Berkeley Pines Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Berkeley Pines Skilled Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Mar 14, 2024

  Based on interview and record review the facility failed to have a registered nurse (RN) on duty for eight hours a day, seven days a week, when there was no RN coverage for 149 days from October 2022 through December 2023. This failure had the potential to place all 36 residents at risk during emergencies when RNs were not available to provide assessment and licensed nursing services. Findings: During an interview on 3/12/24, at 4:10 p.m., with licensed vocational nurse (LVN) 2, LVN 2 stated there were no RNs on duty on the weekends. LVN 2 stated RN coverage was important for initial resident assessments and for emergency resident assessments. During an interview on 3/12/24, at 4:28 p.m. […]

• No harm, potential for more than minimal, widespreadF801Mar 14, 2024

  Based on observation, staff interviews, and review of facility documents, the facility failed to: 1. 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 S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. 2. […]

• No harm, potential for more than minimal, widespreadF802Mar 14, 2024

  Based on observation, interview, and facility document review, the facility did not ensure proper kitchen staff competency for testing sanitizer strength, checking the dish machine temperature, and the use of the 2-compartment ware washing sink. The failure to ensure staff competency for kitchen tasks related to safety and sanitation in the kitchen placed 35 residents who received food from the kitchen at risk for illness from cross contamination of utensils, as well as food borne illness. Findings: 1. During a concurrent observation and interview with Cook 1 on 03/12/24 at 1:26 p.m., Cook 1 demonstrated how to test the strength of the quaternary ammonia (quat) sanitizer solution used for sanitizing surfaces in throughout the kitchen, including food contact surfaces. […]

• No harm, potential for more than minimal, widespreadF803Mar 14, 2024

  Based on observation, interview and record review, the facility failed to ensure: 1. A Vegetarian menu was available for a Vegetarian resident; and 2. Residents received what was on the lunch menu including: a. Broccoli Salad b. Tropical Fruit Mold c. Oven Roasted Potatoes d. Green Beans with Red Peppers These failures had the potential to result in decreased nutrient intake resulting in weight loss and/or malnutrition for 35 residents who received food from the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF804Mar 14, 2024

  Based on observation, interview, and facility document review, the facility failed to ensure food was palatable in regard to taste and temperature. This failure had the potential to result in decreased food consumption for 35 residents who received food from the kitchen. Findings: During and interview on 3/11/24 at 9:44 a.m., Resident 5 stated food should be hotter. Resident 5 further added breakfasts especially comes cold. During an interview on 3/11/24 at 1:16 p.m., Resident 10 stated all the food was bland. During an observation of trayline food service and a concurrent interview with Cook 1 on 3/11/24 at 11:40 a.m., Cook 1 stated he did not measure the temperature of the chicken when it was removed from the oven, and he did not measure the temperature of any food on trayline. […]