Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkeley Pines Skilled Nursing Center during CMS and state inspections, most recent first.
The facility did not participate in or document a full-scale community-based emergency preparedness exercise as required, and failed to provide records or after action reports for the only exercise certificate presented, affecting all residents.
Surveyors found that the facility did not perform the required four-hour load test on its emergency generator, as only two-hour load tests were documented. This deficiency affected all residents and both smoke compartments, as the facility could not demonstrate compliance with NFPA standards for emergency power system testing.
An exit sign with a battery backup near the kitchen corridor failed to illuminate when tested, as observed during a facility tour and confirmed by the Environmental Supervisor. This deficiency affected 15 residents and one smoke compartment, indicating the exit sign was not maintained in accordance with NFPA 101 requirements.
The facility failed to have an RN on duty for eight hours a day, seven days a week, resulting in no RN coverage for 149 days from October 2022 through December 2023. Interviews and record reviews confirmed the absence of RN coverage on weekends, and the facility lacked policies and job descriptions for RN and LVN duties.
The facility failed to employ a full-time dietitian or a qualified dietetic supervisor, resulting in inadequate supervision and training of food and nutrition staff. The Registered Dietitian did not provide sufficient consultation, leading to multiple issues in kitchen operations, including staff competency, menu adherence, and food safety.
The facility failed to ensure proper kitchen staff competency for testing sanitizer strength, checking dish machine temperature, and using the 2-compartment ware washing sink. Incorrect procedures and lack of adherence to policies placed residents at risk for illness due to potential cross-contamination and improper sanitation practices.
The facility failed to provide a vegetarian menu for a resident with a prescribed vegetarian diet and did not follow the lunch menu as planned for other residents. Items such as broccoli salad, tropical fruit mold, oven-roasted potatoes, and green beans with red peppers were either not prepared or not served as specified, leading to potential decreased nutrient intake for the residents.
The facility failed to ensure food was palatable and at a safe temperature, leading to potential decreased food consumption for 35 residents. Observations revealed that food temperatures were not consistently measured, and sampled food was below required temperatures. The Registered Dietitian admitted to not regularly monitoring food temperatures.
The facility failed to ensure food safety and sanitation, with issues including improper temperature control, unsanitized and uncalibrated thermometers, unsafe thawing of fish, and unclean kitchen surfaces and equipment. These deficiencies placed residents at potential risk for foodborne illnesses.
The facility failed to safely store food brought in by family and visitors for residents, leading to potential foodborne illness and decreased food intake. Observations revealed improperly labeled and stored food in the kitchen and staff refrigerator, with staff showing inconsistencies in handling and storage practices.
The facility failed to securely store controlled medications, ensure proper documentation during shift changes, and maintain a secure chain of custody for discontinued medications. An unlocked medication refrigerator and IV e-kit, missing signatures on controlled drug sign-in/sign-out sheets, and discrepancies between the MAR and CDR for a resident prescribed lorazepam were observed.
The facility had a 10.34% medication error rate during a medication pass, including errors in administering insulin, lactulose, and acetaminophen. The LVN failed to mix insulin properly, did not ensure a full dose of lactulose was given, and administered an incorrect dosage of acetaminophen.
The facility failed to monitor and log medication refrigerator temperatures, store food separately from medications, timely dispose of unused medications, remove expired insulin, lock medication carts when unattended, and store discontinued controlled substances in a permanently affixed storage space. These deficiencies were identified through observations, interviews, and record reviews.
The facility failed to prepare pureed food in a form appropriate for a pureed diet, risking aspiration in four residents. Pureed diets were placed on divided plates without indication, and the texture of the pureed green beans was thin and runny. Staff confirmed that pureed food should be firm, hold its shape, and be served on regular plates unless otherwise ordered.
The facility failed to ensure that 12 residents received physician-prescribed fortified diets, which are designed to increase calorie density for residents who cannot consume adequate amounts of calories and/or protein. During an observation, it was noted that the dietary aide did not communicate the need for fortified diets to the cook, resulting in these residents not receiving the additional calories required.
The facility failed to maintain an effective pest control program when ants were observed in the residents' dining/activity room over several days. Staff confirmed the presence of ants, which posed a risk to residents by potentially contaminating their food and causing negative feelings. The facility's pest control policy was not effectively implemented.
