Kyakameena Care Center: Elopement Plan Failures - CA
Federal inspectors cited the facility on November 21, 2025, after finding that Kyakameena failed to maintain an adequate, current care plan for Resident 29, a person identified as being at risk for wandering and elopement who had already eloped multiple times. The deficiency was tagged under care planning requirements and assessed as having the potential for actual harm.
The inspection report is spare on details about Resident 29 — age, diagnosis, how far they got, whether anyone was hurt. What it documents is a gap between what the facility knew and what it did about it on paper. Inspectors found the care plan failed to reflect the resident's known risk for wandering and elopement, the repeated incidents themselves, and the interventions the facility had applied after each one.
That last part is the sharpest edge of the finding. Staff did respond to the elopements. They put interventions in place. But those responses were never written into the care plan in a way that the full care team, the resident, or the resident's family could rely on going forward.
The facility's own policy on wandering and elopements, dated 2001, states that the facility will identify residents at risk of unsafe wandering and work to prevent harm while maintaining the least restrictive environment. A separate policy on care planning, also dated 2001, requires a comprehensive, person-centered care plan to be developed within seven days of a required assessment and updated to reflect significant changes in a resident's condition or status.
Multiple elopements from a single resident would qualify.
Both policies are more than two decades old. The inspection report does not say whether either has been revised since then.
What the report makes clear is that Resident 29's situation had evolved, repeatedly, and the care plan had not kept up. A care plan is not a formality. It is the document that tells every nurse, every aide, every therapist, and every visiting family member what this particular person needs and what the team has agreed to do. When a resident elopes once, that changes the picture. When they elope again, it changes it further. Each incident is information, and that information is supposed to live somewhere the whole team can see it.
Here, it didn't.
The deficiency was cited at a level of minimal harm or potential for actual harm, and the inspection report notes that some residents were affected. It does not describe what happened to Resident 29 during any of the elopements, whether the resident was found quickly or after a delay, whether there was any injury, or whether family members were notified and involved in care planning discussions as the facility's own policy requires.
Kyakameena Care Center is located at 2131 Carleton Street in Berkeley. The complaint inspection was completed November 21, 2025.
The facility's plan of correction was not included in the materials reviewed. For information on how the facility intends to address the deficiency, inspectors directed inquiries to the nursing home or the California state survey agency.
What the record shows is a resident who kept leaving, a staff that kept responding, and a care plan that never caught up to either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kyakameena Care Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 29, 2026 · Our methodology
KYAKAMEENA CARE CENTER in BERKELEY, CA was cited for violations during a health inspection on November 21, 2025.
The deficiency was tagged under care planning requirements and assessed as having the potential for actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.