Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 St John Kronstadt Convalescent Center during CMS and state inspections, most recent first.
Monthly MRRs were not completed for three residents with psychiatric diagnoses and psychotropic medication orders. The DON and consultant pharmacist confirmed the MRR binder lacked multiple months of documentation for residents receiving antipsychotic and antidepressant medications, despite the facility policy requiring the consultant pharmacist to review each resident’s medication regimen and chart at least monthly.
Medication labeling and storage deficiencies were identified when two unlabeled, undated pre-filled cups of Triad ointment were left at a resident’s bedside, expired meds were found in the med storage room and on a med cart, and an opened medication box lacked a best-by date. Staff also found compromised blister packs and mixed storage of internal meds, external meds, and a glucose monitoring device in the same drawers, which the DON and RN confirmed did not meet policy.
Dirty kitchen utensils were found stored in the clean kitchenware drawer, including a pasta tong with debris and a torn rubber tip and two rusty can openers with metal fragments. In addition, thickened water was left at a resident’s bedside beyond the 24-hour period; the resident had dementia, severely impaired cognition, and was totally dependent for ADLs, including eating. The FNSM, IP, and CNA acknowledged the conditions and the CNA stated the old pitcher was not removed when the new one was delivered.
A resident with dementia, depression, and a later schizophrenia/schizoaffective disorder diagnosis did not have a new PASRR screening completed after the diagnosis was added. Records showed prior PASRR Level I and Level II reviews, but no updated PASRR after the new psych dx and related antipsychotic order. The MDSC and ADM both acknowledged the missing PASRR and that the State Mental Health Authority should have been notified for a more detailed MH evaluation.
Incomplete Care Plan for Right Hand Contracture and Palm Protector Use: A resident with dementia, severely impaired cognition, and total ADL dependence had a right hand contracture and an order for RNA to apply a palm protector daily. The record showed a mobility and safety care plan with a goal to maintain ROM to the right hand, but no comprehensive care plan was developed for the contracture or palm protector use, and the DON confirmed there was no separate ROM order beyond exercises done during ADL care.
Physician Not Notified of Repeated Medication Refusals A resident with intact cognition repeatedly refused a Lidocaine 4% patch for pain relief, and staff did not notify the physician for two weeks. The MAR showed the patch was not administered at every scheduled dose, with most doses marked refused, while staff acknowledged the physician should have been informed when the refusals began.
Failure to provide nail care during ADL assistance for four residents with cognitive impairment and needs for substantial/maximal help with personal hygiene. Residents with DM, CVA, Parkinson's disease, and SLE were observed with long, dirty, overgrown fingernails and debris under the nails. CNAs acknowledged the nails were not cleaned or checked during care, and the IP stated direct care staff were responsible for daily nail care per facility policy.
Incomplete daily nurse staffing postings were observed when the facility failed to fully post census and DHPPD information outside the nursing station. The DON signed the form even though required fields such as actual care service hours, average census, actual DHPPD, and CNA direct care hours were missing, and the MRD stated those sections had not been completed since September 2025. Several residents with intact cognition reported timely call light response and no apparent staffing delays.
Failure to perform hand hygiene occurred when a CNA assisted one resident with feeding and then, without sanitizing his hands, began feeding a second resident in the dining room. Both residents had severely impaired cognition and were totally dependent for eating. The CNA acknowledged he forgot hand hygiene between residents, and the IP stated staff assisting with feeding should perform hand hygiene to minimize spread of infection.
A resident with Parkinson’s disease and Type 2 DM was not offered a due pneumococcal revaccination after having previously received PCV 13. The IP stated the vaccine was due for revaccination but was forgotten, and the resident’s immunization record and facility roster confirmed the prior pneumococcal vaccine.
Insufficient resident room space was identified in one of 23 rooms, with a room containing 4 beds and only 77 sq. ft. per bed, below the required 80 sq. ft. per resident for multiple-occupancy rooms. During observation, CNAs were seen transferring a resident with a Hoyer Lift, and one CNA stated there was plenty of space in the room during the transfer.
A resident with dementia and major depressive disorder reported arm pain and alleged rough treatment by a CNA to an LVN, who later observed swelling and obtained an X-ray confirming a fracture. The LVN did not immediately report the abuse allegation to the DON or Administrator, resulting in a delay of several hours before the incident was reported to facility leadership and the state, contrary to regulatory requirements.
