Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Kyakameena Care Center during CMS and state inspections, most recent first.
A resident with adrenomyeloneuropathy, muscle weakness, difficulty walking, and severe cognitive impairment had repeated falls, but the fall CP was not updated to include additional interventions such as a floor mat. The DON stated post-IDT meetings should occur after every fall, yet the record lacked post-fall MFS assessments and additional IDT documentation for several falls; the existing reviews only repeated interventions like keeping the bed low and the call light within reach.
A resident with severe cognitive impairment, impaired mobility, and recurrent falls did not have individualized fall-prevention interventions revised after multiple documented falls. During observation, the resident was in bed with no floor mat at the bedside, and staff confirmed the care plan did not include one. The DON acknowledged the resident was high fall risk and that no additional interventions were implemented after repeated falls, despite facility policy calling for additional or different interventions when falling recurs.
A resident with intact cognitive status was moved to a different room after being verbally informed by nursing staff, but did not receive the required written notification prior to the change. Staff interviews and record reviews confirmed that only verbal notice was given, and there was no documentation of written notification in the resident's health record, in violation of facility policy.
Care plans were not timely completed or updated for two residents. One resident with TBI, seizures, and involuntary movements was transferred without the standing lift that staff said had been used for a long time, and the resident sustained a left tibia and fibula fracture during the transfer. Another resident with mild cognitive impairment, wandering, and repeated elopements did not have a comprehensive care plan developed within the required timeframe, and the IDT had not reviewed the repeated elopement episodes with appropriate interventions.
A resident with mild cognitive impairment, wandering behavior, unsteadiness, and aphasia repeatedly eloped from the facility after removing his wander guard. He was found by staff, police, and in another town on separate occasions, including one event that required ED evaluation and ambulance return. The Admin stated prior elopements were not reported to the state as required, and the DON stated the IDT had not met to review the repeated elopements or provide a comprehensive care plan addressing the resident’s wandering and elopement risk.
Late Quarterly MDS Assessments: Quarterly MDS assessments were not completed at least every 3 months for four sampled residents. The MDSC acknowledged the assessments were overdue and said she was newly hired and trying to catch up, and the Admin stated the facility was aware of the late MDSs and had brought in new staff to help complete them.
A facility failed to electronically transmit accurate and complete quarterly MDS assessments for four sampled residents within the required timeframe. The MDSC and Admin acknowledged the late assessments and stated the facility was aware of the delays and had recently hired staff to help complete the MDSs.
A facility inaccurately coded MDS items for three residents. One resident with cataracts and reported vision problems was coded as having adequate vision, another resident with no natural teeth was coded incorrectly on the oral status item, and a third resident's hospice care item was coded as reflecting the resident's choice even though the record showed hospice admission with ESRD. The MDSC acknowledged the coding errors.
Failure to Provide Toenail Care and Podiatry Treatment: Two residents did not receive appropriate toenail care. One resident with DM and impaired cognition had long, thick, brownish-black toenails and said he had asked staff for help. Another resident with TBI, seizures, and mobility issues had long, discolored, thick, loose toenails and had not been seen by podiatry for an extended period. Staff reported the toenail concerns, but podiatry access was limited by insurance.
Failure to Complete Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for three CNAs. Personnel records showed only annual skills checklists, which the DSD said were being used as performance reviews because no other form had been provided. The DSD stated performance reviews should be completed from hire and annually thereafter, and the facility policy required evaluations at the end of the 90-day probationary period and at least annually.
Failure to Implement Legionella Water Management Program: Based on interview and record review, the facility failed to implement its Legionella Water Management Program because it did not have a water management program in place. The Admin stated the facility had no program for managing water systems to prevent Legionnaires' disease and had not tested water for legionella, despite a P&P stating the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella.
A resident with intact cognition and depression reported missing multiple clothing items, including jeans, tops, and underwear, after staff checked her closet and laundry without finding them. The DON and Administrator knew about the missing items and asked the resident’s daughter to replace them with facility reimbursement, even though the resident said her daughter was financially unable to do so. The facility policy stated residents are not required to waive facility liability for loss or misappropriation of personal property.