The facility failed to maintain essential equipment by not having stopper/plugs available for the two-compartment sink, which prevented its use for dishwashing when the dish machine was out of order. A cook confirmed the absence of stoppers, which are required by the facility's manual dishwashing procedures.
Failure to Conduct and Document Required Emergency Preparedness Exercise
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency exercise within the last 12 months. During the annual Life Safety Code recertification survey, the surveyors requested documentation of such participation, but the facility was unable to provide any records indicating compliance with this requirement. The only documentation provided by the facility was a certificate for participation in the 2024 Great California ShakeOut. However, the facility did not supply an after action report or any record of staff participation related to this exercise. This lack of documentation meant that the surveyors could not verify whether the exercise met the regulatory requirements for a full-scale community-based emergency preparedness drill. During an interview, the Administrator acknowledged that the exercise was overlooked. As a result, the facility was found to be out of compliance with the emergency preparedness testing requirements, which affected all 35 residents in the facility at the time of the survey. No specific details about individual residents' medical histories or conditions were provided in relation to this deficiency.
Plan Of Correction
E 039 E 039 E 039 --- 1. Corrective Action: An after action participation report that will show actual involvement and activity in the community based exercise of the staff will be created on future community based exercise. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Emergency Preparedness Communication plans will be reviewed and updated annually. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of correction: 06/13/2025
Failure to Conduct Required Four-Hour Generator Load Test
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 110 requirements for emergency power systems by not conducting the required four-hour load test on its 15-kilowatt propane generator. During a facility tour, surveyors requested and reviewed generator testing records and found that there was no documentation of a four-hour load test, as required to be performed at least once every 36 months. Instead, only records of two-hour load tests were available for review. The Environmental Supervisor confirmed during an interview that the vendor had only conducted two-hour load tests for the generator. This deficiency affected all 35 residents in the facility and both smoke compartments, as the generator is responsible for supplying essential electrical service in the event of a power outage. The lack of a four-hour load test could result in the malfunction of the emergency generator, as the facility could not demonstrate that the generator would operate under load for the required duration. No specific medical history or condition of the residents was mentioned in the report.
Plan Of Correction
Corrective Action: The facility conducted the 4-hour load test for the 15-kilowatt propane generator on 06/12/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: The four-hour load test for the 15-kilowatt propane generator will be done every 3 years by the facility. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/12/2025
Exit Sign with Battery Backup Failed to Illuminate During Test
Penalty
Summary
During a facility tour and interview with the Environmental Supervisor, it was observed that an exit sign with a battery backup located in the corridor near the exit to the Back Walkway by the kitchen failed to illuminate when tested. The deficiency was identified on 6/10/25 at 8:46 a.m. when the exit sign did not function as required during a test. The Environmental Supervisor confirmed that the exit sign had been tested the week prior to the survey. This failure affected 15 of 35 residents and one of two smoke compartments. The report cites that exit and directional signs must be displayed and continuously illuminated in accordance with NFPA 101, Life Safety Code, 2012 Edition, and that battery-powered exit signs must be tested and maintained as specified. The facility did not maintain the exit sign in accordance with these requirements, as evidenced by the failed test and the lack of continuous illumination.
Plan Of Correction
1. Corrective Action: The battery powered exit sign located in the corridor near the exit to the Back Walkway near the kitchen is now illuminating when tested. A new battery was installed on 06/11/2025. II. How the facility will identify other residents: All residents have the potential to be affected by this practice. III. Systemic Change: Battery powered exit signs will be checked monthly by the Maintenance Supervisor. IV. Monitoring Process: The facility will monitor its performance through our QAPI process. V. Date of Correction: 06/11/2025
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for eight hours a day, seven days a week, resulting in no RN coverage for 149 days from October 2022 through December 2023. This deficiency was identified through interviews and record reviews, revealing that there were no RNs on duty on weekends. The absence of RN coverage was confirmed by the licensed vocational nurse (LVN), the Administrator (ADM), and the Director of Nursing (DON), who all acknowledged the importance of having an RN for initial and emergency resident assessments and to oversee staff. The facility's Payroll Based Journal (PBJ) Staffing Data Reports corroborated the lack of RN coverage on numerous specific dates across the reviewed periods. During interviews, the ADM and DON admitted that the facility did not have a policy and procedure for RN coverage, nor did they have job duty descriptions for LVNs or RNs. The ADM was unable to refute the PBJ Staffing Data Reports that indicated the absence of RN coverage on the specified dates. This failure had the potential to place all 36 residents at risk during emergencies when RNs were not available to provide necessary assessments and licensed nursing services.
