Berkeley Pines Skilled Nursing Center

Inspectors wroteBased on interview and record review the facility failed to have a registered nurse (RN) on duty for eight hours a day, seven days a week, when there was no RN coverage for 149 days from October 2022 through December 2023. This failure had the potential to place all 36 residents at risk during emergencies when RNs were not available to provide assessment and licensed nursing services.

Inspectors wroteBased on observation, staff interviews, and review of facility documents, the facility failed to: 1. Comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. 2. Ensure the Registered Dietitian (RD) provided sufficient consultation to the Food and Nutrition Services department. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility did not ensure proper kitchen staff competency for testing sanitizer strength, checking the dish machine temperature, and the use of the 2-compartment ware washing sink. The failure to ensure staff competency for kitchen tasks related to safety and sanitation in the kitchen placed 35 residents who received food from the kitchen at risk for illness from cross contamination of utensils, as well as food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. A Vegetarian menu was available for a Vegetarian resident; and 2. Residents received what was on the lunch menu including: a. Broccoli Salad b. Tropical Fruit Mold c. Oven Roasted Potatoes d. Green Beans with Red Peppers These failures had the potential to result in decreased nutrient intake resulting in weight loss and/or malnutrition for 35 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was palatable in regard to taste and temperature. This failure had the potential to result in decreased food consumption for 35 residents who received food from the kitchen.

Inspectors wroteBased on interview, record review and observation, the facility did not ensure that food was stored, prepared, and served in a safe and sanitary manner when the following was noted: 1. Time Temperature Control for Safety (TCS; food which requires time and temperature controls to limit the growth of illness causing bacteria) food temperatures were not measured after food was cooked. 2. The food thermometers were not sanitized. 3. The food thermometers were not calibrated. 4. Fish was not thawed safely. 5. The kitchen cabinets, shelving, drawers, and walls were not clean and had peeling paint. 6. The floor in the dry storage room was not clean. 7. The kitchen ceiling lights were not in clean condition. 8. Food preparation utensils and equipment were not cleaned and/or maintained in good condition. 9. A kitchen microwave was not maintained in clean condition. 10. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to safely store food brought in by family and visitors for residents. This failure had the potential to result in decreased intake of food as well as result in foodborne illness for 35 residents who ate food by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to store controlled medications (medications with a high potential for abuse and addiction) in a secure manner to limit potential for diversion, ensure two emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were replaced timely after being opened or contents used/expired, and medication cart controlled drug accountability sheets (a record used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were signed for the outgoing and incoming nursing shifts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for seven residents (Residents 7, 28, and 29). This failure resulted in medications not being given in accordance with the prescriber's orders and the manufacturer's specifications, with the potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and log medication refrigerator temperatures twice daily, to store food items separately from medications in the medication storage room refrigerator, to timely dispose of refused/unused medications, to remove an expired insulin (a medication for the regulation of blood sugar) pen from the medication cart, to ensure nursing staff locked medication carts when unattended, and to store discontinued controlled substances in a permanently affixed storage space. The deficient practices had the potential for unauthorized staff and residents to access medications, for residents to receive medications with unsafe and reduced potency, and for residents to suffer hazardous cross-contamination to their medications.

Inspectors wroteThe facility failed to prepare pureed food in a form appropriate for a pureed diet. This failure had the potential for four residents who received a pureed therapeutic diet to aspirate (to inhale food into the lungs resulting in choking and/or aspiration pneumonia) while their eating food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents (Residents 4, 6, 8, 12, 16, 19, 21, 25, 29, 30, 31, 34) received physician prescribed Fortified Diets. The failure to ensure 12 residents received Physician prescribed Fortified Diets placed them at potential risk for decreased caloric intake and possible malnutrition and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when ants were observed in the the residents ' dining/ activity room on 3/12/24 through 3/14/24. This failure had the potential to result in the transfer of bacteria and placed a risk for food-borne illness to the residents who used the dining/ activity room. During multiple observations on 3/12/24, and 3/13/24, in the resident dining/activity room, multiple ants were observed crawling on the walls and tables. During an interview on 3/13/24, at 10:28 a.m., with Administrator (ADM), ADM was notified there were ants in the resident dining/activity room. ADM stated pest control comes monthly. [...]

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure essential equipment was maintained when there were no stopper/plugs available for the two-compartment sink. This failure did not allow for one piece of equipment to used for dishwashing as intended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored under sanitary conditions when multiple undated and expired food items were stored in the freezer, refrigerator and the dry storage room. This deficient practice had the potential of putting residents at risk for food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to schedule a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. This failure had the potential to place residents at risk during emergencies.

Inspectors wroteBased on interview and record review, the facility failed to monitor the hours of sleep for one of one (Resident 30) sampled residents who used Trazadone (a medication used to treat depression and decrease anxiety and insomnia related to depression). This deficient practice had the potential to result in Resident 30 taking Trazadone unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner when thawing meat was not stored below and separately from other foods. This failure had the potential to result in foodborne illness.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the garbage storage area was maintained in a sanitary condition when one of two garbage dumpsters located outside the building did not have a closed lid and was overflowing with garbage bags. This failure had the potential to lure and harbor disease carrying pests to spread germs.

Inspectors wroteBased on observation, interview, and record review, for one of 12 (Resident 27) sampled residents, the facility failed to ensure accurate labeling of a medication when there was inaccurate labeling for Resident 12's Lantus (medication for high blood sugar). This failure had the potential for Resident 27 to receive the wrong medication dose.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 135) of 12 sampled residents, the facility failed to follow infection control practices to prevent spread of infection. Licensed Vocational Nurse (LVN 1) did not perform hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) in between multiple glove changes. For Resident 135, this deficient practice had the potential to result in infection.