A resident with severe cognitive impairment and a history of aggressive behavior was inadequately supervised, leading to an altercation with another resident over room lighting. The aggressive resident, who had a history of wandering and altercations, was not provided with a care plan to address these behaviors. The facility failed to adhere to its policy on evaluating accident potential and developing care plans, resulting in repeated incidents.
The facility failed to provide gender-specific bathrooms, leading to discomfort and privacy concerns for five residents. Interviews revealed that residents were not informed about sharing bathrooms with the opposite gender, and staff acknowledged the inappropriateness of the situation. The bathrooms lacked locks and proper signage, compromising residents' dignity and privacy.
The facility failed to provide proper nail care for three residents, including one with glaucoma and Parkinson's, another with cerebral infarction, and a blind resident. Despite their dependence on staff for personal hygiene, their long and sharp fingernails were not trimmed, posing risks of injury and infection. The facility's policy required licensed nurses to trim nails for high-risk residents, but this was not followed.
The facility failed to store and label medications properly, with the medication refrigerator observed at 29°F, below the recommended 36-46°F range. Temperature logs showed missing entries and incorrect ranges, and staff did not notify maintenance of out-of-range temperatures. Additionally, six bottles of eyedrops and one insulin pen were improperly labeled, risking incorrect or expired medication administration.
A facility failed to ensure proper medication administration and documentation, leading to deficiencies. An LVN incorrectly primed an insulin pen, risking inaccurate dosing. A resident received calcium and iron simultaneously, potentially affecting iron absorption. Additionally, a resident's controlled medication was not properly documented, complicating dosage monitoring. These actions violated facility policies and standard practices.
A deficiency was identified in a facility where a room with four residents did not meet the required 80 square feet per resident. The Administrator acknowledged the issue and mentioned a room waiver request. Observations indicated that residents' privacy was not affected, and storage was sufficient.
Monthly Medication Regimen Reviews Not Completed
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review (MRR), including review of the medical chart, for three sampled residents. The report states that the consultant pharmacist and the DON confirmed the MRR was not done monthly for each resident, and the facility’s own policy required the consultant pharmacist to review the medication regimen and medical chart of each resident at least monthly. Resident 5 had diagnoses including depression, bipolar disorder, and schizophrenia, with a BIMS score of 10/15 indicating moderately impaired cognition. The resident’s medication orders included Invega Sustenna for schizophrenia, Depakote for bipolar disorder, and Lexapro for depression. Review of the facility’s MRR binder showed no documented MRR for Resident 5 for April through November 2025. Resident 6 had a BIMS score of 7/15 indicating severely impaired cognition and diagnoses including anxiety disorder, depression, and psychotic disorder. The resident received Seroquel for anxiety and for episodes of seeing and hearing people at night. The MRR binder showed no documented MRR for Resident 6 for June, July, August, October, and November 2025. Resident 9 had a BIMS score of 12/15 indicating moderately impaired cognition and diagnoses including anxiety and depression, with duloxetine ordered for depression. The MRR binder showed no documented MRR for Resident 9 for May, June, and August through November 2025. The DON stated the MRR should have been done monthly for these residents according to federal regulations and facility policy.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled and stored according to accepted principles and facility policy. During observation, two unlabeled, undated pre-filled medication cups containing Triad ointment were left on a resident’s nightstand in a shared room. The resident had dementia, severely impaired cognition, and was totally dependent for ADLs with two-or-more person assistance. The ointment had been prepared for treatment of moisture-associated skin damage to the scrotum and groin, but it was left unattended at the bedside instead of being applied immediately. The medication storage room and medication cart also contained multiple storage and labeling problems. In the medication storage room, expired Vitamin B-12 bottles were found, and one opened box of Veltassa did not have a best-by date. On the medication cart, several medications were expired or missing an open date, including nitroglycerine, hyoscyamine, and other items. Anoro had no open date printed on the container, and the DON confirmed the medication should have been discarded. The DON also stated that expired medications should have been thrown away and that all medications should have a best-by date completed on the label. Additional observations showed a compromised medication storage process. Amlodipine, methocarbamol, and omeprazole blister packs had broken or torn foil seals. Internal medications, external medications, and a glucose monitoring device were stored together in drawers without dividers, including items such as Metamucil, Uni Stat, a pain relief patch, hydrocortisone cream, ketoconazole shampoo, an Assure blood sugar monitor, and glargine. RN 2 confirmed that internal and external medications and the glucose monitoring device should not be mixed together, that expired medications should be discarded when found, and that compromised blister packs should be reported to the pharmacy for replacement.
