Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Merritt Healthcare Center Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, traumatic brain injury, and dementia experienced two falls that constituted changes in condition, but the facility did not ensure the resident’s representative and family member were notified. Although the admission and hospital records identified family members as emergency contacts and documentation showed a family member acting as the resident’s representative and participating in care conferences, the contact type field in the facility record was left blank. SBAR forms for both falls lacked any notation of family or health care agent notification, and staff, including the MDSC, could not recall contacting the family. This resulted in the family member being unaware of the resident’s fall incidents.
A resident with metabolic encephalopathy, morbid obesity, paroxysmal atrial fibrillation, and on a blood thinner bit his tongue, resulting in oral bleeding. An LVN identified the bleeding and documented on an SBAR that the resident refused hospital transfer and that the MD ordered continued monitoring. Although the LVN reported checking the resident every 15 minutes and the night-shift RN reported ongoing bleeding and applying pressure, neither could recall specific findings or confirm documentation of assessments and interventions. Review of progress notes showed no evidence of monitoring or treatment from the time of the initial event through the early morning, despite facility policy requiring monitoring and documentation of acute condition changes. The resident was later sent to the hospital, where a tongue laceration with significant bleeding was treated with pressure, special glue, and stitches.
The facility failed to prevent physical abuse when one cognitively impaired resident with a history of agitation around others in his room struck another cognitively impaired, nonverbal, wandering resident on the forehead with a wooden hanger. Staff reported hearing commotion and, upon entering the room with the door closed, found the victim on the floor bleeding from a laceration above the eyebrow and the aggressor on the bed holding a wooden hanger and using profanity. ED documentation described an assault with a wooden hanger causing a 3 cm forehead laceration that required irrigation and closure with steri-strips, despite facility policy prohibiting physical abuse.
The facility failed to prevent two separate incidents of resident‑to‑resident physical abuse, resulting in injuries. In one case, a resident with moderate cognitive impairment was involved in an escalating confrontation with another cognitively impaired resident; both held chairs defensively before one pushed the other from a wheelchair, causing a fall and lacerations to the shin and knee. In another case, a cognitively intact resident with a known history of punching others, who was assigned a 1:1 sitter, abruptly charged and punched his severely cognitively impaired roommate in the face after mistakenly believing the roommate was wearing his shirt, causing facial swelling. These events occurred despite a facility policy guaranteeing residents’ rights to be treated with respect, kindness, and dignity.
A resident with severe cognitive impairment, dementia with agitation, a language barrier, and documented suicidal ideation was care planned for close monitoring and suicide precautions. An LVN later found the resident with a light‑string tightly around the neck, removed it, and the resident was subsequently transported to an acute care hospital by ambulance after police involvement. When the hospital MSW determined the resident was ready to return, the DON refused readmission, citing high self‑harm risk and lack of trained staff to meet the resident’s needs, despite these issues having been identified in the care plan months earlier. This refusal led to an extended hospital stay and placed the resident at risk for an unsafe, unplanned transition.
A resident with severe cognitive impairment and multiple neurologic conditions sustained a forehead laceration requiring stitches after being struck in the head with a chair by another resident. The aggressive resident, who had metabolic encephalopathy, anxiety, and an adjustment disorder, admitted hitting the other resident because he was angry about being awakened. An RN found the injured resident bleeding in the doorway of the aggressor's room while the aggressor stood inside holding a chair and screaming. The aggressor's care plan documented a pattern of physical and verbal aggression, including hitting, pushing, threatening, and throwing objects, while facility policy stated residents have the right to be free from abuse and neglect.
A facility failed to implement a psychiatry recommendation to increase the Olanzapine dosage for a resident with schizophrenia, leading to potential emotional distress. The resident exhibited paranoid delusions and agitation, but the recommended dosage increase from 10 mg to 15 mg was not followed. Staff interviews revealed a lack of awareness and follow-up on the recommendation, highlighting a communication breakdown in the facility's process.
Two residents reported missing personal items during a resident council meeting, but the facility failed to follow its grievance policy to address these complaints. The Activity Director informed staff, but the Social Worker did not receive the referral, and the Administrator was unaware of the grievances. The facility's policy requires prompt resolution of grievances, which was not adhered to in this case.
The facility failed to maintain a safe environment, with broken floor tiles, damaged baseboards, and chipped overbed tables posing risks to residents. A screen door was off track, electrical cords were unsafely taped, and a wall clock displayed incorrect time, causing confusion. A shared bathroom lacked soap for over two days, and the smoking patio had rusty furniture with sharp edges. Maintenance issues were not properly reported or addressed, violating the facility's maintenance policy.
