Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Orinda Care Center, Llc during CMS and state inspections, most recent first.
Failure to Protect and Inventory Residents’ Personal Belongings: The facility did not protect residents’ clothing and personal items or follow its policy to inventory and update personal property records. One resident with severe cognitive impairment had multiple missing items that remained unresolved, while other residents with intact or near-intact cognition reported missing clothing or a hair clipper that were not reported or documented. Staff observed unlabeled resident clothing in the laundry area, and the MRD confirmed missing or absent inventory records for some residents.
A resident with post-polio syndrome reported missing clothing and money, and staff did not complete an inventory of her belongings upon admission as required by facility policy. The Social Services Director was aware of the missing items but could not confirm if reimbursement occurred or if an inventory was ever created, resulting in the resident's frustration.
Skilled nursing staff did not notify the physician when a resident with post-polio syndrome experienced hallucinations and attempted to leave the facility. Despite clear changes in mentation and behavior, there was no documentation of physician notification until after several days, when the resident was ultimately sent to the hospital for evaluation and treatment.
A resident with post-polio syndrome did not receive a dentist-recommended biopsy for a dental abscess, as there was no evidence the procedure was ordered or completed. The same resident also did not receive sufficient assistance from social services to obtain a new ID card needed for independent living, despite multiple attempts and documented barriers. These failures left the resident frustrated and without necessary support.
A resident with intact cognitive status reported insufficient supplies and an unclean room, with observations confirming white crumbs on the floor and personal items improperly stored. Staff interviews and inventory review revealed ongoing shortages of towels, linens, and mattress covers, forcing CNAs to use disposable wipes and leaving many beds unmade. The lack of essential supplies resulted in unsanitary and uncomfortable conditions, affecting residents' dignity, comfort, and safety.
A resident with limited mobility and moderate risk for pressure ulcers did not have a care plan in place, and a wound on the coccyx was initially misidentified as a skin tear rather than a stage 2 pressure ulcer, leading to delayed appropriate treatment. The same resident's foley catheter was changed to a larger size without a written physician's order, and both catheter sizes remained active in the treatment record, causing confusion among nursing staff.
The facility failed to follow food safety standards, as Cook1 prepared dessert without a beard net, exposing his beard. Additionally, five bowls of dry cereal and one bowl of white granulated powder were found unlabeled and undated in the kitchen, violating the facility's policies on food hygiene and storage.
The facility failed to ensure advance directives were offered or documented for eight residents, potentially compromising their healthcare wishes. Despite having policies in place, the facility did not document discussions or assistance regarding advance directives for residents with serious health conditions, as confirmed by staff interviews and record reviews.
Two residents were inaccurately assessed for tobacco use in their MDS assessments, despite being observed smoking daily. Interviews confirmed their long-term smoking habits, and the MDS Coordinator admitted to the coding error, which misrepresented their clinical status and risked inadequate person-centered care.
The facility failed to provide RN coverage for at least eight consecutive hours a day on 11 occasions, as confirmed by payroll records and the Administrator. This deficiency coincided with two resident falls when an RN was not available to perform post-fall assessments, highlighting a lapse in ensuring resident safety and well-being.
The facility failed to secure a medication cart, leaving it unlocked and unattended, and did not maintain proper temperature for refrigerated medications. An LVN admitted to not locking the cart, risking unauthorized access. The DON confirmed that medications were stored at incorrect temperatures, potentially compromising their effectiveness.
The facility violated HIPAA by allowing staff to use personal cell phones to exchange residents' PHI, including full names and clinical details, via the Signal app. Staff, including an LVN and the DON, used personal devices for communication, even when off duty, without ensuring encryption, posing a risk of privacy breach.
The facility failed to follow infection control practices, including not labeling Resident 11's nasal cannula tubing, not disinfecting a stethoscope between residents, and improperly transporting clean blankets. These actions were against the facility's policies and acknowledged by staff, posing a risk of cross-contamination.
A resident with multiple diagnoses, including cerebral palsy and quadriplegia, did not receive care with dignity when an LVN and a CNA failed to provide privacy during wound care treatment. The resident's buttocks were exposed with window blinds open and curtains undrawn, violating the resident's rights to dignity and privacy as per the facility's policy.
