Health inspection·September 13, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, for one of 12 (Resident 27) sampled residents, the facility failed to ensure accurate labeling of a medication when there was inaccurate labeling for Resident 12's Lantus (medication for high blood sugar). This failure had the potential for Resident 27 to receive the wrong medication dose. Findings: Review of Resident 27's admission Record indicated Resident 27 was admitted to the facility with diagnoses that included Diabetes Mellitus (a disorder that causes high blood sugar in the bloodstream). Review of the Physician's Orders (POs), dated 8/6/19, indicated an order for Resident 12 to receive 38 units of Lantus 100 units/milliliter (u/mL) subcutaneously (below the skin) every morning. The POs also indicated Resident 12 was to receive 30 units of Lantus 100 u/mL subcutaneously every evening. During an observation and concurrent interview on 9/11/19, at 9:37 a.m., Licensed Vocational Nurse (LVN) 1 held Resident 12's Lantus 100 unit/ml that indicated Resident 12 was to receive 32 units of Lantus every morning. LVN 1 stated Resident 12's Lantus label did not have the same dose instructions as the POs. LVN 1 stated a Direction Change sticker should have been applied to Resident 12's Lantus vial when the ordered dose was changed so that other nurses were aware and also for the next ordered Lantus medication label from the pharmacy would be the corrected dose (of 30 u/mL). During an interview on 9/11/19, at 12:22 p.m., Director of Nursing (DON) stated the Licensed Nurse receiving the new order from the physician was responsible for applying a direction change sticker to the medication container. Review of facility policy and procedure titled, Medications and Medication Labels, dated 2007, indicated, .Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws .If the prescriber's directions for use or the label is inaccurate, the nurse may place a direction change, change of order-check cart, or similar label on the container indicating there is a change in directions for use, taking care not to cover important label information. When such a direction label appears on the container, the medication nurse checks the resident's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 055892 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Berkeley Pines Skilled Nursing Center 2223 Ashby Avenue Berkeley, CA 94705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)