The facility failed to ensure accurate PASRR assessments for two residents, leading to potential inappropriate placement and lack of necessary mental health services. One resident's PASRR Level 1 Screening was not resubmitted after 30 days, despite multiple mental health diagnoses. Another resident's assessment inaccurately marked 'No' for serious mental disorders and psychotropic medication use. The DON and MDSC acknowledged the inaccuracies, which could have led to appropriate mental health referrals.
The facility failed to enforce smoking safety policies, leading to potential hazards for residents. A resident with limited mobility kept smoking materials despite being unable to safely use them. Another resident was not properly assessed for smoking safety and smoked unsupervised. A third resident did not receive required safety items. Additionally, a janitor smoked near open resident rooms, and cigarette butts were improperly disposed of, posing fire risks.
The facility failed to conduct performance reviews and maintain competency records for three licensed nurses, placing residents at risk of receiving care from potentially incompetent staff. The DSD and DON acknowledged the absence of evaluations, and the facility's policy requires such evaluations upon hire and annually. This issue was previously identified in an annual recertification survey.
The facility failed to conduct required competency evaluations for CNAs, risking resident care quality. The DSD did not complete evaluations for CNAs 4, 6, and 7, and the ADM acknowledged non-compliance with policy requirements for CNA assessments.
The facility failed to maintain sanitary conditions in food storage and preparation areas, potentially exposing residents to foodborne illness. An unlabeled and undated bag of sliced ham was found in the refrigerator, and kitchen vents, fans, and window screens were dusty. The Maintenance Supervisor lacked documentation of cleaning activities, contrary to the facility's policies requiring labeled food storage and maintenance records.
A facility failed to maintain infection control practices as a nurse did not perform hand hygiene during medication administration, handling medication cups, eye drop bottles, and inhalers without sanitizing hands before and after glove use. Additionally, an IV pole used for nutritional feeding was found with dried stains, indicating lapses in cleaning protocols. These deficiencies were confirmed by staff interviews and a lack of cleaning documentation.
A facility failed to ensure effective communication with a non-English speaking resident who required an interpreter. Despite having a communication binder, staff were unaware of its existence and relied on gestures. The Director of Staff Development admitted no training was provided on using communication tools, and the facility lacked an interpreter phone line, contrary to their language access policy.
A resident with a documented interest in drawing and painting was not provided with sufficient materials or engagement opportunities, leading to inactivity and feelings of worthlessness. The activity logs lacked documentation of one-on-one participation, and the facility's policy on supporting residents' well-being was not followed.
A resident with a left hip contracture was not provided with an appropriate wheelchair for seven months, leading to physical discomfort and emotional distress. The resident was mostly bedbound due to the unsuitable Geri-chair and manual wheelchair, which affected their goal of returning to the community. Facility staff were unaware of the Geri-chair's limitations, and there was no documentation of a wheelchair evaluation since admission.
A resident with glaucoma did not receive their prescribed Brinzolamide eye drops because an RN mistakenly believed the medication was unavailable. The RN administered only Artificial Tears, not realizing that the Brinzolamide was part of the Simbrinza eye drop bottle already in the medication cart.
The facility failed to control access to the medication room, allowing unauthorized staff to enter, and left an unlabeled medication cup with a white substance unattended in a resident's room for over 24 hours. The CSS had access to the medication room despite not being authorized to handle medications, and a nurse could not confirm the contents of the medication cup, posing a risk to residents.
The facility did not ensure that the director of food and nutrition services met the required educational qualifications when a full-time registered dietitian was not hired. The Dietary Manager, who was not certified and still in school, worked full-time, while a Registered Dietician visited weekly for resident assessments. The Administrator was aware of the DM's lack of qualifications, placing residents at risk for foodborne illness and decreased nutrient intake.
A facility failed to accurately complete a discharge planning assessment for a resident, leading to an inaccurate reflection of the resident's clinical condition. The resident was assessed as independent in certain activities, despite being bedbound and dependent on staff for daily living activities. The Social Worker admitted to using assumptions rather than direct observations or consultations with care staff, contrary to facility policy requiring objective and accurate documentation.
A facility failed to follow a hospice agreement requiring a coordinated plan of care (POC) for a resident with dementia on hospice care. The resident and family were not included in a care plan conference, and staff interviews confirmed the lack of coordination. The facility's agreement required participation from hospice, facility, and family, which was not met.