A resident with mild cognitive impairment and a progressive neurological condition was found with medications on the bedside table without an assessment for safe self-administration. The resident stated staff were aware of the self-administration, but the LVN and DON confirmed no IDT assessment was completed. Facility policy requires such assessments to ensure safety.
A facility failed to complete a quarterly MDS assessment for a resident, resulting in a lapse of over four months without an updated assessment. The MDSC acknowledged missing the assessment due in October, which placed the resident at risk for unidentified changes in health status and potentially inappropriate care.
A facility failed to accurately complete a resident's PASARR for serious mental illness, resulting in a negative Level I screening and no Level II evaluation. The resident, with diagnoses including epilepsy and major depressive disorder, was potentially deprived of necessary mental health services. The Admission Director admitted the oversight, which was against the facility's policy.
A facility failed to perform a PASARR for a resident with dementia, schizophrenia, and other mental health conditions, as required by policy. The absence of this assessment could lead to the resident not receiving necessary specialized services. The Admission Director confirmed the facility's responsibility to ensure the PASARR is completed correctly.
A resident with a left hand deformity refused to wear a prescribed splint, and the facility failed to provide an alternative treatment. The resident experienced pain when using his hand to wheel his wheelchair, and staff were unaware of his condition. Despite the resident's refusal since December, no alternative plan was developed, and the resident's doctor was not notified.
Two residents with limited ROM did not receive necessary exercises due to a lack of communication between the rehabilitation and nursing departments. Despite recommendations for a restorative program, the residents were not in the system to receive RNA services, leading to potential decline in their functional mobility.
A resident with an above-knee amputation and back pain requested a change in his Oxycodone administration from every six hours to every four hours. Despite being cognitively intact and communicating his needs, the nursing staff failed to follow up effectively with the doctor or among themselves, resulting in unrelieved pain and frustration for the resident.
A facility failed to establish parameters for Glargine insulin administration for a diabetic resident, leading to inconsistent insulin delivery over five months. The resident, aware of their condition, expected daily insulin as per physician orders, but the MAR showed irregular administration. The DON could not find insulin administration guidelines, and the Pharmacy Consultant admitted to missing this oversight.
A resident with a history of seizures was admitted to an LTC facility with a prescription for levetiracetam 1000 mg every 12 hours. The facility incorrectly transcribed the order as 100 mg/ml to be given as needed, leading to the resident receiving the wrong dosage for 22 days. This error resulted in multiple seizures, hospitalization, and the resident's death. The facility's failure to follow its medication reconciliation policy contributed to the adverse outcome.
Failure to Protect and Inventory Residents’ Personal Belongings
Penalty
Summary
The facility failed to protect residents’ personal belongings and did not follow its policy to inventory and document personal property upon admission and update it as needed. Four sampled residents were involved: one resident with severe cognitive impairment, two residents with no cognitive impairment, and one resident with intact cognition. The deficiency was based on observation, interview, and record review showing missing clothing and personal items, incomplete or absent inventories, and unresolved concerns about laundry and lost belongings. For one resident with diagnoses including stroke with hemiparesis and hemiplegia, dementia, and depression, the responsible party reported that many items were missing and had to be replaced. The resident’s personal effects inventory listed clothing and personal items, but multiple later handwritten missing-item lists showed blankets, pants, shirts, socks, and other belongings that were not found. The grievance record stated that not all items had been found and that the issue remained unresolved. During observation in the laundry area, staff acknowledged that residents’ clothing was still mixed together, many items had no names or labels, and there were ongoing issues with residents’ personal clothing. Two other residents with BIMS scores of 13 stated they were missing personal items but had not reported them. One resident said a hair clipper was missing, and the medical record director confirmed it was not on the admission inventory and the inventory had not been updated. Another resident reported missing clothing and said the second set of clothes provided by family was also stolen, while the medical record director confirmed there was no inventory record in either the electronic record or hard chart. A fourth resident with intact cognition stated socks were missing from laundry and that the concern raised in the resident council meeting had not been resolved. The medical record director also provided an inventory for this resident dated after admission, but the admission inventory was not provided. The facility policy stated that residents’ personal belongings and clothing are to be inventoried and documented upon admission and updated as necessary, and the resident rights policy stated residents may retain and use personal possessions to the maximum extent space and safety permit.
