Lake Merritt Healthcare Center LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident Representative (RP) was informed of a resident's change in condition for one out of two sampled resident (Resident 1) when Resident 1's family member (FM) was not notified of Resident 1's fall incidents on 10/9/25 and 10/19/25. This failure resulted in Resident 1's FM being uninformed and unaware of Resident 1's fall. [...]

Inspectors wroteBased on interview and records review, the facility failed to ensure appropriate monitoring and interventions were provided for one of one sampled resident (Resident 1) after Resident 1 bit his tongue on 12/3/25 at 9:40 p.m. This failure could result in potential harm to Resident 1 due to delay of treatment. Resident 1 was transferred to the hospital on [DATE] and treated for tongue laceration (a tear or cut) requiring stitches. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of the two residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 with a wooden hanger on the forehead. This failure resulted in Resident 1 suffering from a laceration (a tear or cut in the skin caused by blunt trauma or sharp objects) on the forehead and being sent to an acute care hospital for further care and treatment. During a record review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two of four sampled residents (Resident 1 and Resident 3) when Resident 2 pushed Resident 1 to the floor; and Resident 4 punched Resident 3 in the face during an altercation. This failure resulted in Resident 1 falling to the floor and sustained a laceration (a cut in the skin) of left shin and right knee. Resident 3 sustained swelling under the right eye on his face. During a record review of Resident 1's admission Record on 3/5/26, the record showed Resident 1 was admitted to the facility on 10 /25/11. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate and resident centered discharge planning process for one of five sampled residents (Resident 5). Resident 5, with a known history of suicidal ideation, was discharged to an acute care hospital for suicidal attempt at the facility and facility refused to accept her back at the facility. This failure resulted in Resident 5's extended acute care hospital stay, and placed at risk for an unsafe and unplanned transition. During a record review of Resident 5's admission Record printed on 3/5/26, the record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5 has a diagnosis of Cognitive communication deficit, Unspecified Dementia with Agitation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect one of five sampled residents, (Resident 1), from physical abuse when Resident 2 hit Resident 1 in the head with a chair. This failure resulted in Resident 1 having a laceration (deep cut in the skin), on Resident 1's left forehead requiring transfer to an acute care hospital. During a review of Resident 1's admission Record printed on 1/6/26, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, (a brain disorder that slowly destroys memory and thinking skills.), Parkinson's Disease, (a chronic, progressive brain disorder affecting movement, and can contribute to memory loss) and agitation, (behavior marked by verbal outbursts and physical aggression). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one ( Resident 1) of 3 sample residents with diagnosis of schizophrenia, a mental health condition, received appropriate treatment to address Resident 1 ' s paranoid delusions when Resident 1 ' s psychiatry recommendation to increase Olanzapine (antipsychotic medication) dosage was not implemented. {Paranoid delusions are fixed, false beliefs that others are intentionally trying to harm, deceive, or persecute the individual} This failure had the potential to cause Resident 1 increased emotional distress, decline in mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow its Grievance/Complaints, Filing policy and procedure to make prompt efforts to respond and resolve grievances/complaints for two (Resident 5 and 26) sampled residents when; the facility did not follow up with Resident 5 and 26's complaint of missing personal items made during the resident council meeting. This deficient practice had the potential to cause residents emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system to perform ongoing repairs and maintenance work when three of three sampled areas of the facility were affected by the following: 1. Floor tiles in resident care hallway were broken and coming off. 2. a. Baseboard on the walls for Room A and Room B was missing and broken at places, with broken dry wall and plaster pieces sticking out of the wall. b. The overbed tables for Resident 42 and Resident 31 were chipped and unfurnished with rough edges, posing a potential risk for them getting scratched and hurting themselves. c. Screen door for Room A shared among Residents 42, 31 and 17 was broken and off the track. d. Electric cable cord for the television and Resident 37's call light cord in Room B were taped to the wall. e. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 44 and 37) Preadmission Screening and Resident Review (PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) was completed and referred to the appropriate state mental authority for Level II evaluation and determination when: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's smoking policy and procedure to prevent accidents hazards, complete smoking/safety evaluation, develop and implement care plan that promote smoking safety for three (Resident 19, 37 and 41) of three sampled residents when: 1. Resident 19 with amputated fingers, bilateral hands and non-compliance with smoking policy and procedure kept cigarettes and lighter in her possession. 2. Facility did not assess and complete a care plan for Resident 41 for safe smoking practices. Resident 41's charge nurses were unaware if Resident 41 smoked cigarettes, when direct care staff including Certified Nursing Assistants (CNA 1 and CNA 3) were aware that Resident 41 had always smoked at the facility. 3. Resident 37 did not receive smoking aprons, and cigarette holder per plan of care during smoking. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete performance review and maintain competency/skills records for three of three sampled licensed nurses (LVN 1, RN 2, and RN 4). A Licensed Nurse is a healthcare professional who has met requirements by state board of nursing to practice nursing skills within defined scope. This failure placed facility to be unaware and address training needs for LVN 1, RN 2 and RN 4 and placed all residents receiving care from LVN 1, RN 2 and RN 4 for receiving care from incompetent licensed nurses.