The facility had seven rooms with multiple beds that did not meet the required 80 square feet per resident, providing only 79.33 square feet per bed. Despite this, observations showed adequate space for care, no interference from equipment, and no resident complaints or safety concerns.
Failure to Notify Resident Representative of Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative and family member of changes in condition following two fall incidents. The resident was admitted with traumatic subdural hemorrhage with loss of consciousness, traumatic brain compression without herniation, and unspecified dementia, and had a BIMS score of 3/15, indicating severe cognitive impairment and limited capacity to make medical decisions. The facility’s admission record listed the family member’s name, relationship, and phone number, but left the contact type field blank, even though the acute care hospital face sheet identified two family members as emergency contacts. The Admissions Coordinator stated that one of these family members was the resident’s emergency contact and that the contact type in the facility record should have been marked as emergency contact. The resident’s plan of care and health status notes documented that a family member was acting as the resident’s representative, participated in care conferences, applied for in-home support services, and provided verbal consent for vaccinations. Despite this, the facility did not document or confirm notification of the resident’s representative or family member after the resident’s falls on 10/9/25 and 10/19/25. Review of SBAR Communication Forms for both fall dates showed no entry indicating the name of any family member or health care agent notified of the incidents. The DON acknowledged that the facility policy did not specify who must be informed of changes in condition, although the SBAR form was intended to prompt nurses to identify and notify the resident representative. The MDS Coordinator confirmed that a fall is considered a change in condition and did not recall notifying the family member about the fall. As a result, the resident’s family member remained uninformed and unaware of the resident’s fall incidents.
Failure to Monitor and Document Care After Resident Tongue Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation of care for a resident who sustained a tongue injury. The resident was admitted with metabolic encephalopathy, morbid obesity, and paroxysmal atrial fibrillation, and was taking a blood thinner. An MDS dated 10/29/25 showed the resident had an intact BIMS score of 15/15. On 12/3/25 at 9:40 p.m., an LVN noted blood in the resident’s mouth, and the resident reported he had bitten his tongue. An SBAR form documented that the resident refused transfer to the hospital and that the MD’s recommendation was to continue monitoring. The facility’s Acute Condition Changes – Clinical Protocol required staff to monitor and document the resident’s progress and responses to treatment so the physician could adjust treatment accordingly. During interview, the LVN stated the resident was monitored every 15 minutes after the bleeding was noted but could not recall the resident’s condition at each check and did not remember documenting these assessments. The night-shift RN reported that the resident’s tongue continued to bleed through the night, but the RN did not know how much bleeding occurred, and although pressure was applied to the tongue, the RN was unsure whether monitoring and interventions were documented. Review of the resident’s progress notes from the evening of 12/3/25 through the early morning of 12/4/25 showed no documentation that the LVN or RN monitored the resident or provided interventions during that period. A subsequent SBAR form on 12/4/25 indicated the resident continued to bleed through the night, and the RN notified the MD of prolonged bleeding at 6:21 a.m., at which time EMS was called and the resident was sent to the hospital, where the tongue laceration required multiple methods to control significant bleeding related to blood thinner use.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, resulting in a head laceration and transfer to an acute care hospital. Resident 1, who had metabolic encephalopathy, unspecified dementia, and daily wandering behavior, was rarely or never understood and could not make himself understood, and a CNA reported that this resident often wandered the hallways and did not have the ability to defend himself. On the day of the incident, Resident 1 was later found in Resident 2’s room, sitting on the floor near the door with active bleeding from a laceration above the left eyebrow. Resident 2 had metabolic encephalopathy, unspecified dementia, and undifferentiated schizophrenia, with a BIMS score of 7/15 indicating severe cognitive impairment. Staff interviews indicated that Resident 2 tended to become agitated when people walked around his room. On the day of the incident, the charge nurse heard commotion and a low voice from Resident 2’s room, which had a closed door. Upon entering, the nurse found Resident 1 bleeding from the forehead and Resident 2 sitting on his bed holding a wooden hanger while using profanity. Although the nurse did not directly witness the strike, he stated it was evident that Resident 2 had hit Resident 1 with the hanger. Progress notes documented that the charge nurse immediately separated the residents and assessed Resident 1, noting bleeding on the left forehead above the eyebrow. Emergency Department provider notes described that Resident 1 had been assaulted with a wooden hanger to the head, resulting in a 3 cm horizontal laceration of the left forehead, which was irrigated and closed with steri-strips. The facility’s abuse prevention/prohibition policy stated that the facility does not condone any form of resident abuse and defined physical abuse as hitting, slapping, pinching, or kicking, but staff acknowledged that although Resident 1’s wandering had been monitored before the incident, they should have been more cautious about his whereabouts.