Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Pleasanton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food service safety and sanitation deficiencies were identified when a dented can of cherry pie filling was stored with regular cans instead of in the designated dented can area, a cheese grater with a broken plastic rim was hung with clean prep items, and a green cutting board with yellow debris and deep marring was stored with clean equipment. The DM confirmed each issue and referenced facility policy requiring dented cans to be set aside and cutting boards to be cleaned and sanitized after each use.
Two cognitively intact residents, each admitted with fractures, reported that a CNA provided rough physical care and used foul language during personal care, causing distress. One resident informed a CNA on the next shift, who notified an LVN and obtained a written statement from both residents, then followed a CC’s direction to place the statement under the DSD’s door. Despite this, the allegation was not brought to Social Services or the abuse coordinator (the Administrator) until several days later, and CDPH was notified by fax only after that delay, contrary to the facility’s policy requiring immediate, but no later than 2-hour, reporting of alleged abuse.
Self-Administration of Unassessed Medications: A resident with muscular dystrophy was observed keeping Biotin, Vitamin K2, Vitamin D3, Vitamin E, and Magnesium Glycinate at bedside and stated she took them independently each day. An LVN confirmed the resident was self-administering the supplements, but the IDT had only determined self-administration was appropriate for Vitamin D, with a physician order for that medication only. The IDT had not completed the required assessment for Biotin, Vitamin E, or Magnesium Glycinate, and there were no corresponding self-administration orders or MAR documentation for those supplements.
A resident with CHF was transferred to the ED after developing SOB, low O2 sat, and edema, but the facility had no documented evidence that a written bed-hold notification was given to the resident or his representative at the time of transfer. The BOM confirmed there was no record of a Bed Reservation Notification or other documentation showing the resident and/or representative were informed of bed-hold rights.
A resident with Type 2 DM and poor chewing ability had a physician-ordered soft and bite sized diet, but the care plan still listed a regular texture diet. The resident said he had only two bottom teeth and needed his food cut up. The CM confirmed the care plan was not updated to match the current diet order, and the DON stated care plans were expected to reflect current orders.
Unsecured treatment cart keys were left at the nursing station and later identified as belonging to an open cart with wound care supplies. In addition, a resident with muscular dystrophy had self-administered supplements, including Biotin, Vitamin K, Vitamin E, and Magnesium Glycinate, stored unsecured on an open shelf in a shared room; an LVN confirmed the medications were not locked or secured, and the DON stated medications should be kept in a locked box accessible to the resident.
Infection control PPE was not followed for two residents. A resident on contact precautions for C. diff had staff enter the room without the required gown, and another staff member entered without gown and gloves while interacting with the resident and meal tray. In a separate event, an LVN entered a resident’s EBP room without a gown and administered meds through a G-tube while her clothing contacted the bed and bedside table; the ICP stated gown use was required for this task.
A resident with fractures after a fall did not receive a STAT X-ray in a timely manner when the contract vendor failed to arrive and staff did not follow up, resulting in imaging being completed much later at an outside hospital. Another resident with dementia and chronic back pain received PRN acetaminophen for pain rated above the ordered mild-pain range, and the LVN did not notify the MD to clarify the order or reassess pain management.
Surveyors found multiple failures in kitchen sanitation and food storage, including dirty equipment, expired and unlabeled food items, improper storage of bulk ingredients, and unclean food-contact surfaces. The kitchen environment was not maintained, with grease and debris on cooking equipment, dirty drains, and unsealed flooring, creating conditions that could lead to food contamination.
A resident with a history of hemiplegia and dysphagia requiring a GT received medications through the tube without the LVN verifying tube placement as required by medical orders and facility policy. The LVN admitted to not checking placement before administering medications, and the DON confirmed that verification should occur before each use.
The facility failed to follow the recipe for preparing pureed chopped beef steak for 11 residents on a pureed diet. A staff member did not measure the ingredients as per the recipe, which was acknowledged during an interview. The Dietary Director and RD noted that this could dilute the nutritional value of the food. Interviews with facility leadership confirmed the expectation that recipes should be followed.
A resident admitted with hearing aids did not have this need documented in their baseline care plan, contrary to facility policy. Staff interviews confirmed the oversight, and both the DON and Administrator acknowledged the requirement to include such information in the care plan.