Failure to Employ Full-Time Dietitian and Provide Adequate Consultation
Penalty
Summary
The facility failed to comply with Federal regulations related to the oversight of food service operations by not employing a full-time dietitian or a qualified dietetic supervisor. The lack of a full-time supervisor resulted in inadequate supervision, training, and knowledge among the food and nutrition staff, which compromised the safety and sanitation of food services. Observations and interviews revealed that the kitchen had been without a full-time supervisor since August 31, and the current supervisor only visited the facility part-time, which was insufficient to manage the workload and ensure compliance with standards. Additionally, the Registered Dietitian (RD) did not provide sufficient consultation to the Food and Nutrition Services department. The RD's contract stipulated that she should conduct monthly food safety and sanitation audits and provide in-service education programs for food service personnel. However, the RD only completed two sanitation checklists in the past year and did not conduct any in-service training for the kitchen staff. The RD's reports mainly focused on labeling and dating food items, and there was a lack of detailed feedback on other critical areas of kitchen operations. During the re-certification survey, multiple issues were identified, including staff competency, failure to follow the planned menu, unpalatable food, inappropriate texture of pureed food, and non-compliance with physician's diet orders. The RD's limited presence and insufficient consultation contributed to these deficiencies, as the kitchen staff did not receive adequate guidance and oversight. The facility's administrator acknowledged the need for a full-time kitchen supervisor but had not yet taken steps to address the issue, citing budget constraints.
Deficiency in Kitchen Staff Competency and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper kitchen staff competency for testing sanitizer strength, checking the dish machine temperature, and using the 2-compartment ware washing sink. During an observation and interview, Cook 1 demonstrated incorrect procedures for testing the strength of the quaternary ammonia sanitizer solution. Cook 1 misinterpreted the color chart for the sanitizer test strip, leading to incorrect conclusions about the sanitizer's strength. Additionally, Diet Aide 1 did not follow appropriate procedures for filling the sanitizer bucket and testing its strength, resulting in a solution with no detectable sanitizer strength. The manufacturer's instructions and facility policies were not adhered to, indicating a lack of proper training and competency among the kitchen staff. Further observations revealed that Diet Aide 1 did not correctly determine the dish machine's operating temperature or log the dish machine's sanitizer strength and temperature. DA1 was unaware of the correct temperature requirements and did not use the dial on the dish machine to check the temperature. The logbook for documenting the dish machine's values was found to be incomplete, showing a lack of adherence to the facility's policies and procedures. The facility's policy required the FNS Director to instruct employees on the fundamentals of sanitation and the correct use of equipment, which was evidently not followed. Additionally, Cook 1 demonstrated a lack of knowledge regarding the proper use of the 2-compartment sink for manual dishwashing. Cook 1 was unaware of the required immersion time for items in the sanitizer solution, and the posted guidelines did not provide this information. The facility's policy for manual dishwashing procedures was incomplete, missing critical information about the immersion time. This deficiency in staff training and competency placed residents at risk for illness due to potential cross-contamination and improper sanitation practices in the kitchen.
