Moraga Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-9), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the social services department was directed and supervised by a qualified social worker according to State regulation for more than 9 years. This failure resulted in all residents receiving social services care from unqualified staff. During an interview on 3/24/26 at 9:45 a.m. with the Social Services Director (SSD), the SSD stated they were the only staff member in the facility's social services department and had worked there for more than 9 years as the social services director. The SSD stated they did not have a bachelor's degree in any field and that their training for the position consisted of a certificate course they completed in 1997. The SSD further stated they had not received any continuing education or additional training since obtaining the certificate in 1997. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) to prevent falls and sustained injuries when Resident 1, with history of unwitnessed falls, lost her balance while walking from her bed to room's doorway and fell forward to the ground. This failure resulted in Resident 1 sustaining a laceration to the left frontal part of the head with uncontrolled bleeding, transferred to Acute Care Hospital for follow up care and diagnosed with subarachnoid hemorrhage (a life-threatening condition caused by bleeding into the space surrounding the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs when:1. Interdisciplinary team (IDT-a group of professionals from different disciplines working together to provide the greatest benefit to the resident, which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person - centered.) did not address Resident 1's angry outbursts and hallucinations (perceptual experiences in the absence of real external sensory stimuli) and identify person-centered non-pharmacological/behavior approaches prior to administering Resident 1 Quetiapine Fumarate (Seroquel), an antipsychotic medication for vascular dementia (a general term to describe a group of symptoms related to loss of [...]

Inspectors wroteBased on interview, record review, and comprehensive assessment, the facility failed to ensure one of three sampled residents (Resident 1), with occasional incontinence of bladder and bowel, received appropriate care services and assistance to maintain and restore continence to the extent possible. This failure had the potential to place Resident 1 at risk for infections, falls and injuries. During a review of Resident 1's admission Record (AR), printed on 5/6/26, AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included history of falling, muscle wasting and atrophy, age related osteoporosis, and dementia with mood disturbances (memory loss). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow state regulation in ensuring residents were housed in approved areas when the facility allowed one of two sampled residents (Resident 2) to be housed in a conference room without a sink from admission to discharge totaling six weeks. This failure placed Resident 2 at risk for infection when the facility was unable to provide a sink for handwashing and could only provide a commode for toileting. A review of Resident 2's admission record indicated Resident 2 was admitted on [DATE] with a diagnosis of neutropenia (blood disorder which white blood cells count is reduced), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), functional diarrhea and heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe labeling, open date, and expiration date of eye drop medication for 2 (Resident 98 and Resident 100) out of 2 residents. These failures had the potential to result in residents being given medication with decreased potency and efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medication when the following was noted: 1. Two bottles of expired 20 milliliters (ml) of lorazepam (a medication used to treat anxiety) for Resident 10 were stored in a dedicated refrigerator for ready to use medications. 2. The lid of black colored Medication Disposal Bin was kept very loosely open in medication storage room. The failure to dispose of expired lorazepam medication, posed a potential risk of utilizing the medication with decreased effectiveness for anxiety to Resident 10. The failure to ensure proper security of the Medication Disposal bin posed a potential authorized/unauthorized access to medications in the bin.

Inspectors wroteBased on interviews and record review, the facility failed to ensure when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met the federal and state educational qualifications for a dietary manager position. The lack of full-time, qualified oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in malnutrition and/or death.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure storage and preparation of food under sanitary conditions when: 1. The facility failed to ensure two of two facility ovens were maintained in safe operating condition to provide cooked meals according to mealtime schedules: oven 1 was unable to cook chicken to the required food safety temperature; oven 2 was inoperable. 2. The facility failed to maintain the physical environment: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration; a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered; a storage cabinet drawer did not fully close. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist provided consultation services to ensure there was a record system for receipt and disposition and reconciliation of all controlled drugs maintained for three years. The failure to maintain records had the potential to result in drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate Medical Records for three (Residents 9, 30, and 15) of eleven sampled residents, when: 1. Licensed Vocational Nurse (LVN) 2 failed to immediately document in Resident 9's medical record, the administration of Resident 9's oxycodone (a controlled medication: medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). 2. LVN 2 and Licensed Vocational Nurse 5 (LVN 5) failed to document administration of multiple medications for Resident 30 on 10/6/23, 10/14/23, 10/18/23, 10/19/23. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices when Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene during medication administration for Resident 2, Resident 5, and Resident 151. This failure to ensure proper hand hygiene had the potential risk for transmission of infection to Residents 2, 5, 151, and throughout the facility.

