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 Park Healthcare Center during CMS and state inspections, most recent first.
A resident admitted with hemiplegia and hypertension did not receive several ordered medications for three days because hospital discharge medication orders were not properly verified or transcribed. The DON later acknowledged confusion over multiple hospital medication lists and confirmed that key drugs for BP control, pain, blood thinning, and cardiac/BP management were omitted from the MAR. The admitting LVN located faxed discharge orders in the electronic record but did not contact the admitting MD to verify or clarify the admission orders and did not document any physician communication. The MD reported he was not contacted at admission, despite facility policy requiring documentation of receipt and verification of physician orders, and the resident was subsequently transferred to the hospital for syncope.
The facility failed to follow the posted lunch menu and did not obtain timely RD approval for a dessert substitution affecting most residents. The weekly menu listed apple pie for lunch dessert, but cheesecake was served instead, as confirmed by observation and by the dietary manager. The RD later stated the menu should be followed and that substitutions must be documented on a Substitute Log with the scheduled item, the replacement item, and the reason, and must be reviewed and signed by the RD. The facility’s substitution record showed apple pie was replaced with cheesecake due to non-delivery, but the entry lacked RD signature, and the RD reported not being informed of the change in advance.
A resident with s/p joint replacement, T2DM, and depression, who had intact cognition, repeatedly requested a large salad for lunch daily and copies of the weekly menu, stating concern that the regular food was unhealthy. The CDM and RD were aware of the preference and believed the resident was receiving a daily salad, but observation showed the resident was served a standard meal instead of the requested large salad. The resident’s preference was not timely incorporated into the diet orders or care plan, and the facility’s own policy requiring assessment, documentation, and communication of food preferences to the IDT was not followed, creating potential for weight loss and anger/depression when the resident’s dietary requests were not met.
A treatment cart containing medications and sharp instruments was left unlocked and unsupervised in a resident-accessible area. The cart remained unlocked while an LVN administered medications in resident rooms. The DON confirmed that the cart should always be locked when unattended, as per facility policy.
The facility failed to maintain safe and sanitary food storage and preparation conditions. Observations revealed dry food stored less than six inches above the floor, unlabeled and undated refrigerated and frozen items, and raw pork stored over ready-to-eat shrimp. The resident refrigerator-freezer contained unlabeled food and instant cold packs, posing cross-contamination risks. The ice machine had suspected mold, requiring cleaning. These practices violated the facility's food handling policies.
A facility failed to follow infection control practices when a LVN used a blood pressure machine on multiple residents without disinfecting it between uses. This included a resident on Enhanced Barrier Precautions. The Infection Preventionist confirmed the need for disinfection between uses, as outlined in the facility's policies.
Failure to Verify and Transcribe Admission Medication Orders
Penalty
Summary
The facility failed to ensure a resident’s hospital discharge medication orders were verified with the admitting physician upon admission, resulting in inaccurate transcription and missed medications. The resident was admitted with multiple diagnoses including hemiplegia and essential hypertension. The hospital’s short-term Medicare referral and discharge documents included an active medication list and discharge orders. The DON later acknowledged being confused by multiple medication lists from the hospital and confirmed that several discharge medications were not transcribed onto the admission orders or MAR and therefore were not administered for three days. The medications omitted included Amlodipine for blood pressure, Buprenorphine for pain, Clopidogrel as a blood thinner, and Hydralazine for heart and blood pressure management. The resident’s responsible party met with the DON and expressed concerns about missing medications on the MAR. The admitting LVN stated the resident did not arrive with paper discharge orders and that he located the discharge orders via fax in the electronic record and used them to create admission orders, but he did not contact the admitting physician to verify or clarify those orders. The LVN also did not document any contact with the physician regarding admission orders. The resident’s primary physician, who was the admitting physician, reported he was not contacted by nursing staff at the time of admission and stated he expected licensed nurses to verify and clarify admission orders upon admission. Facility policy on admission documentation required the admitting nurse to document the time physician orders were received and verified, but there was no documentation that this occurred for this resident, and the resident did not receive the ordered medications for three days, culminating in a transfer to the hospital for syncope.
Failure to Follow Posted Menu and Obtain RD Approval for Dessert Substitution
Penalty
Summary
The deficiency involves the facility’s failure to follow the posted lunch menu and to obtain timely RD approval for a dessert substitution affecting 29 of 32 residents. The posted Fall/Winter 2025–2026 Week 3 Wednesday lunch menu listed black bean soup, mixed green salad, turkey and Swiss sandwich, pasta salad, lettuce, tomato, pickle, apple pie, 2% milk, hot tea, and coffee. During observation of the lunch meal service, residents were instead served cheesecake for dessert. Two residents were observed eating lunch without assistance, and one resident identified the dessert as lemon cheesecake. The Certified Dietary Manager confirmed that cheesecake was served instead of the posted apple pie. The RD reported that the dietary spreadsheet/menu should be followed and that a Substitute Log must document the scheduled food item, the substituted item, and the reason for substitution. The RD stated she was not informed in advance that apple pie was unavailable and would be replaced with cheesecake. The facility’s Menu Substitution Record showed an entry dated 1/16/26 indicating apple pie was substituted with cheesecake because the pie was not delivered, but this entry lacked the RD’s signature. The facility’s Dining Service Menu Guide, dated 2019, states that any menu change, including one-time substitutions, requires Consultant Dietitian approval and that a substitution log must be maintained and reviewed and signed by the Consultant Dietitian. These observations and records show the dessert substitution was made and implemented without timely RD awareness or documented approval.