Failure to Provide Appropriate Vegetarian Menu and Follow Lunch Menu
Penalty
Summary
The facility failed to ensure that a vegetarian menu was available for a resident with a prescribed vegetarian diet. Despite the resident's diet order being clearly documented in her records, including her physician's orders and nutrition care plan, the facility did not provide appropriate vegetarian meals. The resident frequently received meals she did not like, such as refried beans, mashed potatoes, and grilled cheese sandwiches, leading her to rely on food she ordered herself or kept at her bedside. The Registered Dietitian (RD) and Food and Nutrition Services Director (FNSD) were unaware of the resident's dietary needs and preferences, and no vegetarian menu was available at the facility. Additionally, the facility did not follow the lunch menu as planned for other residents. The menu included items such as broccoli salad, tropical fruit mold, oven-roasted potatoes, and green beans with red peppers, but these items were either not prepared or not served as specified. For example, broccoli salad was not made, and no substitute was provided. Tropical fruit mold was not prepared, and canned fruit was served instead. Oven-roasted potatoes were not available for residents on pureed, mechanical soft, or regular vegetarian diets, who received instant mashed potatoes instead. Green beans were served without the red peppers as specified in the recipe. The deficiencies in meal preparation and service were confirmed through observations, interviews, and record reviews. The FNSD acknowledged the issues, stating that the necessary ingredients were available but not used, and that inventory and ordering processes were not properly managed. The RD confirmed that the menu was not followed according to the dietary requirements and recipes. These failures had the potential to result in decreased nutrient intake and negatively impact the health of the residents.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure food was palatable in regard to taste and temperature, which had the potential to result in decreased food consumption for 35 residents. Resident 5 reported that breakfasts especially come cold, and Resident 10 stated that all the food was bland. During an observation of trayline food service, Cook 1 admitted to not consistently measuring the temperature of the food. The temperature of three random pieces of chicken on trayline were measured and found to be below the required temperature, with readings of 100.2°F, 127°F, and 129.4°F. A test-tray sampled in the presence of the Food and Nutrition Services Director (FNSD) showed pureed food temperatures were also below the required levels, with pureed chicken at 108°F, mashed potatoes at 111.6°F, and pureed green beans at 107.8°F. The FNSD acknowledged that the food temperatures were too low and that the green beans needed seasoning. Registered Dietitian 1 (RD1) admitted to not tasting the food often due to being on a strict diet and last monitored food temperatures on trayline in July 2023. RD1 also stated she did not measure food temperatures at the point of service to residents and never conducted test trays. The facility's policy and procedure titled Meal Service indicated that food temperatures should be taken prior to service and recorded, with hot food serving temperatures required to be at or above 140°F. However, the observed practices did not align with these guidelines, leading to the deficiency in food palatability and temperature.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner. Specifically, Time Temperature Control for Safety (TCS) food temperatures were not measured after cooking, and food thermometers were neither sanitized nor calibrated. Additionally, fish was not thawed safely, and various kitchen surfaces, including cabinets, shelving, drawers, and walls, were not clean and had peeling paint. The floor in the dry storage room and the kitchen ceiling lights were also not clean. Food preparation utensils and equipment, including a microwave, wooden countertop, industrial can opener, cutting boards, coolers, food scale, toaster, and a knife handle, were not maintained in clean or good condition. Dessert bowls and sheet pans were stacked wet, and proper hand hygiene procedures were not followed. The sanitizer strength for cleaning surfaces and items in the 2-compartment sink was low, and containers of breadcrumbs and food thickener did not have appropriate tight-fitting lids. Cooler temperatures storing food were not monitored, and expired pureed food was stored in a freezer and available for use. During an interview and observation, it was noted that Cook 1 did not take the temperature of the food when setting up for lunch trayline foodservice. The temperatures of different pieces of chicken on the tray line were measured and found to be below the required temperature. The Food and Nutrition Services Director (FNSD) confirmed that tray line food should be held at or above 145 degrees Fahrenheit, and Registered Dietitian 1 (RD 1) stated that chicken on the tray line should be at least 165 degrees Fahrenheit. The facility's policy and procedure indicated that food temperatures should be taken prior to service, and poultry should be cooked to 165 degrees Fahrenheit or above. Further observations revealed that food thermometers were not sanitized, and Cook 1 was unaware of the last time they were sanitized. The facility's policy indicated that thermometers should be cleaned and sanitized after use. Additionally, thermometers were not calibrated correctly, and Cook 1 and Cook 2 did not know how to calibrate them to 32 degrees Fahrenheit. The facility's policy stated that thermometers should be calibrated each week. Raw fish was observed in standing water, and Cook 1 was unaware that water had to be running over thawing meat. The facility's policy indicated that meat should be thawed under running, potable water at a temperature of 70 degrees Fahrenheit or lower. The kitchen shelving, cabinets, and other surfaces were found to be dirty and in poor condition, with peeling paint and residue build-up. The facility's policy required that all equipment and surfaces be kept clean and in good repair.