A resident at high risk for falls did not have a documented fall prevention intervention implemented, as staff were unaware of the care plan directive to place a floor/landing pad next to the bed. Despite the resident's need for substantial assistance and moderate cognitive impairment, the intervention was not consistently applied, indicating a communication breakdown among staff.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
Food service safety and sanitation requirements were not followed when a 7-pound can of cherry pie filling with a dent near the top was observed in dry storage with regular cans instead of in the designated dented can area. During the observation, the Dietary Manager confirmed the can was dented and stated it did not belong with the regular cans and should have been placed in the designated dented can area. The facility policy stated that dented cans will not be served and will be labeled and set aside in a designated area for return. Food preparation equipment was also found stored with clean items despite being damaged or soiled. A cheese grater with a broken red plastic rim and separated plastic was observed hanging with clean food preparation items, and the Dietary Manager confirmed it should not have been stored for use and stated it should have been discarded because it could lead to an infection control issue. In addition, a green cutting board stored with clean equipment had yellow debris on it and deep marring on one side; the Dietary Manager confirmed the debris and marring and stated it should have been replaced to prevent bacteria growth. The facility policy stated cutting boards are to be cleaned and sanitized after each use.
Failure to Timely Report Alleged Rough Care and Verbal Abuse to CDPH
Penalty
Summary
The facility failed to timely report an allegation of abuse to the California Department of Public Health (CDPH) within the required two hours for two cognitively intact residents. One resident, admitted with a right talus fracture and with a BIMS score of 13, reported that on a PM shift a CNA provided rough care while cleaning her after a bowel movement, continued despite her complaints of pain, and used foul language while providing care to her roommate, who became very upset. The following morning, the resident informed a CNA on the AM shift about the rough and rude care provided to both her and her roommate. The CNA who received the report stated she informed an LVN, who instructed her to obtain a written statement from both residents. After obtaining the shared statement, the CNA asked the Clinical Coordinator what to do with it and was told to slide it under the DSD’s door, which she did during the same AM shift. The DSD later stated that the CNA, LVN, and Clinical Coordinator were aware of the allegation on that date, but it was not reported to Social Services or to him until five days later, at which time Social Services notified CDPH. The Administrator, identified as the abuse coordinator, confirmed that rough care by a CNA is considered an allegation of abuse and that the allegation involving the two residents was not reported to CDPH within two hours, contrary to the facility’s abuse investigation and reporting policy requiring immediate reporting, but no later than two hours, for alleged abuse or incidents resulting in serious bodily injury.
Self-Administration of Unassessed Medications
Penalty
Summary
The facility failed to follow its policy and procedure for self-administration of medications for one sampled resident with muscular dystrophy. During observation, the resident was seen in bed with bottles of Biotin, Vitamin K2, Vitamin D3, Vitamin E, and Magnesium Glycinate stored on a shelf next to the bedside, and the resident stated she took the supplements independently every day. An LVN confirmed the resident had medications at bedside and was self-administering them in her room. The case manager stated the interdisciplinary team had determined it was clinically appropriate for the resident to self-administer Vitamin D and a physician order existed for that medication, but the team had not determined whether it was appropriate for the resident to self-administer Biotin, Vitamin E, or Magnesium Glycinate, and there was no physician order for those supplements. The self-administration medication safety screen indicated the assessment should be completed before self-administration begins and with medication changes, but the resident was not screened for Biotin, Vitamin E, or Magnesium Glycinate. The order summary and MAR also did not show self-administration orders or documentation for those medications.
Failure to Provide Bed-Hold Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notification to Resident 142 and/or his representative when the resident was transferred to an acute care hospital on 1/21/2026. Resident 142’s admission record showed a diagnosis of congestive heart failure. On 1/21/2026 at 3:59 p.m., progress notes documented shortness of breath, a respiratory rate of 21-22, oxygen saturation of 83 percent, and edema, and the resident was then sent to the hospital. Transfer orders dated 1/21/2026 indicated transfer to the emergency department. A review of the clinical record found no documented evidence that a bed-hold notification was provided to Resident 142 and/or his representative at the time of transfer. During an interview on 4/22/2026 at 2:56 p.m., the Business Office Manager stated there was no documented evidence of a written Bed Reservation Notification or any documentation showing that Resident 142 and/or his representative were informed of the bed-hold upon transfer to the hospital. The facility policy titled Bed-Holds and Returns stated residents and/or representatives are to receive written information about bed-hold policies at least twice, including at the time of transfer or within 24 hours if the transfer is an emergency.
Care plan not updated to match current diet order
Penalty
Summary
The facility failed to update the nursing care plan for one resident with Type 2 Diabetes Mellitus and a physician-ordered soft and bite sized texture diet. The resident’s admission record dated 4/21/2026 identified the diabetes diagnosis, and the physician’s orders dated 4/19/2026 showed the resident was on a soft and bite sized diet. During interview, the resident stated he was on a regular diet, showed that he had only two bottom teeth, and said he could not chew well and needed his food cut up. During concurrent interview and record review on 4/22/2026, the resident’s At Risk for Altered Nutritional Status care plan, last revised 4/10/2026, was reviewed and found to still indicate a regular texture diet. The CM stated the altered nutritional care plan was not updated to match the current physician’s diet order and that the care plan should match the current diet order to avoid confusion. The DON stated the expectation was for the care plan to be updated to reflect residents’ current orders. The facility policy on care plans stated that assessments are ongoing and care plans are revised as residents’ conditions change.