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect residents from abuse when two separate resident‑to‑resident altercations occurred, resulting in injuries. In the first incident, a resident with moderate cognitive impairment (BIMS score 10/15) reported that another resident, also with moderate cognitive impairment (BIMS score 9/15), became angry, yelled, and pushed him from his wheelchair to the floor. A nurse later documented that both residents had been holding chairs and positioned defensively in an escalating altercation, and that attempts to de‑escalate were unsuccessful before the aggressor pushed the other resident, causing him to fall forward out of his wheelchair. The injured resident sustained lacerations to the left shin and right knee. The facility’s abuse and residents’ rights policy stated that residents are guaranteed rights to a dignified existence and to be treated with respect, kindness, and dignity. In the second incident, the facility did not prevent an assault by one resident on his roommate, who had severe cognitive impairment (BIMS score 4/15). The aggressor, who had intact cognition (BIMS score 14/15) and a known history of punching others that necessitated a 1:1 sitter, punched his roommate in the face after mistakenly believing the roommate was wearing his shirt. A CNA assigned as a 1:1 sitter stated she did not expect the resident to charge and punch the roommate while he was being escorted, and another CNA described the aggressor abruptly getting up, charging, and punching the roommate in the face while she was at the bedside setting up a meal tray. The injured resident sustained swelling below the right eye, for which pain medication and an ice pack were provided. These events occurred despite the facility’s written policy on abuse reporting, investigation, and residents’ rights to be treated with respect and dignity.
Failure to Provide Resident‑Centered Discharge Planning and Readmission for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an appropriate, resident‑centered discharge planning process and safe transition for a resident with known suicidal ideation and dementia. The resident had diagnoses including cognitive communication deficit and unspecified dementia with agitation, and an MDS BIMS score of 4/15 indicating severe cognitive impairment. The care plan documented a language barrier due to the resident’s primary language being Russian and identified suicidal ideation related to dementia, with interventions for close monitoring and suicide precautions. On one date, an LVN documented that the resident was found around 9:30 a.m. with a string used to turn the room light on/off wrapped tightly around her neck; the nurse intervened, removed the string, and notified the MD and responsible party. Later that day, progress notes indicated that police arrived around 4:00 p.m., attempted to calm the resident, and then called an ambulance, which transported the resident to an acute care hospital at approximately 4:20 p.m. At the acute care hospital, the MSW reported that the resident was considered ready for transport back to the facility the following day, but when the MSW contacted the facility’s DON, the DON declined to accept the resident back, citing the resident’s high risk for self‑harm and the facility’s lack of trained staff to meet the resident’s needs. The MSW also stated this was not the first time the facility had refused to readmit its residents. Hospital progress notes documented that the DON stated the facility would not accept the resident back due to high risk of self‑harm. In a later interview, the DON stated the facility did not accept the resident back because staff could not adequately communicate with the resident due to the language barrier and that the resident had not shown self‑harm behaviors prior to the incident, despite the care plan having identified both the language barrier and suicidal ideation months earlier. This refusal to readmit resulted in an extended acute care hospital stay and placed the resident at risk for an unsafe and unplanned transition.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the head with a chair. One resident, with Alzheimer's disease, Parkinson's disease, agitation, and severe cognitive impairment (BIMS score 4/15), was found by an RN sitting on the floor in the doorway of another resident's room with blood coming from the left side of his forehead. The injured resident could not recall going to the emergency department or how his head was injured. Progress notes documented a laceration on the left side of his forehead, and an acute care hospital encounter summary indicated a 4-centimeter laceration requiring stitches. The other resident involved had diagnoses of metabolic encephalopathy, anxiety, and adjustment disorder with mixed disturbance of emotions and conduct, and his MDS indicated he sometimes made himself understood and sometimes understood others. This resident's care plan, dated the same day as the incident, documented a history of physical and verbal aggression, including hitting, pushing, threatening, and throwing objects, with observed aggressive behavior toward staff and residents. During an interview, this resident stated he hit the other resident in the head with a chair because he was angry about being awakened. At the time of the incident, the RN observed this resident standing in his room holding a chair and screaming, while the injured resident was bleeding in the doorway. The facility had a policy stating residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.
