discarded on or before the use-by date. The IP stated that she checks the refrigerator daily on weekdays and another staff member checks on weekends, but acknowledged missing the missing dates and labeling on the items in question. The facility's written policies also require opened beverages to be dated and discarded after 24 hours, and all food items to be sealed or covered during storage, which was not followed in this instance.
Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow infection prevention and control practices in several key areas during a COVID-19 outbreak. Four out of five rooms designated for residents with COVID-19 had their doors left open, despite signage indicating enhanced airborne precautions requiring doors to remain closed. Staff interviews confirmed awareness of the requirement to keep doors closed, and the Infection Preventionist acknowledged that open doors could contribute to the spread of infection. Facility policy and CDC guidance both require doors to be closed for residents on airborne precautions. A Certified Nursing Assistant (CNA) did not perform hand hygiene after touching resident care areas and before serving food to a resident in a COVID-19 isolation room. The CNA donned gloves without prior hand hygiene and handled food and room surfaces with the same gloved hands. There were no hand hygiene supplies available outside the room. Facility policy requires hand hygiene before and after donning or doffing gloves, and staff interviews confirmed this expectation. Additionally, a resident who was positive for COVID-19 and coughing up phlegm did not have hand hygiene supplies within reach, making it difficult to clean his hands after coughing. The only available hand sanitizer was mounted on the wall approximately 12 feet away, and staff acknowledged that the resident was not expected to get out of bed to use it. In another instance, a resident receiving oxygen therapy had oxygen tubing that was not labeled and was found on the floor, kinked and stuck under a garbage can. Staff confirmed that tubing should not touch the floor and should be secured or wrapped if too long, as per facility policy.
Failure to Timely Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to his requested medical records within the required two-business-day timeframe. The resident, who was cognitively intact with a BIMS score of 15, requested copies of his medical records and the contact information for his former facility physician. Despite submitting a written request and following up multiple times in person and by phone, the resident did not receive the records until three weeks later. The facility's Medical Records Director confirmed that the request was delayed due to consultation with the facility's legal team, as the resident had an active legal case against a sister company. The resident was also denied the contact information for his former physician, as the physician had retired and was no longer affiliated with the facility. Facility policy states that residents are entitled to access or obtain copies of their personal or medical records within two business days of an oral or written request. However, the resident's request was not fulfilled within this timeframe, resulting in undue concern and anxiety for the resident. The delay was attributed to internal communication with the legal team and clarification of the specific records requested, rather than prompt fulfillment of the resident's rights as outlined in facility policy.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Late Completion of Re-Entry MDS Assessment
Penalty
Summary
The facility failed to complete the federally mandated Minimum Data Set (MDS) tracking entry assessment within the required seven-day timeframe following a resident's re-entry. Specifically, the MDS for a resident who was re-admitted with multiple complex diagnoses, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a history of breast cancer, was not completed on time. The assessment was due on 4/15/25 but was not completed until 4/18/25, as confirmed by the MDS Coordinator during an interview and record review. The facility's policy requires that resident assessments be conducted and submitted in accordance with federal and state timeframes, and the MDS Coordinator acknowledged responsibility for ensuring timely completion. The delay in completing the re-entry MDS assessment could have resulted in a delay in identifying the resident's care needs and in the delivery of appropriate treatment, as the assessment is used to inform care planning and interventions.
Failure to Complete and Transmit Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit quarterly Minimum Data Set (MDS) assessments for one of 47 sampled residents, as required by federal regulations. Specifically, the MDS Coordinator acknowledged that the assessments for a resident were not completed and transmitted within the mandated 14-day timeframe following the Assessment Reference Date (ARD). Review of the resident's records showed gaps in timely completion and submission of both annual and quarterly MDS assessments. The facility's policy requires that the assessment coordinator or designee ensures resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with federal and state guidelines. The resident involved had a complex medical history, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a personal history of breast cancer. The failure to complete and transmit the required MDS assessments as scheduled could have resulted in delayed assessment of the resident's needs and monitoring of their progress over time. The MDS Coordinator confirmed during interview and record review that the assessments were late, which was not in compliance with the facility's policy and federal requirements.
Failure to Provide Individualized Activities Assessment and Program
Penalty
Summary
The facility failed to provide a thorough assessment and individualized activities program for one resident who was admitted and subsequently placed in isolation due to a respiratory infection. Despite the resident's ability to communicate his interests, including a preference for music, animals, and keeping up with the news, the activity assessment was incomplete, with key sections left blank. The resident reported not being offered any activities or television channels that matched his interests and expressed frustration and feelings of isolation as a result. The Activity Director acknowledged that the assessment was not fully conducted and that only limited in-room activities, such as television and newsletters, were offered, which the resident often declined. Participation records were inaccurately documented, reflecting participation when the resident had actually refused. Additionally, the Activity Director did not communicate the resident's lack of engagement to the rest of the care team, resulting in no alternative interventions being provided. The Director of Nursing confirmed that the initial assessment was insufficient and that accurate documentation and individualized activities are essential for resident well-being.