Unsecured treatment cart keys and resident self-administered medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a set of keys for a treatment cart was left unattended and unsecured at Nursing Station 1. During a concurrent observation and interview, an LVN retrieved the keys from a black binder on top of the counter and identified them as the keys for an open treatment cart containing ointments, creams, and wound care supplies. The DON stated the expectation was for treatment cart keys to be held by nurses at all times. Self-administration medications for Resident 44 were also not stored in a locked compartment. Resident 44, who was admitted with muscular dystrophy, had Biotin, Vitamin K2 and D3, Vitamin E, and Magnesium Glycinate observed unsecured on an open shelf next to the bedside in a shared room. Resident 44 stated the supplements were taken every day and stored on the shelf. An LVN confirmed the medications were not locked or secured, and the DON stated all medications should be stored in a locked box accessible by the self-administering resident. The facility policy stated self-administered medications are to be stored in a safe and secure place not accessible by other residents.
Infection Control PPE Not Followed for Contact Precautions and EBP
Penalty
Summary
The facility failed to follow infection control practices for two residents. Resident 150 had a diagnosis of a displaced intertrochanteric fracture of the left femur and was placed on contact precautions for pending C. diff test results, with later laboratory results showing C. diff positive. A contact precautions sign was posted at the room entrance directing visitors and personnel to perform hand hygiene before entering, wear a gown and gloves, and wash hands with soap and water before leaving the room. During observation, a Maintenance Assistant entered Resident 150’s room to fix the television while wearing gloves and a face mask but no gown. In a separate observation, a CNA entered the room without a gown and gloves, spoke with the resident, moved items on the meal tray, and then sanitized her hands before leaving. In interviews, the Maintenance Assistant stated he should have worn a gown, and the CNA stated she believed PPE was only needed for direct care such as changing an incontinent brief. The Infection Control Preventionist stated both staff members should have worn the appropriate PPE, including a gown, before entering the room and that staff should wash hands with soap and water before leaving a room on contact precautions for C. diff. Resident 8 was admitted with esophageal obstruction and had an order for Enhanced Barrier Precautions related to enteral feeding, with instructions to perform hand hygiene and apply PPE including gloves, gown, and/or goggles/face shield. During observation, an EBP sign was posted at the doorway indicating gown and glove use. An LVN entered the room with water and morning medications, donned gloves but no gown, and accessed the resident’s G-tube to administer medications while her clothing contacted the bed and bedside table. The LVN stated she did not think a gown was required for medication administration in an EBP room, while the Infection Control Preventionist stated gowns should be worn when medications are administered through a G-tube and that not wearing a gown created a risk for transmitting MDROs to the resident.
Failure to Timely Complete STAT Imaging and Follow PRN Pain Order
Penalty
Summary
A STAT X-ray ordered for a resident after a fall was not implemented in a timely manner. The resident had diagnoses including muscular dystrophy and fractures of the first and second thoracic vertebrae, and had an intact BIMS score. After the resident fell during therapy, the provider ordered an immediate X-ray at 1:17 p.m. on 1/30/2026. The X-ray was not completed until 5:40 p.m. on 1/31/2026, and the resident was transferred to an outside hospital for the imaging after the contract vendor did not show up and the facility did not follow up with the vendor. A second resident with diagnoses including lumbosacral spondylosis and unspecified dementia had PRN acetaminophen ordered for mild pain only, 1-4 on the pain scale. The resident had a BIMS score of 4 and was observed in a wheelchair complaining of low back pain. The resident and his son stated he had frequent back pain and was not sure he had received pain medication. The MAR showed acetaminophen was given when the resident reported pain rated at 6, and the LVN confirmed the medication was administered despite the pain level being above the ordered range. The DON confirmed the resident had five April 2026 occurrences of pain higher than 4 and received acetaminophen, and stated staff should have notified the physician to clarify the order and have the resident re-evaluated for pain management before administering the medication. The facility policy stated diagnostic services should be promptly carried out as ordered and pain medication should be implemented as ordered, with ongoing communication between the prescriber and staff for optimal use of pain medications.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and kitchen sanitation standards, as evidenced by multiple observations of unsanitary conditions and improper food handling. Surveyors observed that the ice machine floor drain was dirty and covered in black film and debris, and the two-compartment sink used for food preparation had a build-up of food and debris. Food items in the walk-in refrigerator and pantry were found to be stored beyond their use-by dates, and many items lacked proper labeling, including use-by or expiration dates. Additionally, an open jar of mayonnaise was left unrefrigerated, and a large box of thickener was left unsealed and exposed, contrary to facility policy and USDA recommendations. Kitchenware and food-contact surfaces were found in poor condition and not properly cleaned. Multiple pans, trays, and utensils had grease build-up, metal flakes, and visible food residue, while some equipment, such as the can opener, blender, and food processor, were not cleaned after use and had accumulated food particles and debris. The food processor was also broken, with dried debris in the damaged area. Drawers used to store utensils contained food particles and dirty equipment, and some utensils were visibly dirty or in disrepair, with melted handles and substances that could not be removed by wiping. The physical environment of the kitchen was also not maintained in a clean and safe manner. The stove and oven had significant grease and food residue build-up, and a kitchen oven mitt was found on the stove top, contrary to facility policy. The dishwashing area had a dirty grease trap, black slimy build-up in the drain, and a floor with accumulated sludge and an unsealed gap between the tile and wall. These conditions were confirmed by both the Certified Dietician and the Director of Maintenance, who acknowledged that such uncleanliness could lead to illness and attract pests. The report documents that these failures had the potential to result in contamination of food and foodborne illness for all residents in the facility.
