Moraga Post Acute

In the surveyor’s words

From the most serious findings on record at Moraga Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 12, 2026

  Based 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).During a review of Resident 1's admission Record (AR), printed on 2/23/26, AR indicated Resident 1 was admitted to the facility on [DATE],… […]

• Actual harm, isolatedF689Feb 24, 2022

  Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at high risk for falls, was provided adequate supervision and assistance, while he was outside the facility alone attempted to control his wheelchair on an incline and open the door to enter the facility. This failure resulted in Resident 1's fall backwards in his wheelchair, and in immediate transfer to the hospital for a six-day hospitalization for fracture of C7 (a break in the bone in the neck [cervical] the cervical bone allows the neck to bend and twist, fractures at this level typically result from trauma such as falls and could lead to paralysis and even death). […]

• No harm, potential for more than minimal, widespreadF761Nov 3, 2023

  Based 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. Findings: 1. During an observation on [DATE] at 09:57 a.m. […]

• No harm, potential for more than minimal, widespreadF801Nov 3, 2023

  Based 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. Findings: During an interview on 10/30/23 9:35 a.m., with Dietary Supervisor (DS), DS stated he worked fulltime as the Dietary Supervisor. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2023

  Based 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. […]