PASRR Screening Not Accurately Completed for Residents With Mental Health Diagnoses: Two residents with diagnoses including schizophrenia, bipolar disorder, and major depressive disorder were screened on PASRR Level I as not having serious mental illness. The DON stated the screenings were not accurately completed or referred to the appropriate state mental authority for Level II PASRR evaluation and determination, and the facility’s PASRR policy required Level I screening to identify residents with or suspected of having SMI or ID/DD/RC.
Failure to provide ordered restorative nursing services: A resident with intact cognition, anxiety, and depression requested regular walking to support mobility, but staff reported he was often walked only once daily or not at all. The physician ordered RNA walking multiple times per week, and the care plan included twice-daily walking, yet the restorative aide was unaware of the twice-daily order and could not produce treatment records for the period reviewed.
A resident with intact cognition, anxiety, and depression reported worsening vision, inability to read or use his laptop, and frustration that he had not been seen by ophthalmology after an eye doctor diagnosed a R eye cataract and left a referral for the facility to schedule the consult. Record review showed a physician order allowing referral for cataract surgery, while the SSD stated the resident’s insurance did not cover vision and he was not seen by the eye doctor. The facility policy stated it was responsible for helping residents locate resources, schedule appointments, and arrange transportation.
A facility failed to have a formal written agreement with the dialysis provider for residents receiving HD, including responsibilities for care coordination, communication, and emergency preparedness. Three residents had ESRD and orders for HD at a dialysis provider, and the Admin stated the facility did not have a written agreement and had difficulty contacting dialysis management.
Excessive Number of Residents in Multiple Rooms: Surveyors found six resident rooms with 5 or 6 beds each, exceeding the limit of no more than 4 residents per room. A resident who lived in one of the overcrowded rooms stated he had enough storage space and was comfortable, and observations showed sufficient space for care, no heavy equipment interfering with care, and adequate personal space and privacy. No resident complaints or negative outcomes were identified.
Insufficient square footage was identified in six multi-bed resident rooms, with each room providing less than the required 80 sq. ft. per resident. Observations showed floor areas of 78.42 sq. ft. per bed in two rooms and 77.59 sq. ft. per bed in four rooms. A resident stated he had enough space for belongings and was comfortable, and an CNA reported care was manageable in the rooms with no problems using shower chairs or lifts.
The facility did not act on the Consultant Pharmacist's recommendations for two residents, leading to a deficiency in medication management. One resident was not instructed to rinse their mouth after using an inhaler, and another was not monitored for bleeding while on apixaban. The DON and Consultant Pharmacist confirmed these oversights.
A resident with ALS experienced medication administration errors, resulting in a 15.38% error rate. An LVN failed to wait the required 30 seconds between puffs of Dulera and did not administer other prescribed medications. Interviews confirmed non-compliance with physician's orders and facility policies.
A resident with a history of heart failure had a wound on the left knee requiring specific topical antibiotics and dressings. Despite the Wound Physician's order, the treatment was not transcribed into the resident's EMR. The LVN responsible for the wound care admitted to the oversight, and both the DON and Administrator confirmed that staff should process and implement treatment orders, leading to a deficiency in maintaining accurate medical records.
A facility failed to implement enhanced barrier precautions for a high-risk resident with an indwelling catheter and pressure ulcer. Staff did not wear gowns during care activities, contrary to guidelines. Observations and interviews revealed a lack of adherence to infection control protocols, as confirmed by the Infection Preventionist and Administrator.
The facility was found to have more than four residents in six of its sixteen bedrooms, with some rooms housing up to six residents. The Director of Nursing stated a room variance waiver was in place, and the Administrator expected equal quality of care for all residents.
The facility did not meet the required room size of 80 sq ft per resident in six rooms, with sizes ranging from 77.59 to 78.42 sq ft. A waiver for room size variance was in place, and the DON confirmed this during an interview. The Administrator expected equal quality of care for all residents, regardless of room size.