Failure to Implement Psychiatry Recommendation for Resident with Schizophrenia
Penalty
Summary
The facility failed to provide appropriate treatment for a resident diagnosed with schizophrenia, as the recommended increase in Olanzapine dosage was not implemented. The resident, who had a history of paranoid delusions, was observed to become easily agitated and aggressive. Despite a psychiatry recommendation to increase the Olanzapine dosage from 10 mg to 15 mg daily, this adjustment was not made, potentially leading to increased emotional distress and a decline in the resident's mental and psychosocial well-being. The deficiency was identified through a review of the resident's records, which showed a positive Level I PASRR screening for mental illness, indicating the need for a Level II evaluation that was not conducted. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), revealed a lack of awareness and follow-up on the psychiatry recommendation. The DON, who was responsible for follow-ups, was unaware of the recommendation due to a failure in the facility's process of communicating psychiatry consult reports to the appropriate personnel.
Failure to Address Resident Grievances on Missing Personal Items
Penalty
Summary
The facility failed to adhere to its Grievance/Complaints, Filing policy and procedure by not promptly responding to and resolving grievances for two residents, identified as Resident 5 and Resident 26. Both residents reported missing personal items during a resident council meeting, with Resident 5 missing a purple brassiere with star symbols and Resident 26 missing two sport shirts. Despite these complaints being documented in the Resident Council Minutes, there was no follow-up action taken by the facility staff to address these grievances. Interviews revealed that the Activity Director informed the staff by leaving a referral for response in the social services mailbox, but the Social Worker stated she did not receive any such referral. The Administrator was also unaware of these grievances and acknowledged that the expectation was for complaints from resident council meetings to be addressed within a week. The facility's policy, revised in April 2017, mandates that the Administrator and staff make prompt efforts to resolve grievances, which was not followed in this instance.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several maintenance issues observed in different areas. In the resident care hallway, floor tiles were broken and coming off, posing a potential hazard. The Maintenance Supervisor (MS) acknowledged the issue but had not addressed it, despite conducting regular room rounds. Additionally, the baseboards in Rooms A and B were missing and broken, with drywall and plaster pieces sticking out, which MS also failed to notice during his rounds. In Rooms A and B, overbed tables for two residents were chipped and unfurnished, with rough edges that could cause injury. The screen door for Room A was broken and off the track, and MS admitted awareness of the issue but had not yet replaced it. Electrical cords for a television and a call light in Room B were taped to the wall, which MS recognized as unsafe but had not corrected due to a lack of staples. Furthermore, the wall clock in Room B displayed an incorrect time, causing confusion for a resident, and the shared bathroom between Rooms A and B lacked soap for over two days, despite being reported to the janitorial staff. The smoking patio contained broken and rusty furniture with sharp edges, which posed a risk of injury to residents. The Director of Staff Development (DSD) and MS acknowledged the condition of the furniture, but it had not been removed or replaced. The facility's maintenance logbook did not reflect these issues, indicating a lack of proper reporting and follow-up on maintenance needs. The facility's policy and procedure for maintenance services, which requires maintaining the building and equipment in a safe and operable manner, was not adhered to, leading to these deficiencies.
Inaccurate PASRR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for two residents, leading to potential inappropriate placement and lack of necessary mental health services. Resident 44's PASRR Level 1 Screening was not resubmitted after the resident remained in the facility for more than 30 days, despite having multiple mental health diagnoses including Unspecified Dementia with Psychotic Disturbance, Anxiety Disorder, Paranoid Personality Disorder, Depression, and Auditory Hallucinations. The facility's policy required a new Level 1 Screening within 40 days of admission if the stay exceeded 30 days, but this was not done, and the Director of Nursing (DON) incorrectly stated that the screening did not need to be repeated. Resident 37's PASRR Level 1 Screening was completed inaccurately, failing to identify the resident's serious mental disorders, including Depression and Schizophrenia, and the use of psychotropic medication, Trazadone, for Depression. The assessment incorrectly marked 'No' for questions regarding serious diagnosed mental disorders and the use of psychotropic medications. The DON mistakenly believed that Trazadone was not a psychotropic medication and that the assessment was accurate despite the resident's schizophrenia diagnosis. The MDS Coordinator (MDSC) acknowledged the inaccuracies and noted that the facility was responsible for reviewing the assessment for accuracy, which could have led to appropriate mental health referrals. The deficiencies in the PASRR process for both residents were identified through interviews and record reviews. The facility's failure to adhere to its own policy and accurately complete the PASRR assessments placed the residents at risk of not receiving the necessary mental health services. The MDSC confirmed the lack of records for psychiatric referrals or consults for Resident 37, highlighting the oversight in addressing the residents' mental health needs.
