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Inspection visit

Health inspection

BERKELEY PINES SKILLED NURSING CENTERCMS #0558923 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to schedule a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Residents Affected - Few This failure had the potential to place residents at risk during emergencies. Findings: During an interview on 05/12/22 7:46 a.m. with Administrator (ADM), ADM stated that the facility does not have an RN to schedule on weekends. ADM stated that the RN's role is supervision. ADM stated the Director of Nursing (DON) is available on-call on the weekends and does not stay for eight hours. During an interview on 05/12/22 8:43 a.m. with ADM, ADM stated the last time an RN worked on the weekend, was 4/9/22. ADM stated the RN's role is for resident assessments and emergencies. ADM stated there was always a potential for emergencies. ADM stated for emergencies on the weekend, the DON can be there in 15 to 20 minutes. During a record review of Licensed Nurse Schedule, dated April 2022, the schedule indicated a registered nurse was not scheduled to work on 4/3/22, 4/10, 4/16, 4/17, 4/23, 4/24, and 4/30/22. During a record review of Licensed Nurse Schedule, dated May 2022, the schedule indicated a registered nurse was not scheduled to work on 5/1/22, 5/7, 5/8, 5/14, 5/15, 5/21, 5/22, 5/28, and 5/29/22. 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 3 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 05/12/2022 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)
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor the hours of sleep for one of one (Resident 30) sampled residents who used Trazadone (a medication used to treat depression and decrease anxiety and insomnia related to depression). Residents Affected - Few This deficient practice had the potential to result in Resident 30 taking Trazadone unnecessarily. Findings: During a review of the Resident 30's admission Record, dated 5/11/22, the admission record indicated Resident 30 was admitted to the facility on [DATE] with multiple diagnosis that included major depressive disorder ( a mood disorder that causes a persistent feeling of sadness, loss of interest and can interfere with daily functioning). During a review of Resident 30's Physician's Orders, dated May 2022, the physcian orders indicated Resident 30 had an order for Trazadone 25 mg ( start date 1/14/22) by mouth every night at bedtime for depression manifested by lack of sleep. During an interview and concurrent record review with the Director of Nursing (DON) on 5/10/22 at 2:25 p.m., DON stated Resident 30 took Trazadone for a sleep problem. DON stated Resident 30 should have been monitored for hours of sleep to ensure if the medication was working. DON was not able to show documentation that Resident 30's hours of sleep were monitored. During a review of the facility's policy and procedure titled Medication Monitoring, Medication Management, dated 2007, indicated Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug: .without adequate monitoring; without adequate indications for it's use. When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 2 of 3 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 05/12/2022 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)
F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that food was stored under sanitary conditions when multiple undated and expired food items were stored in the freezer, refrigerator and the dry storage room. This deficient practice had the potential of putting residents at risk for food-borne illness. Findings: During an observation on 5/9/22 at 9:25 a.m. in the kitchen, an unlabeled container of purple liquid and an open can of condensed milk with no open dates or use by dates were observed on a shelf. During an observation and concurrent interview with the Dietary Supervisor (DS) on 5/9/22 at 9:27 a.m. in the kitchen, the following was observed in freezer #1: one bag of sweet potatoes, one box containing nine mini chocolate cakes, one sandwich bag with a slice of banana cream pie, one grilled cheese sandwich, one bag containing eight blueberry muffins, one bag with five English muffins, five bags containing six slices of French toast each, and one bag of tortillas with no received dates or use by dates; three pie shells with a use by date of 8/11/21. DS stated all food in the freezer should be labeled with received dates and use by dates. DS stated expired food should be discarded. During an observation on 5/9/22 at 9:30 a.m. in the kitchen, the following was observed in Refrigerator #1-one paper bag with French fries and a hamburger, one bag of lettuce , one bag of tossed salad (brownish in color), and one bag of shredded cabbage ( brownish in color) with no received dates or no use by dates. During an observation and concurrent interview with DS on 5/9/22 at 9:35 a.m. in the kitchen, the following was observed in the dry storage room on the pantry shelf: twelve apples that were brown with white spots. DS stated the apples looked like they were no good and should not be used. Review of the facility's policy and procedure titled Sanitation and Infection Control, dated 2018, indicated Procedures: 9.All cooked food must be labeled and dated. 10. Leftover food or unused portions of packaged food should be covered, labeled and dated to assure they will be used first . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055892 If continuation sheet Page 3 of 3

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Citations

3 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0727GeneralS&S Dpotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

FAQ · About this visit

Common questions about this visit

What happened during the May 12, 2022 survey of BERKELEY PINES SKILLED NURSING CENTER?

This was a inspection survey of BERKELEY PINES SKILLED NURSING CENTER on May 12, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BERKELEY PINES SKILLED NURSING CENTER on May 12, 2022?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.