Failure to Update Fall Care Plan and Complete Post-Fall Reviews
Penalty
Summary
The facility failed to ensure Resident 1’s care plan was revised and updated after falls, and failed to complete post-fall assessment risk reviews and IDT meetings following each fall. Resident 1 had diagnoses of adrenomyeloneuropathy, muscle weakness, and difficulty walking. The annual MDS dated 4/29/25 indicated the resident was able to understand others and make self-understood, while the admission BIMS dated 1/28/26 showed a score of 0 out of 15, indicating severe cognitive impairment. During observation on 5/20/26, Resident 1 was in bed with the head of bed elevated, the call light attached to the left quarter rails, and no floor mat observed at bedside. The resident’s fall care plan, originally dated 7/24/24, identified the resident as high risk for falls but did not include a floor mat as an intervention. The DON stated there should always be a post IDT meeting for every fall. Review of the record showed IDT post-fall reviews dated 4/16/25 and 5/21/25, each documenting an unwitnessed fall and listing interventions such as keeping the bed in the lowest position and the call light within reach, but no new interventions were added. The DON stated the facility had no additional IDT documentation for falls on 9/13/24, 6/16/25, and 12/31/26, and no MFS assessments were found after each subsequent fall. The facility policy stated that if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.
Failure to Revise Fall-Prevention Interventions for Resident with Recurrent Falls
Penalty
Summary
The facility failed to implement and revise individualized fall-prevention interventions for a resident with severe cognitive impairment, impaired mobility, and a documented history of recurrent falls. The resident’s record showed diagnoses of adrenomyeloneuropathy, muscle weakness, and difficulty walking. The resident’s admission BIMS score was 0 out of 15, indicating severe cognitive impairment. During observation, the resident was in bed with the head of the bed elevated, the call light attached to the left quarter rails, and the bed in low position, but no floor mat was present at the bedside. The resident stated that her leg hurt and could not recall how it was injured or whether she had fallen. Staff interviews and record review showed the resident had multiple documented falls, including falls on 9/13/24, 4/15/25, 5/19/25, 6/16/25, and 12/31/25, yet no additional interventions were implemented after those events. An LVN stated the resident’s care plan did not include a floor mat, and another LVN stated there was no reason for the resident not to have one and that the resident used to have a floor mat. A CNA stated no additional interventions were in place besides keeping the bed low. The DON reviewed the fall care plan and agreed the resident was high fall risk and that no additional interventions had been implemented following the documented falls. The facility policy stated that if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident was moved to another room without receiving the required written notification prior to the change. The resident, who had an intact cognitive status as indicated by a perfect score on the Brief Interview of Mental Status (BIMS), reported being verbally informed by the wound care nurse on the night before the move but did not receive any paperwork or written notice regarding the room change. Review of the resident's records and interviews with staff, including a registered nurse and the Director of Nursing, confirmed that only verbal communication was provided and no written notification was documented or given to the resident. Further review of the facility's policy and procedure on room changes revealed that advance written notice is required for all parties involved prior to any room or roommate assignment changes. Staff interviews indicated a lack of awareness of this policy, and no documentation of written notice was found in the resident's electronic health record. The facility's census list also confirmed the room change, but there was no evidence that the resident received the mandated written notification in advance.
Care plans were not updated for transfer needs and repeated elopement
Penalty
Summary
The facility failed to complete and update comprehensive care plans in a timely manner for two residents. For one resident with a history of diffuse traumatic brain injury, seizures, difficulty walking, lack of coordination, and myoclonic jerks, the care plan did not accurately reflect the required transfer method. Staff reported that the resident had been transferred with a standing lift because of sudden trembling and jerking movements, but the care plan did not include that transfer method. On 8/11/25, two CNAs transferred the resident from a wheelchair to bed without using a standing lift, and the resident’s left leg was twisted during the transfer. The resident reported hearing a popping sound and feeling burning pain in the left lower leg, and x-ray and emergency records documented acute fractures of the distal tibia and fibula of the left lower leg. Interviews showed that staff did not have a place to reference the resident’s transfer needs, and an on-call CNA stated she did not know a standing lift was required and did not use a gait belt during the transfer. The resident’s regular CNA stated staff had been using a standing lift for a long time, but on-call and registry staff did not know this. The DON, DSD, LVN, MDSC, and DR all stated that the care plan should include the transfer method and be reviewed and revised by the IDT, but the resident’s care plan did not reflect the transfer requirement before the incident. For the second resident, the admission MDS showed mild cognitive impairment, wandering, and diagnoses including unsteadiness on feet, cognitive communication deficit, and aphasia. The resident had repeated episodes of elopement, including being found at a bus station, downtown by police, and wandering in another town before returning by ambulance. The resident also wandered in the facility hallway and stated he removed his wander guard because he did not like it. The facility’s care plan report initiated after these events addressed monitoring location and engaging the resident in activities, but the record showed the comprehensive care plan was not developed within 7 days of the assessment and the IDT had not met to review the repeated elopement episodes with appropriate interventions.