Failure to Secure and Inventory Resident Belongings
Penalty
Summary
Facility staff failed to secure the belongings of a resident who was admitted with post-polio syndrome and was oriented to time and able to recall information accurately. The resident reported that underwear, other clothing items, and $53 stored in her bedside table had gone missing. She stated that she had informed multiple staff members, including the social worker, but only a partial effort was made to locate the missing items. The resident also discovered that the facility had not completed an inventory of her belongings upon admission, despite staff indicating they would check such a list. Interviews with the Social Services Director confirmed awareness of the missing items and that some clothing had been returned, but there was uncertainty regarding reimbursement for the lost money and whether an admission inventory had been completed. Review of the medical record showed no documented inventory of the resident's belongings. Facility policies required that personal belongings and clothing be inventoried and documented upon admission and updated as necessary, but this was not done in this case.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Skilled nursing staff failed to notify the physician of a significant change in condition for a resident who was admitted with post-polio syndrome and had previously been oriented to time and place. The resident experienced a sudden onset of hallucinations, including seeing snakes under the bed and believing bugs were crawling in the room, as well as an attempt to elope from the facility. Despite these notable changes in mentation and behavior, there was no documentation that the physician was notified during the initial episodes. The Director of Nursing confirmed that staff did not inform the physician about the resident's hallucinations, which are recognized as a potential sign of infection. The facility's clinical protocol required nurses to assess and report changes in cognitive and emotional status, but this was not followed. The physician was only notified after several days, at which point the resident was sent to the hospital for further evaluation and treatment.
Failure to Provide Dental Follow-Up and Social Services for Independent Living
Penalty
Summary
A deficiency occurred when the facility failed to provide medically-related social services to support a resident's dental health and ability to live independently. The resident, who had post-polio syndrome resulting in muscle weakness, was evaluated by a dentist who recommended an urgent biopsy for a dental abscess. However, there was no documentation that the biopsy was ever ordered or completed. Interviews with the Social Services Director (SSD) and Director of Nursing (DON) confirmed that the biopsy had not been arranged, and the resident stated the procedure was never done. Additionally, the resident expressed frustration about not receiving adequate assistance to obtain a new identification card, which was necessary for her goal of living independently. Although the SSD had initially made an appointment at the DMV, the resident still did not have a new ID card. The MDS RN attempted to help but encountered barriers due to missing documents and physical limitations, and reported these issues to the SSD. Documentation and interviews confirmed that the SSD did not follow up further, leaving the resident upset and without the necessary identification.
Failure to Provide Clean, Homelike Environment and Adequate Linen Supplies
Penalty
Summary
The facility failed to maintain a clean, orderly, and homelike environment for its residents, as evidenced by multiple observations and staff interviews. Resident rooms were found with a build-up of white crumbs on the floor, and personal items such as disposable briefs and pillows were piled on chairs at the bedside rather than being stored appropriately. One resident, who was cognitively intact according to their BIMS score, reported insufficient supplies and noted that their room had not been cleaned, with lunch trays and personal items still left out. Staff interviews revealed an ongoing shortage of essential linens and towels since December 2024, leading CNAs to use disposable dry wipes for resident care and struggle to find enough mattress covers. Observations of the linen closet and laundry area confirmed the lack of necessary supplies, with only a handful of towels and other linens available for a census of 46 residents. The monthly linen inventory further documented significant shortages in bath towels, wash cloths, bedspreads, blankets, and bath blankets. These deficiencies resulted in an unsanitary and uncomfortable environment, negatively impacting residents' dignity, comfort, and safety.