Inspectors wroteBased on interview and record review facility failed to complete an annual performance review, commonly known as competency/skills checks for one of three sampled Certified Nursing Assistants (CNA 7). Facility did not complete and maintain records for competency/skills checks completed upon hire/orientation for two of three sampled CNAs (CNA 4 and CNA 6). CNA is an unlicensed health professional providing nursing or nursing-related services to residents in the facility. This failure placed facility's residents residing at the facility at risk for not receiving need-based care, compromised safety, and receiving care from incompetent CNAs.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and prepare foods in a sanitary manner that prevented foodborne illness when: - One bag of sliced ham unlabeled and undated was stored in the refrigerator. - Kitchen vents, fans and window screens with dusty areas. These failures had the potential for residents to be exposed to food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Registered Nurse (RN) 2 did not perform hand hygiene during medication administration. 2. Nutritional feeding pole in Resident 33's had multiple dried light brown stains. These failures had the potential for cross contamination and spread of infections among residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff attempted to use appropriate measures to communicate with one of three sampled non-English speaking residents (Resident 43) when; Resident 43's communication tool/binder was not used. This failure placed Resident 43 at risk for not feeling understood, unmet needs and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing and effective activity program to meet resident activity preferences, physical and psychosocial goals for one of 15 sampled residents (Resident 37). This failure placed Resident 37 at risk for mental and psychosocial decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide an appropriate wheelchair to one of 15 sampled residents (Resident 37), for seven months, since admission to the facility. This deficiency placed Resident 37 at risk for physical decline and resulted in Resident 37 feeling worthless, and hopeless about his personal goals of discharge from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medication as ordered by the physician for one of five sampled residents (Resident 20) when Registered Nurse (RN) 2 thought Resident 20's eye drop medication was not available. This failure had the potential for Resident 20 to experience adverse effect from missed eye drop dose.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper medication storage for one of one sampled medication room and one of one sampled resident (Resident 31) when: 1. An unauthorized staff had access to the medication room. 2. Unlabeled, undated medication cup filled with white creamy substance was left unattended on top of Resident 31's overhead light fixture for over 24 hours. This failure had the potential for loss or diversion of medications and residents' accidental access to unknown substance.

Inspectors wroteBased on interview and record review, the facility failed to ensure that when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. The lack of full-time, competent oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in death and/or nutritional related medical complications

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete functional status in discharge planning assessment (an evaluation of residents' clinical and functional condition to arrange resources to help them prepare for a smooth discharge from the facility) for one of 15 sampled residents (Resident 37). This failure resulted in an inaccurate reflection of Resident 37's clinical condition, and placed him at risk for receiving inappropriate care upon discharge from the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow a written hospice agreement that included joint responsibilities to develop and implement a coordinated plan of care (POC) for one sampled resident (Resident 3) admitted into hospice program, when Resident 3's hospice POC did not reflect the participation of facility staff, Resident 3 and Resident 3's representative (FM 1). {POC means a written plan of care established, maintained, reviewed, and modified as necessary, for an individual that reflects the participation of hospice, facility, the patient and patient's family, as appropriate and complies applicable to federal and state laws and regulations}. {Hospice- a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease}.

