Health inspection·January 28, 2025

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on observation, interview and record review the facility failed to ensure one ( Resident 1) of 3 sample residents with diagnosis of schizophrenia, a mental health condition, received appropriate treatment to address Resident 1 ' s paranoid delusions when Resident 1 ' s psychiatry recommendation to increase Olanzapine (antipsychotic medication) dosage was not implemented. {Paranoid delusions are fixed, false beliefs that others are intentionally trying to harm, deceive, or persecute the individual} This failure had the potential to cause Resident 1 increased emotional distress, decline in mental and psychosocial well-being. Findings: During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment and care guide tool), dated 12/9/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1 ' s score was 13. Resident 1 had clear speech, able to express ideas and wants, make self-understood and understood others. Resident 1 ' s diagnoses included schizophrenia a disorder that affects a person ' s ability to think, feel and behave clearly. During a review of Resident 1 ' s Level I Preadmission Screening and Resident Review (PASRR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care), dated 8/31/23, the PASRR indicated, Resident 1 ' s Level I screening result was positive for suspected MI (mental illness) and indicated a Level II mental health evaluation was required. During a review of Resident 1 ' s progress notes, dated 1/16/25, the progress notes indicated , Resident 1 alleged that staff were calling her names. During a concurrent observation and interview on 1/28/25 at 10:20 a.m. Resident 1 laid in bed, awake and verbally responsive. Resident 1 stated she did not want to discuss her allegation regarding staff calling her names. Resident 1 suddenly became upset, agitated and started yelling. During an interview on 1/28/25 at 10:28 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated she was Resident 1 ' s care giver. CNA1 said Resident 1 got easily agitated, screamed and sometimes Page 1 of 2 056350 056350 01/28/2025 Lake Merritt Healthcare Center LLC 309 MacArthur Boulevard Oakland, CA 94610

F 0742 aggressive with staff. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s Order Summary Report dated 6/3/24, the report indicated physician prescribed Resident 1 to receive Olanzapine tablet 10mg give one tablet by mouth one time a day for schizoaffective disorder bipolar type, manifested by paranoid delusion as exhibited by constant screaming to the point of exhaustion. Residents Affected - Few During a review of Resident 1 ' s psychiatry follow up note and recommendations, dated 10/14/24, the psychiatry recommended to increase Resident 1 ' s Zydis (Olanzapine) to 15 mg by mouth every day for schizoaffective disorder, uncooperative with care, irritable, paranoid delusions, yelling. During a concurrent interview and record review on 1/28/25 at 11:40 a.m. with DON, Resident 1's positive PASRR Level 1 screening dated 8/31/23 and psychiatry recommendation dated 10/14/24 were reviewed. DON stated Resident 1's was not refered for Level II mental health evaluation. DON stated she was hired in December 2024 and was not aware of Resident 1 ' s psychiatry recommendation to increase Resident 1 ' s Olanzapine dose to 15 mg daily. DON stated the facility ' s process was that the medical record department received psychiatry consult reports , medical records gives copies of residents ' psychiatry reports to Licensed Nurses, who call the physician to approve or decline residents ' psychiatry recommendation and DON was primarily responsible for the follow-ups. During a concurrent interview and record review on 1/28/25 at 12:03 p.m. with Licensed Vocational Nurse (LVN1), Resident 1 ' s psychiatry recommendation dated 10/14/24 was reviewed. LVN1 stated she was a charge nurse. LVN 1 stated she was not aware of Resident 1 ' s psychiatry recommendation. LVN 1 stated the Director of Nursing (DON) followed up with residents psychiatry recommendations. During a concurrent interview and record review on 1/28/25 at 12:30 p.m. with DON, Resident 1 ' s Psychiatry recommendations report dated 10/14/24, physician orders, medication administration records, progress notes were reviewed with DON. DON stated there was no indication that Resident 1 ' s psychiatry recommendation dated 10/14/24 to increase Resident 1 ' s Olanzapine to 15 mg by mouth every day was followed up. The DON stated she was unable to find documentation if facility notified physician of Resident 1 ' s psychiatry recommendations. 056350 Page 2 of 2