Dirty Kitchen Utensils and Old Thickened Water Left at Bedside
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions when a stainless-steel pasta tong was found in the clean kitchenware storage drawer with sticky white debris and a rubber tip that was ripped in half, and two handheld can openers were found with red-orange debris, rust, and metal fragments on their blades. During the kitchen tour and interview, the Food and Nutrition Services Manager acknowledged the tong was dirty and the two can openers were rusty, and stated these utensils should not have been stored because they could contaminate food served to residents and cause foodborne illness. The dirty tong and both can openers were discarded after the observation. The facility also left thickened water at the bedside of a resident with severely impaired cognition and total dependence for activities of daily living, including eating. The resident had diagnoses including dementia and an order for a fortified puree diet with mildly thick liquids. During observation, two water pitchers containing thick-consistency liquid were on the resident’s nightstand, one dated the prior day and one dated the current day. The Infection Preventionist stated thickened water is good for 24 hours and should be removed once the new pitcher is delivered, and that old thickened water had the potential for bacterial growth past 24 hours. A CNA stated the old pitcher should have been removed when the new one was delivered but said he got busy and did not remove it.
Failure to Complete PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that Resident 7 had a completed PASRR assessment after the resident was newly diagnosed with schizophrenia/schizoaffective disorder. Resident 7’s admission record showed diagnoses that included dementia, schizophrenia, and depression, and the resident had previously undergone a PASRR Level I screening on 11/1/21 followed by a Level II evaluation on 12/10/21, with the determination report received on 12/15/21. Later records showed that the resident’s Comprehensive MDS dated 6/6/22 did not list schizophrenia, but physician orders dated 6/14/22 included Perphenazine 4 mg by mouth three times a day starting 6/20/22 for schizoaffective disorder. The resident’s records did not contain a new PASRR screening after the schizophrenia/schizoaffective disorder diagnosis was added later in 2022, and the facility could not provide documentation showing the exact date the physician officially added the diagnosis. A History and Physical dated 10/18/23 listed schizoaffective disorder. During interview and record review on 11/20/25, the MDSC stated the quarterly MDS showing schizophrenia was the resident’s first MDS assessment reflecting the new diagnosis, and the Administrator stated a new PASRR screening should have been initiated when schizophrenia was added and that the State Mental Health Authority should have been informed so a more detailed assessment for appropriate mental health services could be provided.
Incomplete Care Plan for Right Hand Contracture and Palm Protector Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a right hand contracture and use of a right-hand palm protector. The resident was admitted in 2020 with diagnoses of dementia and dysthymic disorder. The MDS dated 10/7/25 indicated the resident was rarely or never able to make self-understood, rarely or never had the ability to understand others, had severely impaired cognition, and was dependent on all ADLs with two or more-person assistance. The resident's Physician Order Report showed an order dated 9/2/25 for RNA to apply the resident's right palm protector daily for four hours during the day when up in the wheelchair to prevent contracture and maintain skin integrity. The resident's Care Plan, titled Mobility and Safety and created 11/18/25, included a goal that the resident would maintain range of motion to the right hand, but the clinical record showed no care plan developed for the right-hand contracture and/or use of the right-hand palm protector. During interview and record review, the DON stated the care plan should have been created in a timely manner and confirmed there was no order for ROM exercises to at least the right hand and upper extremities other than exercises provided by CNA and/or RNA during ADL care.
Physician Not Notified of Repeated Lidocaine Patch Refusals
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 1 refused the Lidocaine 4% patch for two weeks. Resident 1 was observed awake, alert, oriented, and sitting on the side of the bed while RN 1 asked whether he wanted the Lidocaine patch, and the resident stated it was being refused. Resident 1 was admitted with diagnoses including pneumonia, acute bronchitis, and Rhinovirus, and his MDS dated 9/23/25 showed a BIMS score of 15, indicating intact cognition. During interview, LVN 1 stated Resident 1 had refused the Lidocaine patch for 2 weeks and the physician was not notified. RN 4 stated the physician should have been notified when the resident initially refused. The MAR dated 11/2/25 through 11/20/25 showed the Lidocaine patch was not administered 26 out of 26 scheduled times, with 23 refusals and 3 times refused due to condition. The facility policy titled Medication Administration General Guidelines stated that if two consecutive doses of a vital medication are withheld or refused, the physician is notified.