Failure to Accurately Assess Pressure Ulcer and Improper Foley Catheter Management
Penalty
Summary
A resident with a history of cord compression and a benign neoplasm of the pituitary gland was admitted with limited mobility and a moderate risk for pressure ulcers, as indicated by a Braden Scale score of 13. Despite this risk, there was no care plan in place to address the potential for pressure ulcer development. When a wound was identified on the resident's coccyx, the treatment nurse initially assessed it as a skin tear, despite the presence of thin skin and a darkened area. Two days later, a wound physician correctly identified the wound as a stage 2 pressure ulcer. Nearly four weeks later, the wound had progressed to a stage 4 pressure ulcer. The director of nursing confirmed that the initial assessment was incorrect and that no care plan had been developed for pressure ulcer prevention or management. Additionally, the resident had a foley catheter that was changed from size F16 to F18 without a written physician's order. The nurse practitioner verbally communicated the change, but the order was not properly documented, and the previous order for the F16 catheter was not discontinued. This resulted in both catheter sizes being listed in the treatment administration record, causing confusion among licensed nurses regarding which size to use. The resident expressed concern about staff competency in managing the foley catheter, and the director of nursing acknowledged the lack of proper documentation and order management.
Food Safety Standards Not Followed
Penalty
Summary
The facility failed to adhere to food safety standards as observed during a survey. Cook1 was seen preparing dessert without wearing a beard net, despite having a beard approximately one inch long. This was in violation of the facility's policy on employee hygiene and sanitary practices, which mandates the use of hair nets or caps and beard restraints when handling food. Cook1 was wearing a surgical mask, but his beard was still exposed, and he was unsure if a beard net was necessary with a mask on. Additionally, the facility did not properly label and date food items in the kitchen. Five bowls of dry cereal and one bowl containing white granulated powder were found unlabeled and undated in a kitchen cabinet. The Dietary Services Supervisor confirmed that all food should be labeled and dated, as per the facility's policy on food receiving and storage. The white granulated powder was identified as a food thickener, which also required labeling. These oversights posed a potential risk for food safety and could lead to foodborne illnesses among residents.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that advance directives were offered or documented for eight residents, potentially compromising their healthcare wishes in case of incapacitation. Residents 2, 11, 14, 18, 37, 38, 46, and 249 were identified as not having advance directives on file, and there was no documentation indicating that they or their representatives were asked about the existence of such directives. This oversight was confirmed through interviews with medical records staff and the Social Services Director, who acknowledged the absence of advance directives in the residents' records. Resident 2, for example, was admitted with multiple diagnoses including dementia and paranoid schizophrenia, yet there was no record of an advance directive being discussed or documented. Similarly, Resident 14, with conditions such as epilepsy and congestive heart failure, also lacked documentation of an advance directive. Interviews with responsible parties and staff revealed concerns about the facility's ability to honor residents' healthcare preferences without these directives in place. The facility's policy and procedure on advance directives, revised in 2013, mandates that residents be provided with information about their rights to make medical decisions and be offered assistance in establishing advance directives. However, the policy was not followed, as evidenced by the lack of documentation and staff admissions during interviews. This failure to adhere to policy and ensure advance directives were in place could lead to residents' healthcare wishes not being honored in critical situations.
Inaccurate Assessment of Tobacco Use in Residents
Penalty
Summary
The facility failed to accurately assess the tobacco use status of two residents, Resident 13 and Resident 23, during their comprehensive Minimum Data Set (MDS) assessments. Both residents were observed smoking daily on the facility's patio, yet their MDS assessments inaccurately indicated that they were not using tobacco. This discrepancy was confirmed through interviews with the residents, who both stated they had been long-term smokers, and with a Restorative Nursing Aid who supervised their smoking sessions and confirmed their smoking habits since admission. The MDS Coordinator acknowledged the error in coding the MDS assessments for both residents, which inaccurately reflected their clinical status. This failure to accurately assess and document the residents' tobacco use status placed them at risk for not receiving person-centered care tailored to their actual needs and habits.