Failure to Honor Resident’s Stated Food Preferences and Update Dietary Care Plan
Penalty
Summary
Facility staff failed to ensure that a resident’s dietary needs and preferences were updated and incorporated into the care plan. The resident, admitted with s/p joint replacement surgery, T2DM, and depression, had intact cognition and was able to communicate needs clearly. The active diet order indicated a controlled carbohydrate diet with regular texture, and the care plan noted nutritional problems related to the resident’s diagnoses with an intervention for the RD to evaluate and make diet change recommendations as needed. The facility’s policy required that individual food preferences be assessed upon admission or within 24 hours, communicated to the IDT, and documented in the care plan, with modifications to diet ordered with the resident’s or representative’s consent. The resident reported having told staff numerous times that she wanted a big bowl of salad for lunch every day because she believed the facility’s food was unhealthy, and also stated she had repeatedly requested copies of the weekly menu but had never received them. The CDM acknowledged that the resident wanted a big salad daily, stated this had been verified with the RD and Chef, and reported that the resident had been receiving the big salad every day and that menus could easily be provided. However, observation of the resident’s lunch tray showed a cranberry drink, black bean soup, fresh fruit, and a turkey and Swiss sandwich with pasta salad and lettuce and tomatoes on the side, rather than the requested big bowl of salad. The RD later confirmed awareness of the resident’s preference for a daily big salad at lunch but stated not being aware that the resident had not consistently received it. The report also notes that the failure to address the resident’s dietary requests in a timely manner had the potential for weight loss due to decreased consumption and/or anger/depression when requests were not met.
Failure to Secure Medications and Instruments
Penalty
Summary
The facility failed to properly secure medications and sharp instruments, as observed when a treatment cart was left unlocked and unsupervised in a resident-accessible area. During an observation, a treatment cart containing topical medications, ointments, scissors, nail clippers, and other treatment supplies was found unlocked in a hallway between six resident bedrooms and the activity/dining room. Multiple residents passed by the cart while it remained unlocked from 7:46 a.m. to 11:30 a.m. as the Licensed Vocational Nurse (LVN) went into four separate resident bedrooms to administer medications. In an interview, the LVN confirmed that the treatment cart contained prescribed medications. The Director of Nursing (DON) also acknowledged that the cart contained medications and items that should not be accessible to residents, emphasizing that it should always be locked when unattended. The facility's policy and procedure for the storage of medications indicated that compartments containing drugs and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or potentially available to others.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared under safe and sanitary conditions, as observed during a survey. Dry food items were stored less than six inches above the floor, which the Registered Dietician (RD) acknowledged as a contamination risk. Refrigerated and frozen food items were found unlabeled and undated, including an opened package of hash browns past its use-by date and several packages of unknown meats. Additionally, raw pork was stored directly over ready-to-eat shrimp, posing a risk for foodborne illness. The RD confirmed that these practices were not in compliance with safe food handling standards. Further observations revealed that the resident refrigerator-freezer contained food items not labeled with a resident identifier or date, and instant cold packs were stored among resident food, which the Director of Nursing (DON) identified as a cross-contamination risk. The resident ice machine was found to have a dark brownish matter, suspected to be mold, which the Maintenance Director (MD) and Dietary Manager (DM) agreed needed cleaning and sanitization. The facility's policy and procedure on food receiving and storage, revised in October 2017, was not adhered to, as it required foods to be stored off the floor, labeled, and dated, and toxic substances not to be stored in food areas.
Inadequate Infection Control Practices with Reusable Equipment
Penalty
Summary
The facility failed to adhere to proper infection control practices by not cleaning or disinfecting reusable resident-care equipment between uses on different residents. During an observation, a Licensed Vocational Nurse (LVN) was seen using a blood pressure machine on multiple residents without sanitizing the cuff between uses. The LVN first used the machine on a resident, then proceeded to use it on two other residents, including one who was on Enhanced Barrier Precautions due to infection control concerns, without cleaning the equipment in between. The Infection Preventionist confirmed that multi-use resident care items should be sanitized or disinfected between residents to prevent infection spread, especially for those with compromised immunity. The facility's policy and procedure documents, dated 2018 and 2024, respectively, also indicated that reusable items should be cleaned and disinfected between residents. However, these protocols were not followed, as evidenced by the LVN's actions, which were observed and documented during the survey.
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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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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 | 0.4 mi | ★★★★★ | 0 | 0 |
| Lake Merritt Healthcare Center Llc | 0.8 mi | ★★★★★ | 8 | 0 |
| Bay Area Healthcare Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Oakland Healthcare & Wellness Center | 0.9 mi | ★★★★★ | 12 | 0 |
| Medical Hill Healthcare Center | 1 mi | ★★★★★ | 6 | 0 |
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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.