Failure to Supervise Resident With Repeated Elopements
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for one sampled resident who repeatedly eloped from the facility. Resident 29 had an admission MDS dated 2/4/25 that showed a BIMS score of 10, indicating mild cognitive impairment, and the resident was unable to recall the correct year, month, and day of the week. The MDS also noted clear speech with difficulty communicating some words or finishing thoughts unless prompted or given time, an episode of wandering, and a need for supervision with walking, including verbal cues and contact guard assistance. The resident also had diagnoses including unsteadiness on feet, cognitive communication deficit, and aphasia. During observation and interview on 11/18/25, Resident 29 was seen wandering up and down the hallway and stated he left the facility because he wanted to see his family. He stated he removed the wander guard from his ankle and placed it under his pillow before leaving, and said he did not like the device because it felt like it was messing with his head and made him feel as if he was in jail. The record showed multiple elopement events: on 3/3/25 the resident eloped and was found at a bus station by a CNA; on 5/28/25 the resident eloped at 9:10 p.m., police were notified, and the resident was found downtown and returned; on 11/5/25 the resident eloped again and police were notified; and on 11/7/25 the resident was found wandering in another town, evaluated in the emergency department, and returned by ambulance. The resident’s care plan dated 11/10/25 stated that he leaves the facility without notifying staff and included monitoring his location every shift. During interview, the Administrator stated the resident had eloped more than once and that the facility had not reported the prior elopements to the state department. The Administrator also stated the facility tried to report the 11/5/25 elopement but later learned the fax did not go through. The DON stated the resident continued to elope because he removed his wander guard, that the IDT had not met to review the repeated elopements, and that she could not provide a comprehensive care plan addressing the resident’s wandering and repeated elopement incidents.
Late Quarterly MDS Assessments
Penalty
Summary
Quarterly MDS assessments were not completed at least once every three months for four sampled residents. Resident 1’s last quarterly MDS was completed on 10/28/25, Resident 10’s on 10/3/25, Resident 19’s on 10/12/25, and Resident 27’s on 11/2/25, each noted as being over 120 days old at the time of review. The report states that these quarterly assessments were not completed not less frequently than once every three months as required. During interview, the MDS coordinator stated she was aware the quarterly MDSs were late and said she had recently been hired and was trying to catch up with the overdue assessments. The Administrator also stated the facility was aware of the late completion of residents’ MDSs and said newly hired staff had been brought in to assist with completing them. The report also cites the LTC Resident Assessment Instrument User’s Manual, which states the quarterly assessment should be completed not later than 14 days after the ARD and must be completed at least every 92 days following the previous OBRA assessment of any type.
Late Transmission of Quarterly MDS Assessments
Penalty
Summary
The facility failed to electronically transmit accurate and complete MDS data to the CMS system within the required timeframe for four sampled residents: Resident 1, Resident 10, Resident 19, and Resident 27. Review of the MDS 3.0 Final Validation Report showed that Resident 1’s quarterly assessment was completed on 10/14/25 and transmitted on 11/11/25, Resident 10’s quarterly assessment was completed on 9/19/25 and transmitted on 11/16/25, Resident 19’s quarterly assessment was completed on 10/12/25 and transmitted on 11/18/25, and Resident 27’s quarterly assessment was completed on 10/13/25 and transmitted on 11/18/25. During interview, the MDS coordinator stated she was aware of the late completion of the residents’ quarterly MDSs and said she had recently been hired and was trying to catch up with the late MDSs. The Administrator also stated the facility was aware of the late completion of residents’ MDSs and said newly hired staff had been brought in to assist with completion of the assessments. The report also cited the CMS requirement that quarterly assessments be transmitted electronically within 14 days of the MDS completion date plus 14 days.