RN Coverage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, resulting in a deficiency for a total of 11 days. This was confirmed through a review of the facility's Payroll Based Journal and acknowledged by the Administrator during an interview. The absence of an RN on specific dates was noted, and the Administrator admitted that this practice posed a risk to resident health, as Licensed Vocational Nurses (LVNs) do not possess the same level of knowledge and skills as RNs. Additionally, the lack of RN coverage coincided with two resident falls on days when an RN was not present to perform necessary post-fall assessments. The facility's assessment tool indicated the requirement for sufficient staffing with appropriate competencies to ensure resident safety and well-being, which was not met on the specified dates. The absence of an RN during these times potentially delayed necessary assessments and treatments, impacting the day-to-day care of residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmacy services policies and procedures, resulting in two significant deficiencies. Firstly, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended in the hallway, directly outside the dining and activity room. During an interview, the LVN admitted to not ensuring the cart was fully locked before leaving it unattended, acknowledging the risk of unauthorized individuals accessing the medications. Secondly, the facility did not maintain the required temperature range for refrigerated medications. Observations revealed that the refrigerator storing medications, including vaccines and insulin, was at 30 F, which is below the acceptable range of 36 F to 46 F. The Director of Nursing (DON) confirmed that medications stored outside the specified temperature parameters could be compromised and ineffective. Despite acknowledging the issue, the DON did not take corrective actions to address the improper storage conditions.
HIPAA Violation Due to Use of Personal Devices for PHI
Penalty
Summary
The facility failed to comply with the Health Insurance Portability and Accountability Act (HIPAA) by not safeguarding resident-identifiable information. Clinical and non-clinical staff, including the attending physician, nurses, nursing managers, and administrative personnel, used their personal cell phones to exchange residents' Protected Health Information (PHI) and confidential biographical details. This included using an app called Signal to send group text messages containing sensitive information such as residents' full names, dates of birth, and clinical details. The staff, including the Licensed Vocational Nurse (LVN) and Director of Nursing (DON), admitted to using their personal devices for these communications, even when off duty, without ensuring the app's encryption status. The facility's administration, including the Administrator (ADM) and Clinical Consultant (CC), acknowledged the risk of a potential breach of residents' PHI due to the use of personal devices. The facility's California Employee Handbook allowed the use of personal mobile devices for facility-related business but required strict compliance with confidentiality policies. However, the staff's practice of accessing and exchanging PHI on personal devices, even when not on the clock, posed a significant risk of a privacy breach. The facility's Policy and Procedure on confidentiality, dated 10/2017, emphasized safeguarding residents' personal and medical records, which was not adhered to in this instance.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control prevention practices in several instances. Resident 11's nasal cannula tubing was observed to be undated and unlabeled, which was against the facility's policy that required oxygen tubing to be changed and dated every seven days. This oversight was acknowledged by LVN 3, who admitted that without proper labeling, the nursing team could not determine when the tubing needed to be changed, potentially leading to infection. Resident 11 had multiple diagnoses, including asthma and chronic obstructive pulmonary disease, which could increase the risk of infection. Additionally, LVN 3 was observed using a stethoscope on multiple residents without cleaning and disinfecting it between uses, which was a breach of the facility's policy requiring disinfection of shared equipment between residents. The Infection Preventionist confirmed the risk of cross-contamination due to this practice. Furthermore, the Housekeeping Manager was seen transporting clean blankets without covering them, holding them against her clothing, which was contrary to the facility's policy that required clean linen to be protected from contamination during transport. This was acknowledged by both the Housekeeping Manager and the Infection Preventionist.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to provide care with dignity for a resident, identified as Resident 18, when two staff members did not ensure privacy during nursing care. Resident 18, who has multiple diagnoses including cerebral palsy, quadriplegia, and muscle wasting, was dependent on two or more helpers for dressing and movement. During an observation, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) were providing wound care treatment to Resident 18's left ischium. During this procedure, Resident 18's buttocks were fully exposed, and the window blinds were left open with the curtain not drawn, failing to provide necessary privacy. The LVN acknowledged that Resident 18 was not treated with dignity during the treatment, and the CNA admitted that Resident 18's rights were violated due to the lack of privacy. The Director of Staff Development (DSD) confirmed awareness of the incident and stated that the expectation was for staff to draw the curtain to ensure privacy during such procedures. The facility's policy on Resident Rights emphasizes treating all residents with kindness, respect, and dignity, including ensuring privacy during care.