Inspectors wroteBased on observation, interview and record review, the facility had seven resident rooms (Rooms 8, 9, 12, 14, 15, 16, 21) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. The deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was below five percent (%). When: 1. Registered Nurse (RN) 1 administered medication late to (Residents 255, 26, 13 and 44). 2. Losartan (medication to treat high blood pressure) was not given to Resident 44. 3. RN 1 did not wait five minutes in between administration of eye drop treatment as ordered by the physician. These deficient practices placed Residents 255, 26, 13 and 44 at risk of developing complications related to error in medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed store food and maintain the ice machine and ice scooper in a sanitary manner when: 1. Unlabeled, and outdated food were available for use in the kitchen freezer and dry storage. 2. Unlabeled, and expired food were available for use in the resident refrigerator. 3. Ice machine and ice scooper were not sanitized after the ice scooper was left in the ice machine. These failures had the potential to put residents at risk for infection and food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services (RNS, exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as: range of motion exercises, splint or brace assistance, etc.) for two of 13 residents (Resident 24 and Resident 40) when physician's orders were not followed consistently. These failures had the potential for residents to decline or not maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one of one sampled residents (Resident 40), when Licensed Vocational Nurse (LVN) 2 did not check the placement of Resident 40's enteral feeding tube (a tube placed through the skin of the abdomen directly into the stomach to deliver medication) and did not check the amount of residual (undigested stomach contents) in the stomach before medications were administered through the feeding tube. This failure placed Resident 40 at risk of aspiration (the intake of foreign matter into the lungs) and medications not being administered into the stomach.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled nursing staffs (Registered Nurse (RN) 1 and Certified Nursing Assistant (CNA) 2 were provided with competencies and skills necessary to perform their work roles safely and successfully. This failure had the potential to not provide appropriate nursing services to meet the needs of residents and promote the residents' physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an employee performance review was conducted at least every 12 months for one of five sampled nursing staffs (Certified Nursing Assistant (CNA) 2). This failure had the potential to affect the quality of nursing services rendered to residents in the facility when staff performance reviews remain unchecked.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nurse staffing information on 11/13/23. This failure resulted in nurse staffing information and posting requirements that were not readily available to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident of 26 sampled residents observed during medication administration pass (Resident 44) was free from significant medication error when: Losartan (medication to treat high blood pressure) was not administered as prescribed by the physician. This deficient practice had the potential for increased blood pressure and possible for stroke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly secure medications when two of two Licensed Staff did not keep medication cart 2 locked or under direct observation of authorized staff. This failure had the potential for residents, unauthorized staff, and visitors to have access to medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. Licensed staff did not sanitize portable blood pressure machine before and after each resident use. 2. Two licensed staff did not sanitize tray used to deliver medications to residents during medication administration. 3. Two licensed staff touched a resident's medication with bare hands. 4. Licensed staff touched inside resident's right eye twice with dropper tip during medication administration. 5. Licensed staff did not wash hands before administration of medication via gastronomy tube (G-tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal immunization for one of five sampled residents (Resident 31). This failure had the potential to not help protect Resident 31 against serious illnesses like pneumonia (lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two washing machines in the laundry room was in operable condition. This failure had the potential to disrupt laundry services provided to residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 23), had a call light that was easily accessible. This failure had the potential to neglect Resident 23's call for help in an emergency.

Inspectors wroteBased on observation, interview and record review, the facility had seven resident rooms (Rooms 8, 9, 10, 11, 12, 14, and 15) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. The deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store food and maintain sanitary conditions in the kitchen when: 1. The following outdated food was available for use: A. Gallon of milk B. Beef Base C. Five gallon of dill pickles D Sauerkraut 2. Cleaning procedures were not followed . These failures had the potential to cause food contamination and food borne illness in residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's policy and procedure for infection contol for one (Resident 23) of six sampled residents when: 1. Licensed Vocational Nurse (LVN 1) did not perform hand hygiene and don (to put on) a new pair of gloves before administering eye drops to Resident 23. 2. LVN 1 personal belongings were found in the medication storage room. 3. [NAME] (Cook)1 was observed not wearing a face mask while preparing the lunch trays. These failures had the potential to result in the spread of infectious organisms not only to Resident 23, but to other residents, staff, and visitors at the facility.

Inspectors wroteBased on observation and record review, the facility had eighteen residents (Rt) rooms (Rooms 8, 9, 10, 11, 12, 14, and 15) with multiple beds that provide less than 80 square feet (sq. ft.) per resident who occupy these rooms. The deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on interview and record review, the facility failed to provide assessment of dialysis (artificial means of filtering the blood when the kidneys fail) access site on the arm of one (Resident 10) in a sample of 16 residents who received dialysis when, the facility did not have a complete and accurate monitoring of Resident 10's dialysis access site. This failure had the potential for Resident 10 to have a clogged access site which would prevent Resident 10 from receiving dialysis without surgical intervention to replace the access site.

Inspectors wroteBased on observation, interview and record review the facility failed to keep two (Resident 7 and 15) of 44 sampled resident's beds in working condition when: 1. The remote bed control for Resident 7's bed was not functional, to raise or lower the head of the bed. 2 The remote bed control for Resident 15's bed was not functional to raise or lower the head and foot of the bed. The failure to maintain the bed controls in working condition resulted in increased back pain for Resident 7 and placed Resident 15 at risk for discomfort and back pain. Findings 1 During a record review of Resident 7's Facesheet dated 7/14/21, the Facesheet indicated Resident 7 was admitted to the facility on [DATE] with diagnosis of Spina bifida ( A medical condition which can cause back pain and loss of sensation in lower extremities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 34,) of 2 sampled residents received a safe, clean and comfortable environment when staff did not empty urine from Resident 34's bedside commode for more than two hours. The failure to empty urine from Resident 34's bedside commode resulted in strong odor in Resident 34's room.