Orinda Care Center, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect personal belongings of four sampled residents (Resident 1, 2, 3, 4) and did not follow their policy to ensure the residents' personal property were properly logged upon admission and as necessary when:1. Resident 1's clothes and personal items were reported missing and not all were found.2. Residents 2, 3, and 4 had claimed they were missing clothes and personal items that were not reported.3. Residents losing their clothes was one of the concerns discussed in the Resident council meeting on 4/23/26 and there was no evidence that it was resolved.4. There was no evidence that the personal belongings for Resident 2 and 4 were inventoried upon admission and no evidence that they were updated subsequently for Residents 2 and 3. [...]

Inspectors wroteBased on interview and record review, the facility did not secure the belongings of one of three sampled residents (Resident 1) when Resident 1 ' s had some of her clothing items and money gone missing and facility staff did not create inventory, track, or replace the missing items. This failure resulted in Resident 1 expressing feeling, Frustrating which could affect Resident 1 ' s overall well-being.

Inspectors wroteBased on observation, interview and record review, the skilled nursing licensed staff did not notify the physician for a change in condition for one of three sampled residents (Resident 1). Resident 1 had a change in mentation and was hallucinating. This resulted in Resident 1 feeling it was a Horrible Experience with a possible unnecessary hospital stay.

Inspectors wroteBased on interview and record review the skilled nursing facility did not provide services to support dental health and the ability to live independently for one of three sampled Residents (Resident 1) when: 1. Dentist recommendation following a dental exam of Resident 1 to be scheduled as soon as possible for an abscess biopsy was never ordered and carried out. 2. Resident 1 was not provided the assistance she needed to live independently. This failure resulted in the potential for pain and infection, and contributed to Resident 1 feeling Frustrated, thereby negatively impacting their overall well-being, autonomy, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. Based on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. [...]

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 2), the facility failed to develop and implement an effective discharge planning process that focuses on resident's effective transition to post-discharge care when Resident 2 was discharged to a friend's home without the friend's consent. This failure had led to Resident 2 going to a homeless shelter after police were called to remove Resident 2 from the friend's home.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 2) the facility failed to complete a discharge summary that included the following information: A recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident 2's stay that includes diagnoses, course of illness/treatment or therapy, pertinent laboratory, radiology and consultation results. A final summary of Resident 2's status at the time of discharge and reconciliation of all pre-discharge medications with the resident's post-discharge medications. This failure had the potential to result in the lack of information affecting continuity of care.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 3), the facility failed to ensure Resident 2 received treatment and care in accordance with professional standards of practice when: -A stage 2 pressure ulcer (also known as bedsores or pressure sores, are localized skin and soft tissue injuries caused by prolonged pressure, often over bony areas, resulting in reduced blood flow and potential tissue damage) on a bony prominence (a part of the skeleton where a bone is close to the surface of the skin) was assessed as a skin tear. This failure had the potential to result in delayed management of the wound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow food safety standards: 1. Cook1 did not wear beard net while preparing desert, when he had about an inch long beard. 2. Five bowls with dry cereal and one bowl with white granulated powder were left unlabeled and undated in the kitchen cabinet. These failures posed a potential risk for food safety and placed facility's residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, for eight of 31 sampled residents (Residents 2, 11, 14, 18, 37, 38, 46 and 249), the facility failed to offer or ensure an advance directive (a written instruction for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was on file, when the facility did not offer to locate or help the residents/representatives complete the document. This failure had the potential for Residents 2, 11, 14, 18, 37, 38, 46, and 249's wishes regarding provision of health care to not be honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess two of three sampled residents (Resident 13 and Resident 23) for tobacco use status on comprehensive Minimum Data Set (MDS, an assessment used to guide care). Facility inaccurately coded NO to Current Tobacco Use for Resident 13 and Resident 23 who were smoking daily. The failure resulted in inaccurate reflection of Resident 13 and Resident 23's clinical status and placed them at risk for not receiving person-centered care.

Inspectors wroteBased on interview and record review the facility failed to have Registered Nurse (RN) coverage for at least eight (8) consecutive hours a day for a total of 11 days. This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for resident's day-to-day care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services policies and procedures were followed when: 1. Licensed Vocational Nurse (LVN) 1 left the medication cart unlocked and unattended in the hallway. 2. The refrigerator for medication was not maintained within the required temperature range of 36°F to 46°F as outlined in the facility policy and procedure. These failures had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety due to improper storage conditions.