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure an assessment and evaluation for self-administration of medications was completed for a resident, identified as Resident 11. During an observation, it was noted that Resident 11 had a bottle of Nystatin powder, a cup filled with Pepto Bismol, and Sudafed Nasal Spray on the bedside table. Resident 11, who was admitted with multiple diagnoses including mild cognitive impairment and a progressive neurological condition, stated that staff were aware of the self-administration of these medications. However, there was no documented assessment by the Interdisciplinary Team (IDT) to determine if self-administration was safe and appropriate for Resident 11. The Licensed Vocational Nurse (LVN) acknowledged the presence of the medications on the bedside table but was unaware of any assessment for self-administration. The Director of Nursing (DON) confirmed that no IDT assessment had been completed for Resident 11 to evaluate the safety and appropriateness of self-administering medications. The facility's policy requires an IDT assessment to evaluate a resident's cognitive and physical abilities for safe self-administration and mandates that unauthorized medications found at the bedside be returned to the nurse in charge.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment in a timely manner for one of the sampled residents, identified as Resident 28. This assessment is crucial for tracking a resident's status between comprehensive assessments to ensure any gradual changes in their condition are monitored. Resident 28 was admitted to the facility, and the last assessment was completed on 7/28/24. However, the Minimum Data Set Coordinator (MDSC) did not complete the subsequent quarterly assessment due in 10/2024, resulting in a lapse of over four months without an updated assessment. During an interview and record review, the MDSC acknowledged the oversight, stating that the quarterly MDS assessment for Resident 28 was missed. This failure placed Resident 28 at risk for unidentified significant changes in health status, potentially affecting the appropriateness of care and services provided based on her current health condition.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening Resident Review (PASARR) for serious mental illness was accurately completed and sent to the appropriate state mental authority for a Level II evaluation and determination. The resident, who was admitted with diagnoses including epilepsy, major depressive disorder, delusional disorders, dementia, and congestive heart failure, had a Level I PASARR screening that incorrectly indicated no mental illness, resulting in a negative screening outcome. This error meant that a Level II Mental Health Evaluation was not conducted, potentially preventing the resident from receiving necessary mental health services. During an interview, the Admission Director acknowledged that it is the facility's responsibility to ensure the accuracy of Level I PASARR screenings. The facility did not notice the error in the resident's Level I PASARR, which might have led to the resident not receiving available services from the Department of Developmental Services Regional Center. The facility's policy on PASARR, revised in 2017, states that screenings should be completed timely and errors should be addressed by contacting the Department of Health Care Services.
Failure to Complete PASARR for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to perform a Pre-Admission Screening and Resident Review (PASARR) for a resident, which is a necessary assessment to determine if individuals with serious mental illness or intellectual/developmental disabilities require specialized services. This oversight was identified during a review of the resident's admission records and Minimum Data Set (MDS), which showed active diagnoses of dementia, paranoid schizophrenia, epilepsy, amnestic disorder, and cognitive communication deficit. Despite these significant mental health conditions, there was no evidence of a completed PASARR Level I assessment. During an interview, the Admission Director acknowledged the facility's responsibility to ensure the PASARR Level I is completed correctly. The absence of this assessment could result in the resident not receiving appropriate care and treatment services from the Department of Developmental Services Regional Center. The facility's policy mandates that the PASARR be completed and included in the resident's chart within five days of admission, a requirement that was not met in this case.
Failure to Provide Alternative Treatment for Resident's Hand Deformity
Penalty
Summary
The facility failed to provide an alternative treatment for a resident with a left hand deformity who refused to wear a prescribed splint. The resident, who had a history of plate implant surgery and was on contracture precautions, experienced pain when using his left hand to wheel his wheelchair. Despite the resident's refusal to wear the splint since December 2024, the facility did not notify the resident's doctor or develop an alternative plan to manage the resident's condition. Observations and interviews revealed that staff, including a CNA and an LVN, were unaware of the resident's left hand deformity and associated pain. The therapy progress notes indicated that the resident had declined the splint, but no further action was taken to address the resident's needs. This inaction resulted in the resident experiencing pain and a potential risk for skin breakdown while using his wheelchair.
