Kyakameena Care Center
Inspection Findings
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
29's risk for wandering and elopement, repeated incidents of Resident 29's elopements with appropriate interventions with each incident of elopement.
During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001,
the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
During a review of facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Center, dated 2001, the P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident).
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kyakameena Care Center
2131 Carleton Street Berkeley, CA 94704
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Nursing (DON), Resident 29's admission MDS assessment dated [DATE REDACTED], EA s and progress notes were reviewed. DON stated Resident 29 had eloped on more than one occasion. DON stated she was not aware that Resident 29's risk for elopement was not addressed with care plan because DON was hired after Resident 29's admission to the facility. DON stated facility intervention included monitoring location and wander guard. DON stated Resident 29 continued to elope because Resident 29 removed his wander guard. DON stated Interdisciplinary team (IDT-an interdisciplinary team is a group of professionals from different fields who collaborate to address complex residents' need) had not met to review Resident 29's repeated episode of elopement. DON could not provide comprehensive care plan that addressed Resident 29's risk for wandering and elopement, repeated incidents of Resident 29's elopements with appropriate interventions with each incident of elopement.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrences Reporting, dated 2001, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
Event ID:
Facility ID:
If continuation sheet
KYAKAMEENA CARE CENTER in BERKELEY, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BERKELEY, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KYAKAMEENA CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.