Inaccurate MDS Coding for Vision, Oral Status, and Hospice Item
Penalty
Summary
The facility failed to accurately code the MDS for three sampled residents. For Resident 49, a concurrent observation and interview found the resident reported having problems seeing and using a computer, could not read or use a laptop, and stated an eye doctor had diagnosed cataracts and provided a referral to ophthalmology that had not yet resulted in an appointment. However, the annual MDS dated 8/21/25 coded the resident as having adequate vision and seeing fine detail such as regular print in newspapers/books. During review, the MDS coordinator acknowledged that the MDS section for hearing, speech, and vision was not coded accurately. For Resident 27, observation showed the resident lying in bed with no natural teeth and no dentures in place, and the nursing admission screening/history indicated no natural teeth. The annual MDS was coded incorrectly for the item addressing no natural teeth or tooth fragments, and the MDS coordinator stated it should have been coded as yes. For Resident 31, the admission assessment MDS incorrectly coded the hospice care item to reflect the resident's choice, even though the order summary showed admission to Sutter Hospice on routine care with a terminal diagnosis of end stage renal disease. The MDS coordinator stated this was a coding error and did not reflect the resident's choice.
Failure to Provide Toenail Care and Podiatry Treatment
Penalty
Summary
The facility failed to provide appropriate toenail care and treatment for Resident 30, who had diabetes mellitus and impaired cognition. During observation, Resident 30 was lying in bed with long, thick, brownish-black toenails and stated that he had requested staff help with toenail care and was waiting for assistance. The Assistant Director of Nursing observed the toenails and stated that Resident 30 needed a referral to podiatry. The Social Services Director stated that Resident 30 was not seen by the podiatrist because of insurance, and that the podiatrist only accepted Medicare Part B. The facility also failed to provide toenail fungal treatment and toenail trimming for Resident 48 for 15 months. Resident 48 had diagnoses including diffuse traumatic brain injury, seizures, difficulty walking, and lack of coordination, and was cognitively intact. During observation, Resident 48 had long toenails on multiple toes, with the two big toenails thick, long, discolored yellow and brown, and protruding; several other toenails were long and curved downward, and two toenails were loose. Resident 48 stated she could flip the loose toenails backward and was afraid they could be accidentally ripped off. A CNA stated she had reported the toenail problem to nurses and the administrator, and the Social Services Director stated the resident had not been seen by a podiatrist because of insurance reasons.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete a performance review for three of three CNAs, identified as CNA 2, CNA 3, and CNA 4, at least once every 12 months. During review of personnel files, CNA 2, CNA 3, and CNA 4 were found to have no performance review for 2025, despite hire dates of 3/25, 2/22, and 11/24, respectively. The report states this failure had the potential for a lack of training for any deficiencies identified during the performance review process. During a concurrent interview and record review on 11/20/25, the DSD reviewed the CNAs’ annual skills checklists dated 9/11/25, 10/16/25, and 11/4/25 and stated these were the only documents provided for the CNAs. The DSD stated there was no other form the facility had provided for the performance review and identified the CNA annual skills checklist as the performance review. In a follow-up interview, the DSD stated she had asked the Admin, previous acting DSD, and facility consultant for a copy of the performance review form when she first started but was not provided one, and stated performance reviews should be completed from the date of hire and annually thereafter. On 11/21/25, the DSD showed a form titled Employee Performance Review and stated it would be used to complete the performance review. The facility policy titled Performance Evaluation, dated 6/10, stated a performance evaluation will be completed on each employee at the conclusion of the 90-day probationary period and at least annually thereafter.
Failure to Implement Legionella Water Management Program
Penalty
Summary
Provide and implement an infection prevention and control program. Based on interview and record review, the facility failed to implement its Legionella Water Management Program policy and procedures because it did not have a water management program. During an interview on 11/21/25 at 8:55 a.m. with the Administrator, the Administrator stated the facility did not have a program for managing water systems to prevent Legionnaires' disease and had not tested water for legionella. Review of the facility's policy and procedure titled, "Legionella Water Management Program," revised September 2022, showed the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella.