Failure to Provide ROM Exercises for Residents
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises for two residents, Resident 6 and Resident 18, who were identified as having limited ROM. Resident 6, who was admitted with severe cognitive impairment and multiple diagnoses including cerebrovascular accident and muscle weakness, required maximal assistance with mobility. Despite recommendations for a restorative program upon discharge from occupational and physical therapy, Resident 6 did not receive the necessary ROM exercises. Similarly, Resident 18, who had multiple neurological conditions and was dependent on assistance for mobility, did not receive ROM exercises after being discharged from physical therapy without reaching maximum potential. The deficiency was attributed to a lack of communication between the rehabilitation and nursing departments, resulting in the failure to implement the Restorative Nursing Program for these residents. The Restorative Nurse Assistant confirmed that neither resident was in the system to receive RNA services due to the absence of a therapy referral. The Director of Rehabilitation and the Director of Nursing acknowledged the oversight and the potential for decline in the residents' functional mobility and ROM due to the lack of restorative care. The facility's policy indicated that residents should receive restorative nursing care to promote safety and independence, but this was not followed in these cases.
Failure to Address Resident's Pain Management Request
Penalty
Summary
The facility failed to adequately address a resident's request to change the frequency of his pain medication, resulting in unrelieved pain and feelings of frustration and unhappiness. Resident 249, who had an above-knee amputation and was experiencing back pain after a fall, requested that his Oxycodone medication be administered every four hours instead of every six hours. Despite being cognitively intact and able to communicate his needs, his request was not followed up effectively by the nursing staff. Licensed Vocational Nurse (LVN 1) documented the resident's request and notified the doctor but did not receive a response and failed to follow up further. Another nurse, LVN 3, also did not follow up with the doctor or communicate the resident's needs to other nurses due to being rushed at the end of her shift. The facility's policy on pain assessment and management was not adhered to, as the staff did not develop interventions consistent with the resident's needs, leading to the deficiency.
Lack of Insulin Administration Parameters for Diabetic Resident
Penalty
Summary
The facility failed to establish and implement clear parameters for the administration of Glargine insulin for a resident diagnosed with Type 2 diabetes mellitus with hyperglycemia. Over a period of more than five months, the resident received insulin inconsistently, with administration occurring on some days and not on others, despite similar blood glucose levels. The resident was aware of their diabetic condition and expected daily insulin administration, as per the physician's orders, which specified a daily bedtime dose of 10 units of Glargine insulin. Upon review, it was found that the Medication Administration Record (MAR) showed discrepancies in insulin administration, with the resident receiving insulin on certain days and not on others, even when blood glucose levels were comparable. The Director of Nursing (DON) was unable to locate any parameters guiding insulin administration for the resident, acknowledging the necessity of such parameters to mitigate risks of hyperglycemia or hypoglycemia. The facility's Pharmacy Consultant admitted to possibly overlooking the absence of these critical parameters, which are essential for providing clear instructions to nursing staff on when to administer or withhold insulin.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in severe consequences. Upon admission, the resident, who had a history of non-traumatic intracranial hemorrhage, malignant neoplasm of the brain, post-traumatic seizures, hemiplegia, and hemiparesis, was prescribed levetiracetam 1000 mg every 12 hours for seizure disorder. However, the Director of Staff Development incorrectly transcribed the order as 100 mg/ml, to be given as needed, which was not in line with the prescribed routine dosage. For 22 days, the nursing staff administered the incorrect dosage, leading to multiple seizures, hospitalization, and ultimately the resident's death. The facility's Medication Administration Records indicated that the medication was not given as prescribed, and there was no documentation to justify the change from as-needed to twice a day. The Clinical Consultant and Licensed Vocational Nurse acknowledged the error, and the Pharmacy Consultant admitted to missing the incorrect transcription during her monthly review. The facility's failure to accurately reconcile and transcribe the medication order upon admission, as outlined in their policy, directly contributed to the resident's adverse health outcomes. The resident experienced repeated seizures and was transferred between hospitals for continuous EEG monitoring, where the dosage was eventually corrected. Despite these efforts, the resident continued to have seizures and was transitioned to comfort-focused care before passing away.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,052 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orinda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moraga Post Acute | 3.1 mi | ★★★★★ | 6 | 0 |
| Berkeley Pines Skilled Nursing Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Walnut Creek Skilled Nursing & Rehabilitation Cent | 5.5 mi | ★★★★★ | 4 | 0 |
| Rossmoor Post Acute | 5.5 mi | ★★★★★ | 4 | 0 |
| Tice Valley Post Acute | 5.6 mi | ★★★★★ | 14 | 0 |
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