Health inspection·January 22, 2026

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure lunch menu was followed for 29 of 32 residents when:1. Kitchen served cheesecake instead of apple pie as posted on the menu.2. Registered Dietitian (RD) was not made aware of menu substitution in a timely manner.This failure resulted in 29 residents receiving dessert substitution during lunch, on 1/14/26, without the approval of the RD. A review of the posted undated weekly menu titled Fall/Winter 2025-2026, Week 3 indicated for Wednesday, Lunch included black bean soup, mixed green salad, turkey and Swiss sandwich, pasta salad, lettuce, tomato, and pickle, apple pie, 2% milk, hot tea, and coffee. During a concurrent observation and interview on 1/14/26, at 11:45 a.m., in the Dining/Activity Room, both residents, Resident 2 and Resident 3, ate lunch without assistance. Resident 3 stated the dessert was lemon cheesecake. During an interview and record review on 1/14/26, at 12:18 p.m., in the hallway next to the Dining/Activity Room, with the Certified Dietary Manager (CDM), there were two undated weekly menus posted on the board. The posted facility menu for the current week, Week 3, on Wednesday lunch listed apple pie for dessert. CDM confirmed cheesecake was served instead of the posted apple pie. CDM stated dessert was different from what was posted and RD should have been made aware the night before, regarding the menu substitution. During a telephone interview with the RD on 1/20/26, at 4:30 p.m., RD stated the dietary spreadsheet/menu should be followed. RD also stated there needed to be a Substitute Log to show the scheduled food item that will be substituted with a different food item and the reason for substitution. RD stated she was not made aware the dessert apple pie, due to no availability, was to be substituted with a slice of cheesecake during lunch on Wednesday, 1/14/26. A review of the facility's dietary record titled Menu Substitution Record, indicated a most recent entry, dated 1/16/26, showed the scheduled food item was apple pie, substituted with cheesecake, reason for substitution, didn't deliver pie, and had no RD signature. A review of the facility's Dining Service Menu Guide titled Making Menu Substitutions, dated 2019, indicated, Please be aware that making changes on your menu, whether just a one-time substitution or a permanent menu change, requires approval from your Consultant Dietitian. It is highly suggested that the Dining Services Manager discuss with their Consultant Dietitian the policy and procedure for how meal substitutes and menu changes are to be handled and documented.A log of substitutions must be kept on file, including what food item (s) was/were substituted, the date, reason for the substitution (s) and what new food item (s) was/were served. This log must be reviewed and signed off by the Consultant Dietitian . Page 1 of 3 555113 555113 01/22/2026 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, facility staff failed to ensure dietary needs for one of three sampled residents (Resident 1) were updated and care planned. Registered Dietitian (RD) and Dietary staff were made aware of Resident 1's food preference and requested copy of weekly menu and this information was not addressed in a timely manner. This failure had the potential for Resident 1 to lose weight due to decreased consumption and/or anger/depression when resident's dietary requests were not met. A review of Resident 1's admission Record, printed 1/14/26, indicated Resident 1 was admitted to the facility with diagnoses that included status post (s/p) joint replacement surgery, Type II diabetes mellitus (T2DM, high blood sugar), and depression. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 12/27/26, indicated Resident 1 had Intact cognition, was understood and was able to understand others. A review of Resident 1's Order Summary Report, active orders as of 1/14/26, diet order start date 12/25/25, indicated Controlled Carbohydrate (CCHO, a nutrition plan that keeps carbohydrate intake consistent at every meal and snack to help manage blood sugar, for individuals with diabetes) diet regular texture. A review of Resident 1's Care Plan Report, dated 12/30/25, indicated, Resident has nutritional problem or potential nutritional problem related to the following.(s/p) joint replacement surgery, T2DM, depression. Interventions include, Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. During an interview on 1/14/26, at 11:15 a.m., with Resident 1, in resident's room, Resident 1 stated she had told staff numerous times that she only wanted a big bowl of salad for lunch every day because she believed food served by the facility was unhealthy. Resident 1 also stated she had repeatedly requested copies of each week's menu yet had never received one from dietary or from nursing staff. During an interview on 1/14/26, at 11:21 a.m., with Certified Dietary Manager (CDM), CDM stated Resident 1 wanted a big salad every day and could get that. CDM also stated this had been verified with the RD (who had just met the resident in person on 1/13/26), as well as the building's Chef, and the resident had been receiving the big salad daily. Additionally, CDM stated he could easily provide Resident 1 with a copy of each week's menu. During a concurrent observation and interview on 1/14/26, at 12:10 p.m., with Certified Nursing Assistant 1 (CNA 1), outside the hallway next to Resident 1's room, CNA 1 stated Resident 1's lunch tray was ready in the cart. CNA 1 lifted the plate cover and showed Resident 1's lunch tray contained a pack of cranberry flavored juice drink, a bowl of black bean soup, a bowl of fresh fruits, and a plate with pasta salad, turkey and Swiss sandwich, with lettuce and tomatoes on the side. Resident 1's lunch was not a big bowl of salad as resident had repeatedly requested. During a telephone interview on 1/20/26, at 4:30 p.m., with RD, RD confirmed Resident 1 preferred to be served a big bowl of salad every day during lunch instead of the regular scheduled food served by the kitchen to the residents. According to RD, RD was not aware Resident 1 had not consistently received the big bowl of salad resident had requested daily for lunch. A review of the facility's policy and procedure (P&P) titled, Resident Food Preferences, revised July 2017, indicated, Individual preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents). Modifications to diet will only be ordered with the resident's or representative's consent.Upon the resident's admission (or within twenty-four [24] hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preferences.Nursing staff will document the resident's food and eating preferences in the care plan.The resident has the right not to comply with therapeutic diets. If the resident refuses or is unhappy with his or her diet, the staff 555113 Page 2 of 3 555113 01/22/2026 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0806 will create a care plan that the resident is satisfied with. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555113 Page 3 of 3