Missing resident clothing was not replaced or reimbursed
Penalty
Summary
The facility failed to ensure one resident’s rights were free from misappropriation of property and exploitation when the resident’s missing pants and tops were not replaced or reimbursed. Resident 4 had intact cognition with a BIMS score of 13, clear speech, and was able to make herself understood and understand others. Her diagnoses included depression. During interview, Resident 4 stated she reported missing five pairs of jeans, three tops, and underwear to staff and the DON the prior month, and that staff checked her closet and laundry but could not locate the items. She stated the DON was aware of the missing personal possessions. Resident 4 stated the DON asked her daughter to replace the missing pants and tops and said the facility would reimburse the daughter, but Resident 4 did not want her daughter to take on that responsibility because her daughter struggled financially. The IPP showed only one shirt, pants, socks, brassier, and jacket were identified on admission. The DON and Administrator both stated they were aware of the missing pants and tops and confirmed the daughter had been asked to replace the items with facility reimbursement. The facility policy stated residents are not required or requested to waive facility liability for loss or misappropriation of personal property.
PASRR Screening Not Accurately Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that two residents with mental health diagnoses were accurately screened under PASRR and referred for Level II PASRR evaluation and determination. Resident 3’s annual MDS dated 8/18/25 showed diagnoses including schizophrenia, bipolar disorder, and anxiety disorder, but the resident’s PASRR Level I screening dated 8/21/18 indicated no diagnosis of serious mental illness. During interview and record review, the DON stated that Resident 3’s PASRR Level I was not accurately screened or referred to the appropriate state mental authority for Level II PASRR evaluation and determination. Resident 4’s admission MDS dated 7/13/25 showed a diagnosis of Major Depressive Disorder, but the PASRR Level I screen dated 7/5/25 indicated no diagnosis of serious mental illness. The DON stated the Level I PASRR was initiated from the hospital before admission, and the Admin stated the facility’s process was for the admission coordinator to review PASRR upon admission and determine if follow-up was required. The DON stated Resident 4’s PASRR Level I was not accurately screened or referred to the appropriate state mental authority for Level II PASRR evaluation and determination. The facility’s PASRR policy stated that Level I screening is used to identify whether an individual admitted to a nursing facility has or is suspected of having serious mental illness or ID/DD/RC.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
Resident 49 was identified as having intact cognition with a BIMS score of 13, clear speech, and the ability to make self-understood and understand others. The resident’s diagnoses included anxiety disorder and depression. During interview, Resident 49 stated he needed regular exercise to help with mobility and requested to walk outside of the facility twice a day as ordered by his physician. He also stated he was walked sometimes once a day and most days nobody walked him. The physician order dated 9/23/25 directed Resident 49 to receive RNA walk two times a day, three times weekly without a front wheel walker on Tuesday, Thursday, and Sunday for 12 weeks. During interview and record review, the restorative nursing assistant stated she was not aware of the order to walk Resident 49 twice daily and said she walked him once daily when on duty. She could not provide RNA treatment records from September 2025 to November 2025. The care plan identified Resident 49 as at risk for decline in functional mobility and included RNA two times a day, three times a week, with walking for 30 minutes twice a day outside or inside due to weather with supervision and without a FWW. The facility policy on Restorative Nursing Services stated residents will receive restorative nursing care as needed to help promote optimal safety and independence.
Failure to Assist Resident With Ophthalmology Referral for Cataract Surgery
Penalty
Summary
The facility failed to ensure that a resident was assisted in obtaining vision services when the resident was not helped with a referral for cataract surgery as ordered by the physician. Resident 49 had an MDS dated 8/21/25 showing a BIMS score of 13, indicating intact cognition, and was able to make self-understood and understand others. The resident’s diagnoses included anxiety disorder and depression. During an interview, the resident stated he had vision problems, could not read or use his laptop computer, and said an eye doctor had seen him at the facility the prior year and diagnosed a cataract in the right eye with a referral for ophthalmology and facility scheduling of the appointment. The resident stated the referral had been given to staff, but he had not seen an ophthalmologist and was frustrated and did not know what to do. Record review showed an Advanced Eyecare note dated 3/29/24 documenting that the resident was seen by an eye doctor, diagnosed with cataract in the right eye, and referred to ophthalmology with the facility to schedule the appointment. The OSR dated 7/3/24 showed a physician order that the facility may refer the resident to ophthalmology for cataract surgery. During interview, the SSD stated the eye doctor usually visited the facility every six months and that the resident’s insurance did not cover vision and he was not seen by the eye doctor. The facility policy titled, Visually Impaired Resident, Care of, stated it is the facility’s responsibility to assist the resident and representatives in locating available resources, scheduling appointments, and arranging transportation.
