Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 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 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.
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 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.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.