Failure to Provide Nail Care During ADL Assistance
Penalty
Summary
The facility failed to ensure nail care was provided for four sampled residents who required assistance with ADLs and personal hygiene. Resident 27 had Parkinson's disease and Type 2 DM, had a BIMS score of 4 indicating severe cognitive impairment, and required substantial/maximal assistance with personal hygiene. During observation, Resident 27 was noted to have dirty and long fingernails on both hands, and the CNA agreed the nails should have been cleaned regardless of medical condition. Resident 39 had CVA, a BIMS score of 6 indicating severe cognitive impairment, and required substantial/maximal assistance with personal hygiene. During observation while being assisted with transfer from bed to wheelchair, Resident 39 was found to have black and brown matter underneath overgrown fingernails. The CNA acknowledged the fingernails were long and dirty and stated it looked like the resident had not had the nails trimmed for a long time. Resident 5 had Type 2 DM, a BIMS score of 10 indicating moderate cognitive impairment, and required substantial/maximal assistance with personal hygiene. Resident 9 had Type 2 DM and SLE, a BIMS score of 12 indicating moderate cognitive impairment, and required substantial/maximal assistance with personal hygiene. During observation, both residents had long, overgrown fingernails with black matter underneath. Resident 5 stated the CNA did not offer to clean his fingernails, and Resident 9 stated the CNA did not check or clean her nails when assigned to her. The CNA stated he did not check either resident's nails during ADL care that morning and said morning shift was busy. The IP stated direct care staff were responsible for ensuring daily nail care for Residents 5, 9, 27, and 39, and that overgrown nails can accumulate dirt and spread infection. The facility policy stated nail care is given to clean the nail bed and keep the nail trimmed, with CNA trimming fingernails except for residents with diabetes or circulatory impairments, for whom a licensed nurse trims high-risk residents' nails.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the daily census and direct care service hours per patient day (DHPPD) posting was complete and included all required information. During observation and interview with the DON, the DHPPD forms were posted daily outside Nursing Station 1 and were supposed to be updated by the night shift nurse in charge and the day shift DON or charge nurse, but the 11/21/25 form was not completed. The form did not show the daily census changes for 8:00 a.m., actual care service hours, average patient census, actual DHPPD, actual total CNA direct care service hours, or actual CNA DHPPD, even though the DON had signed it indicating review and that the information was true and correct. During interview, the MRD stated she had not completed the sections for actual care service hours, average patient census, actual DHPPD, actual total CNA direct care service hours, and actual CNA DHPPD, and said this information for each 24-hour patient day had not been completed since September 2025. Review of the census and DHPPD documents from September 2025 through November 2025 showed the same sections remained incomplete. The report also included interviews with three cognitively intact residents, each with BIMS scores of 15/15, who stated they were not experiencing delays in staff response to call lights and did not observe rushed care.
Failure to Perform Hand Hygiene Between Feeding Two Residents
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when CNA 1 did not perform hand hygiene between assisting two residents with feeding in the Community Room back dining room. Resident 25 was admitted to the facility in 2020 and had diagnoses including dementia with severely impaired cognition; the MDS indicated the resident was totally dependent for all ADLs, including eating. During lunch observation, CNA 1 assisted Resident 25 with feeding, then stood up and walked toward the door where Resident 11 was seated. Resident 11 had diagnoses including Alzheimer's Disease and severely impaired cognition, and the MDS indicated the resident was totally dependent for all ADLs, including eating. Without performing hand hygiene, CNA 1 picked up the spoon from Resident 11's plate and began assisting with feeding. CNA 1 stated he should have sanitized his hands in between feedings and that he forgot to do hand hygiene when he left Resident 25 to assist Resident 11. The Infection Preventionist stated CNAs, LNs, and other staff members qualified to assist with feeding should perform hand hygiene before assisting residents to minimize spread of infection. The facility's Infection Control policy stated standard precautions include washing and drying hands before and after patient contact, and washing hands immediately after gloves are removed and between patient contacts.
