St. John Kronstadt Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to: Ensure three of three sampled residents' (Residents 5, 6 and 9) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 5, 6 and 9 at risk of not having medication irregularities identified.1. During a review of Resident 5's admission Record printed on 11/20/25, admission Record indicated Resident 5 was admitted to the facility on [DATE]. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/19/25, indicated Resident 5 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) Score of 10/15. Meaning Resident 5's mental cognition was moderately impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 out t of 2 residents did not have prefilled medication cups with ointment left at the bedside, expired medications were not available for use, best by date was printed on a medication box, internal and external medications were separated when in the same drawer, compromised medication bubble packs were returned to the pharmacy, and glucose monitoring device was separated from internal medications. The deficient practice had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date or best by date and medications with different routes of administration were not separated in accordance with facility policy and procedure (P&P). 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when:1. (a) a stainless-steel pasta tong was dirty and was in poor condition. (b) two handheld can opener had rust and metal fragments on the blade and surrounding parts.2. water pitcher with thickened liquid was left at Resident 25's bedside for more than 24 hours. These failures had the potential to cause food contamination and food borne illness. 1. During the initial tour of the kitchen and concurrent interview on 11 at 9/18/25 at 9:44 a.m. with the Food and Nutrition Services Manager (FNSM), the following items were stored in the clean kitchenware storage drawer: (a) a stainless-steel tong had sticky white debris and rubber tip that holds food was ripped in half; (b) two handheld can openers with red-orange debris and metal fragments on its blades. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 7) had a completed Pre-admission Screening and Resident Review (PASRR, a federal requirement to screen individuals for mental illness, intellectual disability, or related conditions to determine if the resident required specialized services) assessment when resident was newly diagnosed with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). This failure resulted in the facility to not notify the State Mental Health Authority and caused Resident 7 to not receive an in-depth mental health evaluation and care appropriate to his needs. A review of Resident 7's admission Record, printed on 11/24/25, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), schizophrenia, and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of two sampled residents (Resident 25) with right hand contracture and use of palm protector. This failure resulted in the lack of information regarding care and had potential to result in unmet care needs for Resident 25. A review of Resident 25's admission Record indicated resident was admitted to the facility in 2020 with diagnoses of dementia (memory loss) and dysthymic disorder (chronic depression). A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 was rarely/never able to make self-understood, rarely/never had the ability to understand others, and had severely impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified that one of four sampled residents (Resident 1) had been refusing his medications for two weeks. The failure to notify the physician had the potential to delay effective treatment for the resident, allow the physician to prescribe alternative pain management and adjust the plan of care. During an observation on 11/20/25 at 9:00 a.m., Resident 1 was awake, alert, oriented and sitting on the side of his bed. RN 1 asked Resident 1 if he wanted the 4% Lidocaine patch, (a type of topical anesthetic used for temporary pain relief by numbing the area where they are applied). The resident stated the Lidocaine patch was being refused. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 27, 39, 5 and 9), received care when following was noted:1. Resident 27 had overgrown and dirty fingernails in both hands.2. Resident 39 had overgrown and dirty fingernails in both hands.3. Resident 5 had long and dirty fingernails in both hands.4. Resident 9 had long and overgrown dirty fingernails in both hands. 1. During a review of Resident 27's face sheet, undated, indicated Resident 27 was admitted to the facility on [DATE] with multiple diagnoses that included, Parkinson's disease (progressive brain disorder that affects movement and balance) and Type 2 Diabetes Mellitus (DM -when body does not use insulin properly, which can weaken immune system placing a person at high risk for respiratory infections like pneumonia). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the census and direct care service hours per patient day (DHPPD) posting was complete and was not missing information. This failure resulted in the actual direct care service hours and DHPPD not readily available to residents and visitors at any given time. During an interview and observation with the Director of Nursing (DON) on 11/21/25 at 12 noon of the posted DHPPD. The DON stated the DHPPD forms are posted daily outside of nursing station 1. The information is posted by the night shift nurse in charge and updated by the dayshift DON or charge nurse. It was noted the 11/21/25 actual direct care service hours and DHPPD were not completed. [...]

