Health inspection·February 23, 2026

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' hospital discharge orders were verified with admitting physician upon Resident 1's admission to the facility in accordance with professional standard of practice when Resident 1's admission order was not clarified and transcribed accurately and Resident 1 did not received medications as ordered.This failure resulted in Resident 1 not receiving medications as ordered by the physician for three days and Resident 1's transfer to the hospital for syncope (fainting or passing out). During a review of Resident 1's admission Record (AR), dated 2/13/26, the AR indicated Resident 1 was admitted to the facility in January 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only one side of the body) and essential hypertension (high blood pressure).During a review of Resident 1's Progress Notes (PN), dated 1/30/26, PN indicated Resident 1's responsible party (RP) met with Director of Nursing (DON) and expressed concerns regarding missing medications on Resident 1's Medication Administration Record (MAR). During a review of Resident 1's hospital referral document titled, Short-term Medicare Referral (MR), dated 1/22/26, MR indicated hospital transferred Resident 1 to facility for Physical Therapy & Occupational Therapy (PT/OT). MR included discharge orders of active medication list. During a concurrent interview and record review on 2/13/26, at 9:31 a.m., with Director of Nursing (DON), Resident 1's MR, discharge orders, active medication lists, Order Summary Report OSR and Medication Administration Records (MARs) were reviewed. DON stated he was confused with the multiple medication lists provided by the hospital. DON stated there were discharge orders of medications that were not transcribed and administered to Resident 1 for three days. The following medications were not transcribed from Resident 1's discharge order active medication list: 1. Amlodipine 2mg tablet one tablet orally every day to lower blood pressure.2. Buprenorphine 150 mcg buccal dissolve in the mouth every twelve hours for pain.3. Clopidogrel Bisulfate 75mg tablet one tablet oral every day to thin blood.4. Hydralazine HCL 25mg tablet take three tablets by mouth three times a day for heart and blood pressure among others. DON stated facility expectation was for admission nurse to make attempt to verify and clarify admission orders with discharge hospital and admitting physician. DON could not provide documentation that Resident 1's physician was contacted and discharge and admission physician 's orders were verified. During an interview on 2/13/26, at 1:22 p.m., with Resident 1's primary physician (MD), MD stated he was Resident 1's admitting physician and was aware that some discharge medications orders were not transcribed upon admission to facility and also not administered for 3 days. MD stated his expectation was for licensed nurses to contact and timely follow-up with physician to verify and clarify admission orders upon residents' admission to facility. MD stated he was not contacted by Resident 1's admitting nurse upon admission to the facility. During an interview on 2/13/26, at 4:22 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated he was Resident 1's admitting nurse. LVN 1 stated Resident 1 did not arrive at the facility with discharge orders. LVN 1 stated he found Resident 1's discharge order fax document on the Residents Affected - Few Page 1 of 2 555113 555113 02/23/2026 Lake Park Healthcare Center 1850 Alice Street Oakland, CA 94612

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few electronic records and transcribed as admission orders. LVN 1 stated he did not contact admitting physician to verify or clarify Resident 1's admitting orders. LVN 1 stated he did not document Resident 1's admission information on nursing documentation to indicate LVN 1 contacted admitting physician to verify admission orders. During a review of the facility's policy and procedure (P&P) titled, admission Documentation undated, indicated, When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nursing documentation, admission form, or other appropriate place, as designated by facility protocol:The time the physician's orders were received and verified. 555113 Page 2 of 2