Lake Merritt Healthcare Center LLC

In the surveyor’s words

From the most serious findings on record at Lake Merritt Healthcare Center LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF600Mar 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF565Oct 25, 2024

  Based 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. Findings: During a review of the facility's record titled, Resident Council Minutes, dated 9/27/24, the document indicated, Resident 5 complained of missing purple colored brassiere with stars symbols and Resident 26 complained of missing two [NAME] spots shirts. […]

• No harm, potential for more than minimal, patternF584Oct 25, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF644Oct 25, 2024

  Based 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… […]

• No harm, potential for more than minimal, patternF689Oct 25, 2024

  Based 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. […]