Delayed Response to Resident Call Bell Due to Inadequate Call System
Penalty
Summary
The facility failed to ensure that a resident's call bell system was answered in a timely manner. The resident, who was quarantined for COVID-19, had a standalone wireless call bell that was not connected to the facility's call light monitoring panel at the nursing station. This call bell did not activate a visual signal outside the room and did not allow for tracking of response times. Multiple observations and interviews revealed that staff responses to the resident's call bell were often delayed, with response times ranging from 10 to 25 minutes or more. On several occasions, the resident had to use a personal cell phone to call the front desk for assistance after waiting for extended periods. The resident reported feeling frustrated due to these delays and had been using the same call bell system for over a week. Staff interviews confirmed that the call bell emitted an audible sound in the hallway, but there was no system in place to monitor or track when the bell was activated. Staff members, including the charge nurse, receptionist, activity director, and nursing supervisor, indicated that they could not always hear the bell, especially if they were not nearby. The facility's policy required immediate response to call lights and completion of tasks within five minutes if possible, but this was not consistently followed for the resident in question. The lack of a properly functioning and monitored call system resulted in delayed responses to the resident's needs.
Failure to Meet Minimum Square Footage Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed and confirmed through interviews and record review. Specifically, rooms 14, 15, 12, 16, 17, 18, 19, 20, 21, and 22 were identified as not meeting this standard, with some rooms having as little as 49.5 to 70 square feet per resident, and one room with 4 beds providing only 68.5 square feet per resident. Despite these deficiencies, observations and interviews conducted during the survey period indicated that there was adequate space for residents' belongings and for caregivers to provide care, and no complaints were reported by residents or staff regarding room space.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to ensure a comprehensive Admission Minimum Data Set (MDS) assessment was completed within 14 calendar days of admission for three sampled residents. Resident 45 was admitted on [DATE], but the MDS assessment was completed late on 12/29/23, missing the required completion date of 12/23/23. Similarly, Residents 313 and 317 had their MDS assessments completed late, as indicated in the MDS 3.0 Final Validation Report dated 12/30/23. The Minimum Data Set Coordinator (MDSC 1) acknowledged the delay and stated that the timely completion of admission assessments is crucial for planning resident care. The Director of Nursing (DON) confirmed that admission MDS assessments should be completed within 14 days from the assessment reference date (ARD). During interviews, the Administrator (ADM) stated he did not recall any issues with late MDS entries for December 2023. The Centers for Medicare and Medicaid Services (CMS) guidelines require that the Admission Assessment be completed no later than 14 days after admission to a facility. The failure to complete these assessments on time resulted in delayed care planning for Residents 45, 313, and 317, potentially impacting the care and services they received based on their health status.
Failure to Complete MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessments for three sampled residents were completed within the required 14 days from their discharge date. During an interview, the MDS Coordinator acknowledged awareness of the late MDS discharge entries and admitted that there was no facility protocol on MDSC policies. Specifically, Resident 45 was discharged on January 9, 2024, but their MDS discharge assessment was not completed until February 14, 2024. Similarly, Resident 315 was discharged on January 10, 2024, with the assessment completed on February 7, 2024, and Resident 316 was discharged on January 24, 2024, with the assessment completed on February 9, 2024. This delay in completing discharge assessments resulted in an inaccurate reflection of the resident census, potentially interfering with census tracking and staffing ratios.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to prepare and serve food under safe and sanitary conditions. During an initial observation of the kitchen, moldy and unusable French bread, a dented can of unsweetened applesauce, and unsealed food items such as hashbrowns and brown rice were found in the dry storage room. The Registered Dietician (RD) acknowledged the presence of moldy bread that should have been discarded and stated that dented cans should have been separated from the stock. The facility's Policy and Procedure (P&P) indicated that dented and rusty cans should be separated and returned for a refund. Additionally, the facility's dry storage chart specified that opened bread should be stored for one day and that rice and hashbrowns should be stored in airtight containers once opened.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 13.79% medication error rate when four medication errors out of 29 opportunities were observed during medication administration for two residents. Resident 165 did not receive an eye drop and an oral medication according to the physician's order. Specifically, the resident was supposed to receive Restasis eye drops but was given Refresh eye drops instead, and was also given an incorrect dosage of Vitamin C. LVN 1 admitted that Refresh eye drops were the only ones available in the medication cart for Resident 165 and acknowledged the error in the Vitamin C dosage. Resident 264's medication administration also contained errors. The LVN administered Vitamin D3 without verifying the correct dosage with the physician, as the physician's order did not specify the dosage. The Director of Nursing confirmed that the dosage should have been verified with the doctor. These failures resulted in medication not being given in accordance with the prescriber's orders, which may negatively affect the residents' health.
Failure to Provide Adequate Living Space per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet of living space per resident for 24 residents occupying multiple resident bedrooms. Specifically, rooms 12, 14, 15, 16, 17, 18, 19, 20, 21, and 22 were identified as having less than the required space per resident. During random interviews and observations of care and services, it was noted that there was sufficient space for the provision of care, no heavy equipment obstructing care, and adequate personal space and privacy for residents. There were no complaints from residents regarding insufficient space for their belongings, and no negative consequences or safety concerns were observed. However, a record review of the Client Accommodations Analysis confirmed that the rooms did not meet the 80 square feet requirement per resident, with specific measurements provided for each room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pleasant Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Post Acute | 0.5 mi | ★★★★★ | 15 | 0 |
| La Casa Via Transitional Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Tampico Healthcare Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Shadelands Post Acute | 2.2 mi | ★★★★★ | 20 | 0 |
| Concord Post Acute | 2.3 mi | ★★★★★ | 5 | 0 |
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