Deficiency Records for Pleasant Hill Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Pleasant Hill Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-17 | 2023-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-17 | 2023-06-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-17 | 2023-05-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-17 | 2023-05-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-17 | 2023-05-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-17 | 2023-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-17 | 2023-05-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-03-17 | 2023-04-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-17 | 2023-04-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-17 | 2023-04-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-17 | 2023-04-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-17 | 2023-04-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-17 | 2023-04-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-17 | 2023-04-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-03-17 | 2023-04-17 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-17 | 2023-04-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-03-17 | 2023-04-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-17 | 2023-04-17 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-17 | 2023-04-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-17 | 2023-03-17 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-23 | 2022-12-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-13 | 2022-10-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-13 | 2022-09-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-23 | 2022-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-10 | 2022-03-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-10 | 2022-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-09 | 2021-12-13 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-09-24 | 2021-11-05 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-24 | 2021-11-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-09 | 2021-06-08 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-10-27 | 2020-12-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-10-27 | 2020-12-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-27 | 2020-12-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-10-27 | 2020-12-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-10-27 | 2020-12-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-10-27 | 2020-12-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-10-27 | 2020-12-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide activities to meet all resident's needs. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-27 | 2020-12-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-10-27 | 2020-12-11 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-27 | 2020-12-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-27 | 2020-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-27 | 2020-12-11 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-10-27 | 2020-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-27 | 2020-12-11 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-27 | 2020-12-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-11 | 2019-07-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-11 | 2019-02-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-11 | 2019-02-25 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-11 | 2019-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-02-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-01-11 | 2019-02-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-11 | 2019-02-25 | N |