Lack of Written Dialysis Agreement
Penalty
Summary
The facility failed to have a formal written agreement with the dialysis provider for residents who required dialysis, including an agreement that outlined responsibilities for care coordination, communication, and emergency preparedness. This deficiency was identified for three sampled residents: Resident 9, Resident 19, and Resident 55. The report stated that the lack of a written agreement had the potential for these residents to not receive consistent care that meets professional standards. Resident 19’s record showed a diagnosis of ESRD and a physician order for hemodialysis every Monday, Wednesday, and Friday at a dialysis provider. Resident 55’s record also showed ESRD and a similar hemodialysis order on the same schedule. Resident 9’s admission record showed ESRD, and the order summary indicated dialysis every Monday, Wednesday, and Friday at a dialysis provider; the MDS also indicated dialysis treatments while the resident was in the facility. During interviews, the Administrator stated the facility did not have a written agreement with the dialysis provider and had difficulty contacting dialysis management or obtaining a contract from the dialysis center administrators.
Excessive Number of Residents in Multiple Rooms
Penalty
Summary
The facility had six resident rooms, including room [ROOM NUMBER], 27, 29, 31, 33, and 35, that each accommodated more than four residents, with the rooms containing 5 or 6 beds each. During observation and record review, surveyors found that these rooms exceeded the allowed number of residents per room. During an interview, Resident 24 stated that he stayed in a room that accommodated more than four residents and reported having enough space for storage of his belongings and being comfortable with no complaints regarding bed space. During random observation of care and services, there was sufficient space for the provision of care in all rooms, no heavy equipment was kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings, and no negative outcomes were attributed to the decreased space or safety concerns in the six rooms.
Insufficient Square Footage in Multiple-Occupancy Resident Rooms
Penalty
Summary
Rooms 23, 25, 27, 29, 31, and 33 had multiple beds but provided less than 80 square feet per resident. During observation on 11/20/25 at 11:11 a.m., the rooms were documented as having floor areas of 78.42 sq. ft per bed in Rooms 23 and 25, and 77.59 sq. ft per bed in Rooms 27, 29, 31, and 33. The report stated that these rooms were occupied by residents and that the space per resident did not meet the required standard for multiple-occupancy rooms. During interview, Resident 24 stated that he stayed in a room that accommodated more than four residents and reported having enough space for storage of his belongings and being comfortable with no complaints regarding bed space. A CNA stated that it was manageable to care for residents in rooms with more than four residents and that shower chairs and lifts could be used in these rooms without problem. Random observations of care and services from 11/18/25 through 11/21/25 found sufficient space for care in all rooms, no heavy equipment interfering with care, and adequate personal space and privacy. The report also stated there were no complaints from residents regarding insufficient space for belongings and no negative outcomes attributed to the decreased space in the six rooms.