Failure to Safely Store Food Brought in by Family and Visitors
Penalty
Summary
The facility failed to safely store food brought in by family and visitors for residents, which had the potential to result in decreased intake of food and foodborne illness for 35 residents who ate food by mouth. The facility's policy and procedure on foods brought by family/visitors required perishable foods to be stored in re-sealable containers with tight-fitting lids in the refrigerator, labeled with the resident's name, the item, and the use-by date. However, the policy did not provide guidance regarding timeframes for use-by dates. During an observation, a paper bag with Resident 16's name and room number was found in the reach-in refrigerator in the kitchen, containing a cooked rice mixture and soup. Cook 1 was unaware of when the food was placed in the refrigerator. Additionally, food belonging to Resident 14 was found in the staff refrigerator without proper labeling or a use-by date, and the Director of Nursing confirmed that resident food should not be stored in the refrigerator downstairs or in the kitchen. Interviews with staff revealed inconsistencies in the handling and storage of food brought in by families. LVN 1 stated that she asked families to take food home if the resident did not want to eat it right away and did not store food brought in by families. CNA1 mentioned that she stored food in the refrigerator downstairs and believed it could be stored for up to two days. The Director of Nursing stated that perishable food brought in by family and visitors for residents was not stored, and anything that needed to be reheated or chilled was not safe to store. Resident 14 confirmed that his spaghetti with meat sauce had been placed in the refrigerator by a staff member a few days ago. These actions and inactions led to the deficiency in safely storing food brought in by family and visitors for residents.
Failure to Secure and Document Controlled Medications
Penalty
Summary
The facility failed to store controlled medications securely, as evidenced by an unlocked padlock on the medication refrigerator containing a vial of injectable lorazepam. Additionally, an unlocked IV e-kit was found with missing saline solution bags, and an expired SPS e-kit was not replaced timely. The Director of Nursing (DON) acknowledged that all licensed nurses had access to the refrigerator padlock key, which should have been locked at all times. The facility's Policy and Procedure (P&P) indicated that Schedule II medications, including those requiring refrigeration, should be stored separately under locked compartments, which was not adhered to in this case. The facility also failed to ensure proper documentation and accountability for controlled medications during shift changes. A review of the controlled drug sign-in/sign-out sheets revealed 82 missing signatures between nursing shift changes, indicating that the required controlled medication reconciliation count was not consistently performed. The DON confirmed the missing signatures and acknowledged that nursing staff were expected to complete the reconciliation count and sign the sheets accordingly. This lack of documentation compromised the accountability of controlled medications. Furthermore, the facility did not have a secure chain of custody for discontinued controlled medications. The DON stored discontinued controlled medications in a rolling cabinet in her office without any witnesses to confirm the removal from the medication cart and placement into the cabinet. This process lacked accountability and documentation, increasing the potential for diversion. Additionally, discrepancies were found between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for a resident prescribed lorazepam, with missing documentation of administered doses. The DON confirmed these discrepancies and stated that nursing staff were expected to document the removal and administration of controlled medications immediately, which was not done in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 10.34% medication error rate when three medication errors out of 29 opportunities were observed during a medication pass for seven residents. One error involved a Licensed Vocational Nurse (LVN) preparing Humulin N insulin for a resident without mixing or rolling the vial first, contrary to the physician's order and manufacturer's specifications. The LVN admitted that intermediate-acting insulin should be shaken prior to administration, and the facility's policy indicated that medications should be administered in accordance with the manufacturer's specifications and good nursing principles. Another error was observed when the same LVN prepared lactulose for a resident but did not ensure the resident received the full dose due to the thick liquid medication coating the measuring cup. The facility's policy stated that suspensions and thick liquids should be rinsed with water to ensure the entire dose is given. Additionally, the LVN administered only one tablet of acetaminophen to a resident instead of the prescribed two tablets. The LVN could not recall the correct dosage during the observed medication pass and confirmed the error upon reviewing the medication administration record and physician's orders.