Failure to Enforce Smoking Safety Policies
Penalty
Summary
The facility failed to adhere to its smoking policy and procedures, leading to potential accident hazards for three residents. Resident 19, who has amputated fingers and limited range of motion, was found to be non-compliant with the smoking policy, keeping cigarettes and a lighter in her possession despite being assessed as unable to safely light, hold, and extinguish tobacco. The facility staff, including the Activity Assistant and Licensed Vocational Nurse, were aware of her non-compliance but did not enforce the necessary supervision or safety measures. Resident 41 was not properly assessed for smoking safety, and his care plan did not reflect his smoking habits. Despite being a known smoker, the charge nurses were unaware of his smoking status, and he was allowed to smoke unsupervised. The smoking evaluation conducted was incomplete, and the staff failed to communicate his smoking status to the attending physician or other direct care staff. This lack of oversight and communication resulted in Resident 41 smoking without the necessary supervision or safety precautions. Resident 37, who was assessed to require a smoking apron and cigarette holder due to balance issues, did not receive these safety items. The facility did not have smoking aprons available, and staff were unaware of their location or existence. Additionally, a janitor was observed smoking in the smoking patio with doors to adjacent rooms open, exposing residents to secondhand smoke. Cigarette butts were improperly disposed of in flower planters, posing a fire risk. These actions and inactions by the facility staff contributed to an unsafe environment for residents who smoke.
Failure to Conduct Competency Evaluations for Licensed Nurses
Penalty
Summary
The facility failed to complete performance reviews and maintain competency/skills records for three licensed nurses, identified as LVN 1, RN 2, and RN 4. This deficiency was discovered through interviews and record reviews conducted with the Director of Staff Development (DSD) and the Director of Nursing (DON). LVN 1, who was hired on June 17, 2024, reported not receiving any orientation, training, or competency evaluation upon or after hire. Similarly, RN 2 and RN 4, hired on May 5, 2023, and August 23, 2023, respectively, had no documentation of competency evaluations in their personnel files. The DSD acknowledged the absence of these evaluations and expressed uncertainty about how to anticipate staff training needs. The facility's policy and procedure, revised in May 2019, mandates that competency evaluations be conducted upon hire, annually, and as necessary based on facility assessments. However, the DON admitted to not having completed any competency evaluations since starting at the facility. The Administrator confirmed that the DON was responsible for these evaluations and noted that this issue had been identified in a previous annual recertification survey. The lack of competency evaluations for the licensed nurses placed residents at risk of receiving care from potentially incompetent staff, as the facility was unable to identify and address training needs effectively.
Failure to Conduct CNA Competency Evaluations
Penalty
Summary
The facility failed to complete annual performance reviews and competency checks for its Certified Nursing Assistants (CNAs), which are essential for ensuring the provision of competent care to residents. Specifically, the facility did not conduct or maintain records of competency checks for CNA 7, who has been employed since November 2020, and did not complete orientation competency checks for CNAs 4 and 6, who have been employed since May 2024 and January 2024, respectively. The Director of Staff Development (DSD) admitted to not having completed any competency checks in the past two months since starting the role, and the facility's policy requires these evaluations upon hire, after 90 days, and annually. The Administrator acknowledged that the facility's policy mandates standard orientation and competency assessments for CNAs, but these were not being conducted as required. The facility had been non-compliant with this requirement during a previous annual recertification survey as well. The lack of completed evaluations and documentation placed residents at risk of receiving care from potentially incompetent CNAs, as the facility did not ensure that CNAs were adequately trained and evaluated in necessary skills and techniques.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store and prepare foods in a sanitary manner, which could potentially expose residents to foodborne illness. During an initial tour of the kitchen, an opened bag of sliced ham was found in the refrigerator without a label or use-by date. This was observed by the Dietary Aide and Dietary Manager. Additionally, during a subsequent observation and interview, the kitchen's vents, fans, and window screens were found to be dusty. The Maintenance Supervisor, who was responsible for cleaning these areas monthly, admitted to not having any records or documentation of the cleaning. The facility's policy and procedure for food receiving and storage, revised in July 2014, requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Furthermore, the facility's sanitation policy from 2023 indicates that the Maintenance Department should assist Food & Nutrition Services in maintaining equipment and performing janitorial duties, with maintenance records kept on all equipment.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration by a registered nurse (RN). On multiple occasions, RN 2 did not perform hand hygiene before and after glove use while administering medications to residents. Specifically, RN 2 was observed preparing and administering medications to three different residents without sanitizing hands before donning gloves or after removing them. This included handling medication cups, eye drop bottles, and inhalers, as well as touching the medication cart and keys with contaminated gloves. During an interview, RN 2 acknowledged the importance of hand hygiene to prevent the transfer of bacteria and viruses. Additionally, the facility did not ensure the cleanliness of medical equipment, as evidenced by the condition of an IV pole in a resident's room. The IV pole, which was used for nutritional feeding, was observed with multiple dried light brown stains. Both a licensed vocational nurse (LVN) and the infection preventionist (IP) confirmed that the IV pole appeared unclean and acknowledged that there was no documentation of its cleaning schedule. The facility's policy required regular cleaning and disinfection of environmental surfaces, including IV poles, to prevent infection. The facility's failure to adhere to its own policies and procedures regarding hand hygiene and environmental cleaning posed a risk of cross-contamination and the spread of infections among residents. The infection preventionist confirmed that hand hygiene should be performed before and after glove use, and that environmental surfaces should be cleaned according to CDC recommendations. However, the observations and interviews indicated lapses in these practices, highlighting deficiencies in the facility's infection control program.