Inspectors wroteBased on an interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool used to guide care) functional status on mobility for one of two sampled residents (Resident 15). The MDS assessment inaccurately showed Resident 15 was not able to walk due to health and safety reasons. This failure resulted in an inaccurate reflection of Resident 15's medical condition and placed her at risk for receiving inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete and/or update the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 15) for a period of over four years. This failure resulted in an inaccurate reflection of Resident 15's medical status and had the potential to result in Resident 15 not receiving the care and services appropriate for her condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance needed for fingernail care for one (Resident 30) of three sampled residents when Resident 30 had long fingernails with blackish material under the nail tips. This failure had the potential for Resident 30 to be injured by long fingernails and develop an infection.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) when: 1. DSS did not ensure: the kitchen was maintained in a safe and sanitary manner and maintenance needs were reported for the kitchen (Cross-reference F 812); food preparation methods conserved nutritive value of the food (Cross-reference F 803); food was palatable (Cross-reference F 804); resident food preferences were provided (Cross-reference F 806); and kitchen staff were trained on perspective duties (Cross-reference F 802); 2. DSS did not ensure there was a system for dating food with appropriate use-by-dates; 3. DSS did not ensure thermometers were calibrated; 4. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to store, prepare, and distribute food safely when: 1. Perishable food was not stored in a reach-in refrigerator at 41 degrees Fahrenheit (F) or below. 2. Dirty water from the dirty side of the dish machine area splashed into the adjacent 3-compartment sink area where clean pans were stored. 3. Dietary staff did not follow proper hand hygiene and glove use procedures when cleaning and handling dishes and handling ready to eat food. 4. Multiple areas and surfaces in the kitchen were dusty, had buildup of debris and grime including two food equipment storage cabinets, floors in the dry storage room, over 50 dead flies stuck on the wall by the toaster, and dust and dirt build up in the window tracks and sills that ran all along the length of the windows behind the tray line steam table. 5. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the infection control program for was fully implemented for COVID-19 and revised their policy and procedure (P&P) to include when and whom to report possible communicable disease or infections when; 1. The facility did not report an outbreak of nausea, vomiting, and diarrhea to the California Department of Public Health (CDPH) of a gastroenteritis (sometimes called stomach flu) outbreak. 2. There was no screening of staff members for COVID-19 (a new coronavirus causing a respiratory illness and outbreak that is easily spread) symptoms from 7/3/21-7/5/21 prior to providing care to the residents. 3. The facility did not immediately test residents with nausea, vomiting, and diarrhea to rule out possible COVID-19. 4. There was no surveillance and verification of staffs' COVID-19 vaccination status. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to act upon the pharmacist's identified medication irregularity for one (Resident 41) of 12 sampled residents when; 1. Licensed nurses did not hold midodrine (for low blood pressure) as ordered by the physician. 2. Resident 41 continued to received fludrocortisone (corticosteroid) twice daily instead of once every day. These failures had the potential for Resident 41 to receive unnecessary drugs and suffer adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of 12 sampled residents (Resident 7) was aware of the benefits and limitations of having a knee high plastic zipped barrier at the entrance to her room. This failure resulted in Resident 7 to be unaware of the rationale for having a plastic zipped barrier at her door and potential for isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician order to apply a splint to one of 12 sampled residents (Resident 30)'s left contracted (shortening of the muscle, tendon, or scar tissue causing deformity and possibly permanent disability) arm. This failure had the potential to worsen Resident 30's left arm contracture.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide one resident (Resident 293) a therapeutic diet prescribed by a physician when a medical nutrition shake was not provided as ordered. This failure had the potential to cause a reduction in calorie and/or protein intake intended for the resident resulting in weight loss and/or muscle wasting.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of the kitchen staff, who washed dishes, when she did not follow proper hand hygiene and glove use procedures (Cross-reference F 812) and she did not appropriately demonstrate how to check the sanitizer strength for the dish machine. The failure to ensure the competency for one of six staff on dishwashing, hand hygiene, and glove use procedures had the potential to result in cross-contamination of food.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to prepare food in a manner to conserve nutritive value and that was palatable when the recipe was not followed for pureed broccoli and rice and pureed rice was very gummy and sticky. This failure had the potential to decrease the nutrients in food served and decrease food intake for two residents who received a pureed diet out of a facility census of 47.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide one resident (Resident 293) her preferred foods as well as a physician ordered supplement in the consistency and flavor preferred by the resident. This failure had the potential to result in a decreased amount of caloric intake leading to weight loss for 1 of 47 residents residing at the facility.