Inspectors wroteBased on interview, and record review, the facility failed to comply with Health Insurance Portability and Accountability Act (HIPAA) to protect Resident-identifiable information, including but not limited to full name, date of birth (DOB), and clinical status. Clinical staff including attending physician, nurses, nursing managers; and non-clinical staff including Administration, medical records personnel used their personal cell phones to exchange residents' Protected Health Information (PHI) and confidential biographical details and received text messages for above details even when they were off duty. This failure posed a potential significant risk to protect the privacy and security of facility's residents' information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control prevention practices when: 1. Resident 11's nasal cannula (nc, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was undated and unlabeled. 2. LVN (Licensed Vocational Nurse) 3 did not properly disinfect stethoscope (a device used to amplify internal body sounds) between residents. 3. Housekeeping Manager (HKM) held Resident 14's clean blankets against her clothing during transport to Resident 14's room. These failures had the potential for cross contamination and spread of infections among residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care with dignity for one of three sampled residents (Resident 18) when two facility staff did not provide privacy for Resident 18 during nursing care. This deficient practice resulted in not ensuring resident 18's right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment and/or an evaluation for self-administration of medications was completed for one of 46 sampled residents (Resident 11) when the following were observed on Resident 11's bedside table: a. a bottle of Nystatin (antifungal antibiotic topical treatment) powder b. one cup filled with Pepto Bismol (oral medication used for heartburn, indigestion, diarrhea, and nausea) c. Sudafed (allergy) Nasal Spray This facility failure increased the potential for the unsafe self-administration of medications. It also had the potential to result in the use of the medications by other residents, who could come into the room and obtain the treatment from the bedside table where it was stored.

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS, a resident assessment used to guide resident's care, Quarterly MDS assessment is used to track a resident's status between comprehensive assessment to ensure resident's gradual change in status are monitored) assessment in a timely manner for one of two sampled residents (Resident 28) for over four months. This deficient practice resulted in Resident 28 not receiving the assessment and placed her at risk for not receiving appropriate care and services based on her health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's (Resident 14) Pre-admission Screening Resident Review (PASARR-Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for serious mental illness was accurately completed and sent to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 14 from receiving appropriate required mental health services.

Inspectors wroteBased on interview and record review, the facility failed to ensure/perform a Pre-admission Screening and Resident Review (PASARR-a screening tool to determine if individuals with serious mental illness or intellectual/developmental disability or related condition require nursing facility services or specialized services) for one (Resident 2) of four sampled residents. This failure had the potential to result in Resident 2 not being provided specialized care and services to address a mental illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an alternative for use of splint (a medical device used to support and immobilize a part of the body, to promote healing and reduce pain) for over a month, for one of 14 sampled residents (Resident 38) to manage left hand deformity, when Resident 38 refused to wear a splint. Resident 38 stated he had a history of plate implant surgery on his left hand. This failure resulted in Resident 38 to experience pain when he used his left hand to wheel the wheelchair and potential risk for skin breakdown of his left hand while pushing the wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure range of motion (ROM) exercises were provided for two of five sampled residents (Resident 6 and 18) reviewed for limited ROM. This failure had the potential to result in decline in the Resident 6 and Resident 18's ROM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on one of 14 sampled residents (Resident 249)'s request to change routine pain medication (Oxycodone) from every six hours to every four hours. This failure resulted in Resident 249 to experience unrelieved pain and made him feel frustrated and unhappy.

Inspectors wroteBased on interview and record review, the facility failed to plan and implement parameters for Glargine insulin (a type of insulin helps maintain blood glucose levels throughout the day and night) administration for one of six sampled residents (Resident 7) for over five months period. Resident 7 received insulin for certain blood glucose levels on some days and did not on other days. The failure placed Resident 7 at risk for not receiving insulin as needed and posed risk for hyperglycemia (high blood glucose) or hypoglycemia (a condition which blood glucose is too low).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents was free from significant medication errors when the facility incorrectly reconciled and transcribed the dosage of a prescribed anti-seizure (seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) medication to Resident 99. Licensed nursing staff then administered the incorrect dosage of the medication to Resident 99 for a period of 22 days. This failure resulted in Resident 99 experiencing multiple seizures, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for safety when a resident food refrigerator contained items that were not labeled and/or dated. This failure put 41 of 45 residents who can access the resident refrigerator at increased risk for food contamination and foodborne illness.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure infection control practices were implemented when staff did not wear a gown while handling residents' dirty laundry and soiled linens for 45 of 45 residents. This failure placed the facility's residents at risk for healthcare-associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming to one of 12 sampled residents (Resident 37), when they did not shave their facial hair. This failure had the potential to cause Resident 37 to feel undignified and upset. During a review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 9/5/23, the MDS indicated Resident 37 was admitted 8//23 and was a female. The MDS also indicated Resident 37 had a Brief Interview for Mental Status (BIMS - a tool used to assess mental function) score of 12, meaning moderately impaired. Additionally, the MDS indicated Resident 37 needed extensive assistance (resident involved in activity, staff provide weight-bearing support), from one person to shave and complete personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation when: 1. Dietary [NAME] (DC)1 did not perform hand hygiene while handling and preparing chicken puree. 2. Food preparation sink and ice machine did not have an air gap (a gap created to prevent back flow of contaminated water). These failures had the potential to cause food contamination and food born illnesses in residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' food brought from outside was labeled and stored appropriately in one of one residents' food refrigerator and freezer. This failure had the potential to cause food contamination and food borne illnesses in residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy in verifying the effectiveness of Spirit II disinfectant against the bacterial organism found in one (Resident 18) of 39 sampled residents . This failure had the potential to result in the spread of Enterobacter Cloacae(member of the normal gut flora) which could result in the infection of additional residents, possible facility outbreak, and the possibility of resident death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored properly, when the medication cart was found unattended in the main hallway with the drawers unlocked. This failure had the potential for unauthorized staff and residents to access medications and biologicals, which could lead to potential harm.