Failure to Implement Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act upon the Consultant Pharmacist's recommendations for two residents, leading to a deficiency in medication management. Resident #2, who was admitted with a diagnosis of heart failure, had an order for mometasone furoate inhalation aerosol for asthma. The Consultant Pharmacist recommended adding a directive for the resident to rinse their mouth with water after use to prevent potential adverse effects. However, this recommendation was not implemented by the facility staff. Similarly, Resident #32, admitted with a diagnosis of hypertension and severe cognitive impairment, was prescribed apixaban for deep vein thrombosis prophylaxis. The Consultant Pharmacist advised the facility to add shift monitoring to detect any bleeding, a common side effect of the medication. Despite this recommendation, there was no evidence of monitoring for bleeding prior to the survey date. Interviews with the Director of Nursing and the Consultant Pharmacist confirmed that the recommendations had not been addressed, indicating a lapse in the facility's medication management process.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by a 15.38% error rate during a medication administration observation. Specifically, there were 4 medication errors out of 26 opportunities, involving a resident with a medical history of amyotrophic lateral sclerosis (ALS). The errors included the improper administration of Dulera, an asthma medication, where the Licensed Vocational Nurse (LVN) administered two puffs with only a five-second interval instead of the required 30 seconds. Additionally, the LVN did not administer other prescribed medications, including omega-3 fatty acid capsules, riluzole, and Peridex Solution, during the observation. Interviews with the LVN, Director of Nursing, and Administrator confirmed the failure to adhere to the physician's orders and manufacturer's instructions for medication administration. The facility's policies on medication administration were not followed, contributing to the observed deficiencies. The LVN acknowledged the errors, and both the Director of Nursing and Administrator expressed expectations that medications should be administered according to the prescribed orders and guidelines.
Failure to Transcribe Physician's Order for Wound Care
Penalty
Summary
The facility failed to transcribe a physician's order for wound care for a resident, leading to a deficiency in maintaining accurate medical records. The resident, who was admitted with a medical history of heart failure, had a wound on the left inferior knee that required specific topical antibiotics and dressings as per a surgical consult. Despite the wound being stable and the need for continued topical wound dressing, the order for this care was not transcribed into the resident's medical record. Interviews revealed that the Wound Physician had ordered the wound care treatment, expecting it to be transcribed by the treatment nurse. However, the Licensed Vocational Nurse (LVN) responsible for the resident's wound care admitted to failing to transcribe the physician's order into the electronic medical record (EMR). The Director of Nursing and the Administrator both confirmed that the staff were expected to process and implement treatment orders, but this did not occur in this instance, resulting in the deficiency.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident identified as high risk for multidrug-resistant organism (MDRO) colonization and transmission. The resident, admitted on 09/08/2020, had a medical history including a cutaneous abscess, cellulitis, functional quadriplegia, chronic osteomyelitis, and neuromuscular dysfunction of the bladder. The resident was dependent on staff for most activities of daily living, had an indwelling catheter, and an unstageable pressure ulcer. Despite these conditions, staff members did not adhere to the Enhanced Standard Precautions recommended by the California Department of Public Health, which include wearing gowns and gloves during specific care activities. Observations revealed that staff members, including a Certified Nurse Aide (CNA) and a Licensed Vocational Nurse (LVN), did not wear gowns while performing tasks such as emptying the resident's catheter bag, providing incontinence care, and performing wound care. Interviews with the staff indicated a lack of awareness or misunderstanding of the requirement to use enhanced barrier precautions for the resident. The Infection Preventionist confirmed that the staff should have worn gloves and gowns, and the Administrator expected staff to wear gowns when necessary, indicating a gap in the implementation of infection control protocols.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as evidenced by the presence of more than four residents in six of the sixteen resident bedrooms. Specifically, the Daily Census dated June 17, 2024, indicated that Rooms 26 and 35 housed five residents each, while Rooms 27, 29, 31, and 33 housed six residents each. During interviews, the Director of Nursing mentioned that a room variance waiver was in place for these rooms, and the Administrator expressed an expectation that residents in these overcrowded rooms receive the same quality of care and services as others.
Room Size Deficiency Due to Insufficient Square Footage
Penalty
Summary
The facility failed to ensure that residents' rooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. Specifically, six rooms in the facility provided less than the required space, with room dimensions ranging from 77.59 to 78.42 square feet per resident. The facility had requested a renewal of a waiver for these room sizes, acknowledging the deficiency in meeting the standard room size requirements. During interviews, the Director of Nursing confirmed the existence of a room size variance waiver, and the Administrator stated that residents in these rooms were expected to receive the same quality of care and services as other residents, despite the room size variance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,038 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Berkeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elmwood Care Center | 0.3 mi | ★★★★★ | 8 | 0 |
| Ashby Care Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Berkeley Pines Skilled Nursing Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Chaparral House | 1.2 mi | ★★★★★ | 2 | 0 |
| The Rehabilitation Center Of Oakland | 2.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.