Failure to Utilize Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a non-English speaking resident, identified as Resident 43, who preferred to communicate in Chinese and required an interpreter for interactions with healthcare staff. Despite having a communication binder available, the staff, specifically CNA 5, was unaware of its existence and relied on gestures and pointing to communicate with the resident. This lack of awareness and utilization of the communication tool led to a communication barrier, as observed during an interaction where the resident was unable to effectively communicate her needs. The Director of Staff Development acknowledged that CNAs were expected to use communication binders for non-English speaking residents but admitted that no in-service training had been provided on this matter. Additionally, the facility lacked an interpreter access phone line, and the administrator mentioned that staff could use Google Translate as an alternative. The facility's policy on language access, revised in November 2020, stated that individuals with limited English proficiency should have meaningful access to information and services, a standard that was not met in this instance.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing and effective activity program to meet the preferences and goals of a resident, identified as Resident 37. The resident was admitted to the facility with a documented interest in activities such as drawing and painting, as noted in the Admission Minimum Data Set and discharge planning review. Despite these documented preferences, the resident was observed lying in bed without engagement in activities and expressed feelings of worthlessness due to inactivity. The resident reported a lack of adequate art supplies and insufficient visits from the activity staff to support his interests. The activity assistant confirmed that Resident 37 received only three visits per week for art and games at bedside and attended the activity room twice a month. However, the activity participation logs lacked documentation of one-on-one activity participation since July 2024. The facility's policy on activity programs, revised in 2018, states that activities should support the physical, mental, and psychological well-being of each resident, which was not adhered to in this case, leading to a risk of mental and psychosocial decline for the resident.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate wheelchair for a resident with a left hip contracture, who was admitted seven months prior. The resident's care plan indicated the use of assistive devices as ordered, but there was no documentation of a wheelchair evaluation in the therapy treatment records since admission. The resident expressed the need for a larger wheelchair, as the current Geri-chair was too small and uncomfortable, causing physical discomfort and limiting mobility. The facility had only one Geri-chair, which residents shared, and the manual wheelchair available was unsuitable in size and had non-functional brakes. The resident's goal was to return to the community with home health services, but the lack of appropriate mobility support left the resident mostly bedbound, contributing to feelings of worthlessness and hopelessness about achieving personal goals. The resident expressed sadness about missing significant family events and felt separated from family due to being confined to bed. Interviews with facility staff revealed a lack of awareness regarding the Geri-chair's weight limit and the responsibility for evaluating medical equipment needs, highlighting a gap in the facility's care provision and assessment processes.
Medication Administration Error Due to Misunderstanding of Eye Drop Contents
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident diagnosed with glaucoma. During a medication administration, a registered nurse (RN) was unable to locate the prescribed Brinzolamide eye drops in the medication cart and mistakenly believed they were unavailable. The RN proceeded to administer only the Artificial Tears eye drops, which were also prescribed for the resident's dry eyes. The RN was unaware of how long the Brinzolamide eye drops had been unavailable and planned to reorder them from the pharmacy. Upon further review, it was discovered that the Brinzolamide eye drops were in the medication cart all along, as they were part of the Simbrinza eye drop bottle, which contains both Brinzolamide and Brimonidine. The RN had mistakenly thought Simbrinza and Brinzolamide were two different medications. This oversight was documented in the resident's progress notes, and the facility's policy on administering medication clearly states that medications should be administered as prescribed.