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to monitor and log medication refrigerator temperatures twice daily, store food items separately from medications in the medication storage room refrigerator, timely dispose of refused/unused medications, remove an expired insulin pen from the medication cart, ensure nursing staff locked medication carts when unattended, and store discontinued controlled substances in a permanently affixed storage space. During an observation and interview with the Director of Nursing (DON), it was found that the medication refrigerator temperature logs were incomplete on seven occasions, and a can of soda was stored alongside patient medications in the medication room refrigerator. Additionally, a small paper medication cup with approximately seven tablets/capsules was found in the medication cart, which the DON confirmed were refused medications that should have been destroyed. An expired insulin pen was also found in the medication cart, which the DON acknowledged should have been removed. Furthermore, during two separate observations, a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended, allowing residents and unlicensed staff access to the medications. The DON also confirmed that discontinued controlled medications were stored in a locked rolling metal cabinet rather than a permanently affixed storage space, as required by regulations. These deficiencies were observed through a combination of direct observation, interviews, and record reviews, highlighting lapses in the facility's adherence to its policies and procedures regarding medication storage and security.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare pureed food in a form appropriate for a pureed diet, which had the potential to cause aspiration in four residents who received a pureed therapeutic diet. During an observation of trayline food service, it was noted that Cook 2 placed all pureed diets on divided plates, despite the tray tickets not indicating a need for such plates. A test-tray sampled in the presence of the Food and Nutrition Services Director revealed that the texture of the pureed green beans was very thin and runny. Interviews with RD1 and Cook 1 confirmed that pureed food should be firm, hold its shape, and be served on regular plates unless a physician's order specifies otherwise. The facility's Diet Manual for Long Term Care Facilities also indicated that pureed food should be of a smooth and moist consistency and able to hold its shape.
Failure to Administer Physician-Prescribed Fortified Diets
Penalty
Summary
The facility failed to ensure that 12 residents received physician-prescribed fortified diets, which are designed to increase calorie density for residents who cannot consume adequate amounts of calories and/or protein. During an observation of the lunch tray line food service, it was noted that the dietary aide did not communicate the need for fortified diets to the cook, resulting in these residents not receiving the additional calories required. Specifically, the fortified diets usually include extra gravy and/or butter, but on the observed day, all residents received the same amount of gravy as part of the menu, without the additional fortification for those prescribed such diets. Interviews with the cook and the Food and Nutrition Services Director confirmed that the fortified diets were not properly administered. The cook acknowledged that fortified diets should receive extra gravy or butter, but this was not done because gravy was already part of the menu for all residents. The facility's policy on fortified diets, which aims to increase calorie intake for residents at risk of malnutrition or weight loss, was not followed. This oversight placed the affected residents at potential risk for decreased caloric intake and possible malnutrition and/or weight loss.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program when ants were observed in the residents' dining/activity room over a period of three days. Multiple ants were seen crawling on the walls and tables during observations on 3/12/24 and 3/13/24. The Administrator acknowledged the issue and mentioned that pest control services the facility monthly. However, the Environmental Supervisor and other staff members were not previously aware of the ant problem and confirmed the presence of ants during interviews and observations on 3/14/24. The Environmental Supervisor stated that pest control should be called immediately for urgent needs, and the ants were considered an urgent situation. The Licensed Vocational Nurse also confirmed the presence of ants and noted that it posed a risk to residents by potentially causing negative feelings and contaminating their food. The facility's undated policy and procedure titled 'Pest Control' indicated that the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents. Despite this policy, the presence of ants in the dining/activity room was not addressed promptly, leading to a potential risk for food-borne illness and negative resident experiences. The Director of Nursing acknowledged that ants were a nuisance and not acceptable in the facility.
Failure to Maintain Essential Equipment
Penalty
Summary
The facility failed to ensure essential equipment was maintained when there were no stopper/plugs available for the two-compartment sink. During an interview and observation, a cook described how the two-compartment sink would be used for warewashing if the dish machine was out of order. However, the cook stated that there were no stoppers to plug the drain holes, preventing the sinks from being filled as required. The facility's policy and procedure for manual dishwashing indicated that drain stoppers were necessary supplies for the three-compartment sink washing procedures when the dishwasher was inoperable.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Berkeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashby Care Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Elmwood Care Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Kyakameena Care Center | 0.7 mi | ★★★★★ | 26 | 0 |
| Chaparral House | 1.8 mi | ★★★★★ | 2 | 0 |
| The Rehabilitation Center Of Oakland | 2 mi | ★★★★★ | 2 | 0 |
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