Failure to Offer Due Pneumococcal Immunization
Penalty
Summary
The facility failed to provide pneumococcal immunization for one of five sampled residents when Resident 27 was not offered the pneumococcal vaccine. Resident 27 was admitted with multiple diagnoses including Parkinson’s disease and Type 2 diabetes mellitus. During interview and record review, the Infection Preventionist stated that Resident 27 had received a pneumococcal vaccine on 11/9/17 and was due for revaccination in 2022, but the vaccine was not offered because she forgot to offer it to the resident. The resident’s vaccination record and the facility’s immunization roster both showed pneumococcal vaccine (PCV 13) administered on 11/9/17. The facility’s Resident Immunization Program policy stated residents would be immunized against vaccine preventable diseases unless overridden by a physician, medically contraindicated, or refused, and it included pneumococcal revaccination guidance. The CDC Vaccine Information Statement provided by the facility indicated pneumococcal conjugate vaccine is recommended for adults 50 years or older who have not previously received PCV, and some adults who already received PCV may be recommended to receive another dose.
Insufficient Resident Room Space
Penalty
Summary
The facility failed to provide at least 80 square feet for each resident in one of 23 rooms, with room [ROOM NUMBER] identified as having 4 beds and 77 sq. ft. per bed. During a concurrent observation and interview on 11/18/25 at 10:33 a.m., CNA 3 and CNA 1 were observed transferring Resident 39 from bed to wheelchair using a Hoyer Lift, and CNA 3 stated there was plenty of space in Resident 16's room even when using the Hoyer Lift for transfer. A record review on 11/21/25 of the Client Accommodations Analysis showed the room was below the required space standard.
Failure to Timely Report Alleged Abuse with Injury
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident involving a resident with dementia and major depressive disorder. On the morning of the incident, the resident complained to an LVN of left arm pain and alleged that a night shift CNA had been mean, rough, and had hit her arm. The LVN observed swelling in the resident's left arm several hours later, obtained a physician's order for an X-ray, and the results revealed a fracture. The resident was subsequently transferred to the hospital for further evaluation. Despite being aware that allegations of abuse with injury should be reported immediately or within two hours, the LVN did not notify the Administrator or DON at the time of the initial complaint, stating she forgot to report the incident. The Administrator was not informed of the alleged abuse until later that evening, and the mandated SOC 341 report was faxed to the state department approximately eight hours after the injury was first observed. Review of facility policy indicated a lack of clear direction regarding immediate reporting of abuse allegations with injury to the Administrator and state officials. Both the DON and Administrator acknowledged that the incident should have been reported within the required timeframe, as outlined in federal regulations.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision for a resident who required supervision due to physical and verbal aggression. This deficiency resulted in an altercation between two residents, where one resident, who had severe cognitive impairment and a history of aggressive behavior, engaged in a conflict with another resident over the room's lighting. The aggressive resident turned on the lights, leading to a verbal disagreement and physical altercation, where the other resident patted the aggressive resident on the cheek, and in response, the aggressive resident scratched the other resident's arm. The aggressive resident had a history of wandering and engaging in altercations with other residents, as documented in the facility's records. Despite these incidents, the facility did not have care plans addressing the resident's aggressive behaviors and altercations with other residents. The Director of Nursing acknowledged the absence of care plans and Interdisciplinary Team meeting notes to address or discuss interventions for the resident's behavior. The facility's policy and procedure on accidents and incidents required the interdisciplinary team to evaluate accident potential and develop care plans for residents at risk. However, the facility failed to adhere to this policy, as evidenced by the lack of documented care plans and interventions for the aggressive resident's behavior, leading to repeated altercations with other residents.
Failure to Provide Gender-Specific Bathrooms
Penalty
Summary
The facility failed to provide gender-specific bathrooms for five residents, leading to discomfort and potential humiliation. Observations and interviews revealed that a female resident shared a bathroom with two male residents, and another female resident shared a bathroom with a male resident. This arrangement was found to be concerning for the residents involved, as it compromised their privacy and dignity. During interviews, residents expressed their discomfort with the shared bathroom situation. One male resident stated that sharing a bathroom with a female resident was unacceptable and concerning. A female resident reported feeling uncomfortable and that her privacy was compromised when others entered the bathroom without knocking. Staff members, including a CNA and an LVN, acknowledged the inappropriateness of the situation and expressed concerns about the impact on residents' dignity. The facility's Director of Nursing confirmed that the shared bathrooms lacked locks and proper signage to ensure privacy. Additionally, there was no documentation indicating that residents or their families were informed about the shared bathroom arrangements. The facility's policy on dignity and respect emphasized maintaining residents' dignity and individuality, which was not upheld in this situation.
