A list of the most recent deficiencies for Lake Merritt Healthcare Center LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-11-16 | 2024-01-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-16 | 2024-01-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-16 | 2024-01-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-16 | 2024-01-14 | N |
| Post nurse staffing information every day. | Health | 2023-11-16 | 2024-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-16 | 2024-01-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-16 | 2024-01-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-16 | 2024-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2024-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2024-01-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-16 | 2024-01-14 | N |
| Keep all essential equipment working safely. | Health | 2023-11-16 | 2024-01-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-11-16 | 2024-01-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-16 | 2024-01-14 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-20 | 2023-12-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-27 | 2021-11-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-16 | 2021-08-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-16 | 2021-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-16 | 2021-08-24 | N |
| Keep all essential equipment working safely. | Health | 2021-07-16 | 2021-08-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-16 | 2021-08-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-22 | 2021-08-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-05 | 2021-05-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-05 | 2021-04-30 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-26 | 2020-04-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-13 | 2020-03-13 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-02-13 | 2020-03-13 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-13 | 2020-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-13 | 2020-03-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-13 | 2020-03-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-13 | 2020-03-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-13 | 2020-03-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-13 | 2020-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-13 | 2020-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-13 | 2020-03-13 | N |
| Keep all essential equipment working safely. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-13 | 2020-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | Not Fixed | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-12 | Not Fixed | N |