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 25 and Resident 11), Certified Nursing Assistant 1 (CNA 1) failed to implement infection prevention and control practice when CNA 1 did not perform hand hygiene in between feeding residents in the Community Room (back dining room). This deficient practice had the potential to result in the spread of infection. A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 was admitted to the facility in 2020 with diagnoses that included dementia (memory loss) and had severely impaired cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal immunization for one of five sampled residents, when Resident 27 was not offered the pneumococcal immunization. This failure had the potential to not protect Resident 27 against serious illnesses like pneumonia (lung infection). During a review of Resident 27's face sheet, printed on 11/18/25, revealed Resident 27 was admitted to the facility on [DATE] with multiple diagnoses that included, Parkinson's disease (progressive brain disorder that affects movement and balance) and Type 2 Diabetes Mellitus (DM -when body does not use insulin properly, which can weaken immune system placing a person at high risk for respiratory infections like pneumonia). During a concurrent interview and record review on 11/18/25 at 2:10 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet for each resident for one of 23 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. During a concurrent observation and interview on 11/18/25 at 10:33 a.m. Certified Nursing Assistant (CNA) 3 and CNA 1 was seen transferring Resident 39 from bed to wheelchair using a Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place). CNA 3 stated, there was plenty of space in Resident 16's room even when using Hoyer lift for transfer. There was no negative outcome in the delivery of nursing care and services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 1's alleged abuse incident was reported within the prescribed timeframes. This failure placed the Resident 1 at risk for further possible abuse incidents, mental anguish or emotional distress. This failure also resulted in the delay in the abuse investigation.

Inspectors wroteBased on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide gender specific bathrooms to five of five sampled residents (Residents 1, 30, 32, 33 and 41). A female resident (Resident 32) shared a [NAME] and [NAME] bathroom (a bathroom that has two doors and is accessible from two bedrooms) with two male residents (Resident 30 and Resident 33) in the adjacent room. A female resident (Resident 1) shared [NAME] and [NAME] bathroom set up with a male resident (Resident 41). This failure placed Residents 1, 30, 32, 33 and 41 at risk for humiliation and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 16, Resident 23, and Resident 11) received proper grooming including nailcare when: 1) Resident 16 had long sharp fingernails. 2) Resident 23 had long sharp fingernails. 3) Resident 16 had long, thick fingernails. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromise physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. The medication refrigerator temperature was below recommended temperature range for storage of refrigerated medications. 2. The medication refrigerator temperature was not consistently monitored and recorded twice daily for seven out of seven months, from [DATE] to [DATE]. 3. The temperature log had an incorrect temperature range for monitoring. 4. Nursing staff failed to notify the Maintenance Supervisor (MS) when the medication refrigerator temperature was out of range. 5. Six (6) bottles of eyedrops and one (1) insulin pen were not correctly labeled. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective medication administration and accurate accountability of a controlled substance (medications that can be easily abused and are under strict government control) when: 1. Nursing staff did not correctly prime the pen needle during the administration of insulin (medication to lower blood sugar) for one of two sampled residents (Resident 27) receiving an insulin injection. This had the potential to result in Resident 27 to not receive a full dose of insulin. 2. One of 31 sampled residents (Resident 19) received calcium and iron at the same time. This had the potential for an interaction leading to the decreased absorption of iron, and the resident not receiving the full therapeutic effect of the medication. 3. [...]

Inspectors wroteBased on observation and interview, the facility had one resident room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied the room. This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents.

Inspectors wroteBased on observation, staff interviews, and review of facility documents, the facility failed to 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 dietetic supervisor when the dietitian was not full time. The lack of a full-time, competent supervisor resulted in Food and Nutrition Services staff not having adequate training and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Cake was not served to 10 of 10 Controlled Carbohydrate diets (CCHO; a diet to control the amount of carbohydrate or sugar a person receives at each meal); 2. A smaller portion of vegetables and potatoes than what was indicated on the menu were served to 9 of 9 residents on regular portion/regular textured diets; 3. A smaller portion of meat, a larger portion of vegetable, and a larger portion of cake than what was indicated on the menu were served to 7 of 7 residents on regular pureed diets; 4. A larger portion of meat and a larger portion of potatoes than what was indicated on the menu and traycard was served to Random Resident 1 (RR1) 5. A smaller portion of meat than what was indicated on the menu and traycard was served to Resident 6. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to serve food that was palatable when the food was bland (lacking flavor) and the food was not maintained at a warm temperature. This failure had the potential for 34 residents to consume less food resulting in the consumption of fewer calories and nutrients provided by the planned menu, out of a facility census of 34.