Unauthorized Access and Improper Medication Storage
Penalty
Summary
The facility failed to ensure proper medication storage and access control, leading to two significant deficiencies. Firstly, an unauthorized staff member, the Central Supply Staff (CSS), had access to the medication room. The CSS was able to unlock the medication room door using a key provided to him when he started working at the facility. The Director of Nursing (DON) confirmed that the CSS was not authorized to prepare and administer medications, yet he was allowed to access the medication room to obtain over-the-counter medications. This was in direct violation of the facility's policy, which states that only authorized personnel should have access to the medication room. Secondly, an unlabeled and undated medication cup filled with a white creamy substance was found unattended on top of a resident's overhead light fixture for over 24 hours. The resident, identified as Resident 31, was lying in bed during the observation. The substance was suspected to be Eucerin cream by Registered Nurse 2 (RN 2), but this could not be confirmed due to the lack of labeling. RN 2 acknowledged that medication cups should be discarded after use and expressed concern that confused and ambulatory residents could easily access and ingest the unknown substance. This oversight posed a risk of accidental access to the substance by residents.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the person designated to serve as the director of food and nutrition services met the required federal and/or state educational qualifications when a full-time registered dietitian was not hired. The Dietary Manager (DM), who worked full-time, admitted during an interview that she was not a certified director of food and nutrition and was still in school. The facility had a Registered Dietician (RD) who visited weekly to complete new admission assessments of residents. The Administrator acknowledged awareness of the DM's lack of educational qualifications for the position. This lack of full-time, competent oversight of food and nutrition staff placed residents at risk for foodborne illness and/or decreased nutrient intake, which could potentially result in death and/or nutritional-related medical complications.
Inaccurate Discharge Planning Assessment
Penalty
Summary
The facility failed to accurately complete the functional status in the discharge planning assessment for one of the residents, leading to an inaccurate reflection of the resident's clinical condition. The resident, identified as Resident 37, was admitted to the facility and was assessed as being dependent on staff for various activities of daily living, including toilet hygiene, showering, lower body dressing, personal hygiene, and wheelchair mobility. However, during an observation, it was noted that the resident was bedbound and unable to fully extend both legs, contradicting the assessment that indicated independence in using a wheelchair and performing other activities. The Social Worker (SW) responsible for completing the discharge planning assessments admitted to using assumptions rather than direct observations or consultations with the resident's direct care staff. The SW had never observed the resident using a wheelchair or performing activities independently, yet the discharge planning review inaccurately reflected these capabilities. The Regional Social Services Director (RSS) acknowledged that the SW was trained to gather input from all disciplines working with residents, but this was not done in this case. The facility's policy on documentation emphasized the need for objective, complete, and accurate records, which was not adhered to in this instance.
Failure to Coordinate Hospice Care Plan
Penalty
Summary
The facility failed to adhere to a written hospice agreement that required joint responsibilities to develop and implement a coordinated plan of care (POC) for a resident admitted into a hospice program. The deficiency was identified when the resident's hospice POC did not reflect the participation of facility staff, the resident, and the resident's representative. The resident, who was on hospice care due to senile degeneration of the brain and had a diagnosis of non-Alzheimer's dementia, was not included in a care plan conference with the facility and hospice agency. The resident's family also reported not being invited to participate in the hospice POC. Interviews with facility staff, including the Director of Nursing, Registered Nurse/Hospice Nurse, and MDS coordinator, confirmed that a care planning conference involving the resident, family, and hospice agency had not taken place. The Regional Social Services Director acknowledged that the social services department was responsible for coordinating the care plan conference but had not invited the resident and family to participate. The facility's Nursing Facility Services Agreement stipulated that the POC should reflect the participation of hospice, facility, and the hospice patient and family, which was not adhered to in this case.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility was found to have seven resident rooms with multiple beds that did not meet the required space of at least 80 square feet per resident. Each of these rooms had three beds with a total area of 238 square feet, resulting in only 79.33 square feet per bed. This deficiency was identified through observation, interview, and record review. Despite the insufficient space, observations from 10/21/24 through 10/24/24 indicated that there was adequate space for the provision of care, no heavy equipment was present that could interfere with care, and residents had sufficient personal space and privacy. There were no complaints from residents about space for their belongings, and no negative consequences or safety concerns were noted due to the decreased space in these rooms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,067 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Paul's Towers | 0.6 mi | ★★★★★ | 0 | 0 |
| Oakland Healthcare & Wellness Center | 0.6 mi | ★★★★★ | 12 | 0 |
| Lake Park Healthcare Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Piedmont Gardens Health Facility | 0.8 mi | ★★★★★ | 0 | 0 |
| The Rehabilitation Center Of Oakland | 1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.