Failure to Provide Proper Nail Care for Residents
Penalty
Summary
The facility failed to provide proper grooming and nail care for two of the four sampled residents, leading to potential health risks. Resident 16, who has glaucoma and Parkinson's disease, was observed with long, sharp fingernails that he could not trim himself due to his impaired vision and dependence on staff for self-care. Despite his requests for assistance, the facility staff had not trimmed his nails, which resulted in him scratching his arm and causing redness. The care plan for Resident 16 indicated a need for assistance with activities of daily living, including personal hygiene. Resident 23, with a cerebral infarction diagnosis and intact mental status, was also found with long, sharp fingernails. He expressed that he had repeatedly asked the facility staff to trim his nails, but no action had been taken. The observation confirmed that Resident 23 was dependent on staff for personal hygiene, and the lack of nail care posed a risk of self-inflicted injury and potential infection. Resident 11, who is blind and totally dependent on staff for personal hygiene, had long and thick fingernails that could not be trimmed with regular nail clippers. Despite being aware of the issue, the facility had not arranged for the necessary tools or external assistance to address the problem. The facility's policy indicated that licensed nurses should trim the nails of high-risk residents, but this had not been implemented for Resident 11, leading to discomfort and potential health risks.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications in accordance with manufacturer specifications and accepted professional principles. The medication refrigerator was observed to be at 29 degrees Fahrenheit, which is below the recommended storage temperature range of 36 to 46 degrees Fahrenheit. This refrigerator contained various medications, including vaccines and insulin pens, which could be affected by improper storage temperatures. The facility's policy required that the refrigerator temperature be monitored and recorded twice daily, but the logs showed numerous missing entries and incorrect temperature ranges, indicating a lack of consistent monitoring. Nursing staff did not notify the Maintenance Supervisor when the refrigerator temperature was out of range, as required by the facility's procedures. Interviews revealed that staff were unaware of the correct temperature range and the need to report deviations. The Pharmacy Consultant recommended replacing the medications due to the unknown effects of storage at incorrect temperatures. Additionally, the temperature logs contained incorrect information about the acceptable temperature range, further contributing to the oversight. The facility also failed to properly label medications, with six bottles of eyedrops and one insulin pen lacking necessary information such as resident names and open dates. This oversight posed a risk of administering incorrect or expired medications to residents. The Director of Nursing acknowledged that medications should be labeled with the resident's name, room number, and the date they were opened to prevent such errors. The lack of proper labeling and monitoring practices had the potential to affect the effectiveness and safety of medications administered to residents.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and accountability, leading to several deficiencies. One incident involved a Licensed Vocational Nurse (LVN) incorrectly priming an insulin pen for a resident, potentially resulting in an incorrect insulin dose. The LVN primed the pen horizontally with the needle cap on, contrary to the manufacturer's instructions and the facility's policy, which require the pen to be held upright. This improper technique was confirmed by the Pharmacy Consultant, who noted that incorrect priming could lead to inaccurate dosing. Another deficiency was observed when a resident received calcium and iron supplements simultaneously, which could interfere with the absorption of iron. The facility's schedule had both medications administered at the same time, despite evidence that calcium can reduce iron absorption. The Director of Nursing (DON) acknowledged the interaction after conducting online research, and the Pharmacy Consultant admitted awareness of the interaction but did not communicate it to the facility, considering it minor. Additionally, during a controlled medication audit, it was found that a resident's administered medications were not properly documented on the Controlled Drug Record (CDR) and Medication Administration Record (MAR). The DON noted that the failure to document could hinder monitoring the medication's effectiveness and dosage adjustments. The facility's policy requires documentation on both the CDR and MAR when controlled substances are administered, but this was not followed, as evidenced by the missing entries for a resident's oxycodone administration.
Deficiency in Room Size Requirements
Penalty
Summary
The facility was found to have a deficiency related to room size requirements. Specifically, room [ROOM NUMBER] was identified as having less than the required 80 square feet per resident in a multiple-occupancy room, with four residents occupying the space. During interviews, the Administrator acknowledged the room's non-compliance with space requirements and mentioned that a room waiver had been requested. The Maintenance Supervisor confirmed that this was the only room with four residents and less than the required space per bed. Observations noted that the residents' privacy was not impacted by the space shortage, and storage was adequate for their needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 805 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Castro Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Pointe Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 20 | 0 |
| East Bay Post-acute | 1.3 mi | ★★★★★ | 34 | 0 |
| Canyon Creek Post-acute | 1.4 mi | ★★★★★ | 2 | 0 |
| Baywood Court Health Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Sage Post Acute | 1.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St John Kronstadt Convalescent Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.