Other·August 1, 2017

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public health during the investigation of one entity reported incident and two complaints. Entity Reported Incident Number: CA00523016 Representing the Department: 31403, HFEN Complaint Numbers: CA00523459 CA00523456 The inspection was limited to the specific entity reported incident and complaints investigated and does not represent the findings of a full inspection of the facility. No deficiencies were issued for entity reported incident number CA00523016 and complaint number CA00523459. Two deficiencies were issued for complaint number CA00523456.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 06/20/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056350 (X3) DATE SURVEY COMPLETED 06/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to provide services which met professional standards of care for one, Resident 3, of four sampled residents. Resident 3 had a low blood potassium [a chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells] level and staff did not notify the physician. This failure had the potential to result in Resident 3 experiencing disruptions in the electrical activity of his heart, muscle weakness, or paralysis. Findings: Review of Resident 3's "Minimum Data Set," (MDS - an assessment tool used to guide care), dated 12/2/16, indicated Resident 3's diagnoses included high blood pressure. Review of Resident 3's "Physician Orders," dated 1/24/17, indicated Resident 3 was to receive Lasix (medication used to reduce fluid in the body and can lead to a loss of potassium) 20 mg two times per day and potassium one time per day. Review of Resident 3's "Physician Orders," dated 1/30/17, indicated staff were to arrange for a Basic Metabolic Panel (BMP - a lab test used to check chemical levels in the blood, including potassium) blood draw on 2/7/17. Review of Resident 3's "Lab Results," indicated the potassium level from the 2/7/17 lab draw was 3.3 millimoles per liter (mmol/L) (normal range for blood potassium level is 3.6 to 5.2 mmol/L). In an interview with the Director of Staff Development (DSD) on 3/9/17 at 9:30 a.m., the DSD stated Resident 3's low potassium result was faxed to the physician. The DSD also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056350 (X3) DATE SURVEY COMPLETED 06/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated there was no fax confirmation sheet and could therefore not confirm the potassium level had been faxed to the physician. Review of Resident 3's "Physician Orders," (order) dated 2/13/17, indicated an order for Resident 3 to receive an additional dose of potassium immediately and an order for another BMP blood level. The orders also indicated instructions for the staff to fax the BMP lab results to the physician as soon as they were available. In an interview with the DSD on 3/9/17 at 9:30 a.m., the DSD stated she was unsure what staff had done between the 2/7/17 blood draw (when Resident 3's potassium was 3.3 mmol/L) and 2/13/17 (when the doctor ordered an immediate dose of potassium and another BMP lab draw). The DSD stated staff were required to fax the lab results to the physician and then receive an order from the doctor over the phone regarding how to treat the low potassium. The DSD also stated that in addition to notifying the doctor, staff were to enter the critical lab value on the facility's 24 hour report (a report with important resident information that was shared among all the shifts). The DSD confirmed there was no documentation in the 24 hour report for 2/7/17 and 2/8/17 or in the nursing notes regarding Resident 3's low potassium. The DSD stated the doctor should have been notified since Resident 1 was at risk for serious medical problems due to the low potassium. Review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status," dated 2015, indicated "Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056350 (X3) DATE SURVEY COMPLETED 06/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the Centers for Disease Control and Prevention, "Hypokalemia, (low potassium), can lead to ventricular tachycardia, (fatal heart rhythm), hyper and/or hypotension, (high or low blood pressure), muscle weakness and paralysis." [Reference: www.atsdr.cdc.gov/ToxProfiles/Tp24-c2.pdf]

F333 SS=G RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 07/06/2017 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure there were no significant medication errors for one of four sampled residents (Resident 4). Resident 4 did not receive the physician ordered intravenous (IV delivered through a vein and into the blood) antibiotics on 2/14/17 or 2/15/17. This failure resulted in Resident 4 developing an elevated body temperature and being sent to the hospital emergency room. Findings: Review of Resident 4's hospital "Most Recent After Visit Summary," admission date 2/10/17, indicated Resident 4 had diagnoses that included sepsis (a life threatening condition caused by the body's response to an infection FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056350 (X3) DATE SURVEY COMPLETED 06/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in the blood) and had physician orders, dated 2/10/17, to receive 300 milligrams of Amikacin (antibiotic medication) intravenously (IV through a vein) every 12 hours through 2/19/17. Review of Resident 4's hospital "Medication Administration Record" (MAR), dated 2/13/17, indicated Resident 4 had started the Amikacin IV antibiotics on 2/10/17 and received it every 12 hours (at 7:00 a.m. and 7 p.m.) while in the hospital. Review of Resident 4's "Nursing Notes," dated 2/14/17, at 9 p.m., indicated Resident 4 was admitted to the facility on 2/14/17 at 5:30 p.m. The Nursing Notes did not indicate an assessment of the condition of Resident 4's IV insertion site or documentation of the plan to begin administration of the IV antibiotics. The Nurse's notes also indicated "...Faxed all resident medications to pharmacy. Per pharmacy all her (Resident 4's) medications will receive tonight...." Review of the facility pharmacy "Delivery Manifest," dated 2/15/17, at 10:53 a.m., indicated the facility received Resident 4's Amikacin antibiotic on 2/15/17 at 10:50 a.m. In an interview with the Director of Staff Development (DSD) on 3/9/17, at 1 p.m., the DSD stated she could not locate Resident 4's MAR that reflected her stay at the facility from 2/14/17 at 5:30 p.m. until 2/15/17 at 5:30 p.m. (when Resident 4 returned to the hospital). In an interview with Licensed Vocational Nurse (LVN) 1 on 5/4/17, at 9:15 a.m., LVN 1 stated she did not give any antibiotics to Resident 4 on the evening of 2/14/17 because she was not certified or licensed to give IV medications. LVN 1 stated she informed the Registered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056350 (X3) DATE SURVEY COMPLETED 06/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKE MERRITT HEALTHCARE CENTER LLC 309 Macarthur Boulevard Oakland, CA 94610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nurse (RN) on the same shift that she (LVN 1) was not able give the antibiotics to Resident 4 and only an RN could administer the IV medication. LVN 1 stated Resident 4 did not receive any antibiotics while in the facility. LVN 1 worked with Patient 4 the next evening (2/15/17) and was told to transfer Resident 4 to the hospital emergency room so she could receive the antibiotics. Review of the discharge nursing note on 2/15/17, at 6 p.m., indicated Resident 4 returned to the hospital to receive her antibiotic treatment. Review of Resident 4's "Emergency Department Progress," dated 2/15/17, indicated Resident 4 was admitted to the hospital for IV antibiotics because the facility was "Unable to give IV antibiotics or check labs..." The Emergency Department Progress notes also indicated on admission to the emergency room , Resident 4 had a body temperature of 100.8 degrees Fahrenheit (°F) that rose to 101.1 (°F) (normal is 98.6 °F). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GPGO11 Facility ID: CA020000110 If continuation sheet 6 of 6