Failure to Verify Feeding Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to verify the placement of a gastrointestinal tube (GT) prior to administering medications to a resident. The resident, who had a history of hemiplegia and dysphagia resulting in GT placement, was observed receiving two crushed medications diluted in water through the GT without confirmation of proper tube placement. The LVN attached a syringe to the feeding tube, flushed it with water, and administered the medications using gravity flow, but did not check the GT position immediately before the procedure. The resident's medical orders specifically required verification of GT placement before administering feedings or medications. During interviews, the LVN acknowledged not checking the GT placement before the medication administration and stated that she typically only checked placement at 8 a.m. before the first water flush. The Director of Nursing confirmed that GT placement should be verified before each administration of medication or feeding. Facility policy and national guidelines also require verification of tube placement prior to administering medications or feedings.
Failure to Follow Recipe for Pureed Diets
Penalty
Summary
The facility failed to adhere to the recipe for preparing pureed chopped beef steak for 11 residents who were on a pureed diet. The facility's policy on Texture and Consistency Modified Diets mandates that the food and nutrition services department is responsible for preparing and serving food and beverages in the correct consistency as ordered. However, during the preparation of pureed beef, a staff member did not measure the amount of water and beef base added to the ground beef, nor did they follow the specified recipe instructions. This deviation from the recipe was acknowledged by the staff member when questioned about the correct amounts of broth and beef to be used. Interviews with the Dietary Director, Registered Dietitian (RD), Director of Nursing, and the Administrator revealed a consensus that the cooks were expected to follow recipes when preparing pureed foods. The RD highlighted that adding too much liquid could dilute the nutritional value of the food, which was a concern shared by the Dietary Director. The deficiency was observed through a combination of document reviews, interviews, and direct observation, indicating a systemic issue in the preparation of pureed diets for the affected residents.
Failure to Document Hearing Aid Use in Baseline Care Plan
Penalty
Summary
The facility failed to include a resident's use of hearing aids in the baseline care plan within 48 hours of admission, as required by their policy. The resident, who was admitted with hearing aids, did not have this need documented in their care plan. This oversight was identified during a review of the resident's admission records and baseline care plan tool, which showed no indication of the need for hearing aids, despite the resident being admitted with them. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Vocational Nurse, confirmed that the resident used hearing aids and that this was not reflected in the care plan. The Director of Nursing and the Administrator both acknowledged that the facility's policy required the inclusion of such information in the care plan, indicating a lapse in adherence to established procedures.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a documented fall intervention for a resident identified as being at high risk for falls. The resident, who was readmitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, required substantial assistance with transfers and had moderate cognitive impairment. The care plan, revised upon readmission, included an intervention to place a floor/landing pad next to the resident's bed to prevent falls. However, observations on multiple occasions revealed that the floor/landing pad was not in place while the resident was in bed. Interviews with staff members, including a Licensed Vocational Nurse (LVN) and a Certified Nurse Aide (CNA), indicated a lack of awareness regarding the intervention to place a floor/landing pad next to the resident's bed. The charge nurse and CNA assigned to the resident were not informed of this specific intervention, and the LVN who implemented the intervention expected it to be consistently in place. The facility administrator expressed an expectation for staff to adhere to the policy and procedure, highlighting a communication breakdown in ensuring the intervention was consistently applied.
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What surveyors actually found near you
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pleasanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekview Skilled Nursing | 2.7 mi | ★★★★★ | 0 | 0 |
| Avondale Villa Post-acute | 5 mi | ★★★★★ | 1 | 0 |
| Stratford Villa Post-acute | 5 mi | ★★★★★ | 3 | 0 |
| The Vineyards Healthcare Center | 5.1 mi | ★★★★★ | 2 | 0 |
| Niles Canyon Post Acute | 8.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.