Inspectors wroteBased on observation, interview, and document review, the facility failed to store, prepare, and distribute in a safe and sanitary manner when: 1. Perishable and time/temperature control for safety (TCS) food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism [an organism which can cause disease] growth or toxin [a naturally occurring organic poison] was not stored at a safe temperature (Cross-reference F801); 2. Sanitizer strength for a low temperature dish machine was not monitored and the dish machine water temperature was below the recommended temperature (Cross-reference F801); 3. Surface sanitizer was not used on appropriately for kitchen and equipment surfaces, such as countertops and food processors, to ensure surfaces sanitized (Cross-reference F801); 4. The ice machine was not clean; 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices, when following was noted: 1. Oxygen (O2) tubing for Resident 20 was unlabeled/ undated and was touching the floor. 2. Resident 24's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing was left uncovered on the nightstand. The tubing was not labeled and or dated with yellowish tinged discoloration. 3. Facility did not create and maintain an active water management plan. The above failures placed Residents 20 and 24 at risk for respiratory and skin infections, not having a water management plan placed all 34 residents at risk for gastrointestinal infection (gut inflammation caused by consuming contaminated water or food, characterized with stomach pain, nausea, vomiting, diarrhea, fever etc.) Findings. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a qualified and certified Infection Preventionist (IP) (a professionally trained individual responsible for facility's Infection Prevention and Control Program) staff for over two years. This failure resulted in facility not having a qualified staff responsible for assessing, developing, implementing, monitoring, and managing facility's Infection Prevention and Control Program and placed 34 residents at risk for infections. Findings A review of the Resident Census dated February 13, 2023, showed the facility had a total number of 34 residents in the facility. During an interview and record review on 02/14/23, at 10:43 a.m., DON's training certificate titled Module 1- Infection Prevention and Control Program dated 5/8/20 was reviewed. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the 2-compartment sink for manual warewashing when there were no stoppers available to allow the sinks to be filled. This failure did not allow the kitchen staff to follow the appropriate procedures for cleaning equipment and utensils used for food preparation when the dish machine was not working which led to the potential for food borne illness for 34 residents who received food from the kitchen out of a facility census of 34.

Inspectors wroteBased on observation, and interview the facility failed to maintain working clocks for 10 of 10 sampled residents (Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36) in their rooms. This failure placed Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36 at risk for confusion and disorientation. Findings. During an observation and interview on 02/14/23, at 10:24 a.m., with Licensed Vocational Nurse (LVN 3), the wall clock in shared room for Resident 23 and Resident 26, indicated the time was 6:20. During an observation and interview on 2/14/23, at 10:29 a.m., in Resident 12 and 22's shared room, LVN 3 stated, the wall clock indicated time was 2:48. During an observation and interview on 2/14/23, at 10:31 a.m., with LVN 3, wall clock in Resident 36's room showed time was 11:45; and the wall clock in Resident 2 and 16's room indicated time was 11:30. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an easily accessible bathroom to three of three sampled residents (Resident 5, 32 and 29). Resident 5 and 32 shared a bathroom with two female residents, that they could not use. Resident 29 did not have a bathroom in the room. This failure resulted in Resident 5, Resident 32 and Resident 29 to not have a homelike environment, having to wait for extended periods of time to use the bathroom, and an increased number of incontinent (unable to voluntarily control their bladder and/or bowels) episodes.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for four of five CNA's (Certified Nurse Assistant) at least once every 12 months. This failure had the potential to result in inadequate care and services provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications below five percent (5%) error rate when: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine( drug used for relief of nasal and non-nasal symptoms of seasonal allergies) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan 0.1% and Dorzolamide-timolol 2-0.5%, to Resident 34. 3. LVN 3 documented she gave Metformin (a medication used for diabetes) 500 mg to Resident 8B, but did not give the medication as prescribed. These significant medication errors resulted in Residents 29, 34 and 8B receiving medications that were not prescribed by their physicians.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per physician order or manufacturer's specifications to three of seven sampled residents when the following was noted: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine (drug used for relief of nasal and non-nasal symptoms of seasonal allergies. ) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan (eye drops for glaucoma) 0.1% and Dorzolamide-timolol(eye drops for glaucoma and intraocular/eye pressure) 2-0.5%, to Resident 34. 3. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure a cook was competent in the task of following a recipe to puree food. The failure had the potential to affect the nutrient content and or palatability of the food and result in decreased nutrient intake by nine residents on a physician prescribed pureed diet out of a facility census of 35.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure pureed food was prepared in a consistency to meet resident needs. This failure placed eight (8) residents who received a pureed diet at risk for choking and/or aspirating (inhaling food into the lungs) out of a facility census of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of at least 80 square feet per resident for one of 23 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents.