Lakeport Post Acute

Inspectors wroteF760 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) The facility must ensure that its- S483.45(f)(2) Residents are free of any significant medication errors. Based on observation, interview and record review, the facility failed to follow facility policies & procedures that required triple-checking of medication before administration which resulted in failure to administer the correct medication prescribed for one of three sampled residents (Resident 1). As a direct result, Resident 1 experienced a life-threatening adverse reaction requiring emergency rescue medications, transfer to a General Acute Care Hospital (GACH), and hospitalization in the intensive care unit for life threatening symptoms. This failure resulted in actual harm and exposed the resident to a substantial likelihood of death. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide nursing staff based on the 3.5 direct hours per patient day (DHPPD) for 27 out of 39 days reviewed. This failure resulted in two sampled residents, Resident 17 and Resident 37, ability to receive timely nursing care. This failure also had the potential to impact all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for two of 18 sampled residents (Resident 15 and 222) when: 1. Licensed Vocational Nurse (LVN) 1 administered pain medication one hour seven minutes after Resident 15 requested pain medication and did not conduct a pain reassessment within an hour after administration. 2. Licensed Nurses did not conduct pain reassessments within an hour after administering pain medication to Resident 222. This failure had the potential for Resident 15 and 222 to have unrelieved pain and diminished quality of life.

Inspectors wrote2. During a concurrent observation and interview on 6/19/25 at 1:40 PM, with Licensed Vocational Nurse (LVN) 1 at the medication cart. One box containing hemorrhoid ointment was observed with an expiration date of 4/25. LVN 1 stated the ointment was expired and should have been removed from the medication cart. During an interview on 6/19/25 at 2:17 PM, with the Director of Nursing (DON), DON stated medications should not be available for use past their expiration date because the effectiveness of the medication could not be ensured. The DON stated, staff should inspect the medication carts weekly and remove any expired medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess one of 18 sampled residents (Resident 12) for the ability to self-administer medications according to facility policy. This failure resulted in the potential for errors in Resident 12's medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person centered care plan for one of 18 sampled residents (Residents 222) when Resident 222's care plan intervention to store cigarettes and lighter in a lock box was not implemented. This failure had the potential for unauthorized access by residents which could result in harm.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure quality of care when physician orders to monitor fasting blood sugar levels of Resident 35, who is on insulin medication, were not followed and recorded. This deficient practice had the potential to adversely affect the resident's medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10 percent when three identified medication errors out of 30 opportunities were observed: 1. Aspirin 81 mg (miligram- unit of measurement) enteric coated (lower strength of aspirin that is often used to help prevent heart attacks and strokes) was administered without a physician's order for two residents (Resident 34 and Resident 54). 2. Lactulose (medication used to lower ammonia, a toxin in the body) was omitted without a physician's order for one resident (Resident 321).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen food preparation and storage areas were maintained in a safe and sanitary manner when two fans blowing air into the kitchen had fine white colored particles. This failure placed all residents who received food prepared in the kitchen, at risk for foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when powder like substance was observed on the surface areas around two of two pill crushers. This failure had the potential to result in harm from cross contamination.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to give acetaminophen (generic for Tylenol, a medication for mild pain and fever reducer) as ordered to one of two sampled residents (Resident 1) when Resident 1 was given more than 3000 mg (milligrams) of acetaminophen on 29 days of 34 days at the facility. This failure to follow Resident 1 ' s physician ' s orders had the potential to cause liver damage in a vulnerable resident who had several serious medical problems.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the list of information such as the name and the correct Department of the State Survey Agency, & the State Licensure were accurate and written visibly available to all vulnerable residents, staff and visitors. This failure had the potential to result in unreported and uninvestigated complaint or any incident to the State Agency or State Licensing by a resident/s, staff and visitors who may have had concerns and requires advocacy.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the food was palatable, was served timely and was served at temperatures in accordance with resident preferences for seven out of seven sampled residents (Residents 376, 68, 65, 375, 226, 52 and 50). These failures had the potential to result in residents not eating the food served which could result in weight loss and further compromise their medical status.

Inspectors wroteBased on observation and interviews, the facility failed to ensure 1. residents' food items were labeled with name and dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items.

Inspectors wroteBased on observation, interview and record review, the Governing Body (a group of people that has the authority to exercise governance over an organization) failed to ensure to designate or appoint a California Licensed Nursing Home Administrator (NHA) (Administrator is responsible for establishing and implementing policies regarding the management of the facility) who would be legally responsible for establishing and implementing policies regarding the management and operation when: 1) The Administrator in training (AIT) claimed to be the Administrator of the facility, for over 6 weeks including during the recertification survey dated 12/11/23 - 12/14/23. 2) The AIT was licensed by the State of Montana and was currently scheduled to take the reciprocity administrator licensing exam on 12/14/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Quality Assurance Committee (QAA) is composed of the required committee members, such as an active licensed Nursing Home Administrator (NHA) of California during the QAPI meeting dated 10/23 & 11/23. This failure had the potential to result in mismanagement of the practices required by the Administrator to keep the vulnerable resident safe and healthy.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to 1. ensure staff were offering and performing hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) to the residents before or after meals for 12 out of 12 sampled residents (Residents 47, 22, 40 11, 48, 50, 24, 63, 52, 72, 2 and 28), when [NAME] 1 did not perform HH and continue to cook eggs after he wiped his gloved hand in front of his shirt, and ensure staff were following the facility's guideline for donning Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when staff did not wear gloves when she scooped ice in the ice machine located in the kitchen 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure five sampled residents (Resident 1, Resident 14, Resident 35, and Resident 38, Resident 51) and resident's representative(s) participated in the plan of care when Care Conferences were not held for the last two quarters according to facility Policy and Procedure. This failure had the potential to interfere with the five resident's ability to achieve and maintain their highest level of activity and independent.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure 1. they were adequately staffed for 21 out of 31 days for CNAs and nine out of 31 days for licensed nurses in 10/2023, 19 out of 30 days for CNAS and 8 out of 30 days for licensed nurses for 11/2023 and 8 out of 12 days for CNAs and 4 out of 12 days for licensed nurses for 12/2023 which resulted in residents' complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for five out of five sampled residents (Residents 380, 376, 68, 332 and 226 ) and residents feeling scared and anxious staff would not get to them on time in case of medical emergency 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure training materials, resources, and policies and procedures explained all allegations of abuse must be reported in two hours. This failure resulted in staff not knowing the correct timeline to submit an SOC341 (State of California Report of Suspected Dependent Adult / Elder Abuse) (This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult.), after they had become aware of an allegation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the Medical Doctor's (MD) appointment for Level II Preadmission Screening (PASARR) for one (1) of eight (8) residents, Resident 52. This failure resulted in cancellation of MD's evaluation for mental illness and a delay of care and services needed for Resident 52.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff were aware of the Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) completion time frame and BCP's were completed timely for two out of two sampled residents (Residents 40 and 49). These failures had the potential to put residents' safety at risk and for residents not receiving the care that they need.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when 1. the facility failed to notify the physician of resident's blood sugar of 400 or more for one out of one sampled resident (Resident 49) 2. the facility failed to provide regular scheduled showers for three out of three sampled residents (Residents 65, 49 and 37). These failures could lead to 1. complications associated with Diabetes Mellitus such as hypoglycemia (a condition in which your blood sugar (glucose-body's main energy source) level is lower than the standard range, hyperglycemia (high blood glucose (blood sugar)and stroke (brain attack, occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to help schedule an appointment for evaluation of a hearing aid device for one resident, Resident 37. This failure resulted in Resident 37 feeling frustrated and angry due to hearing loss and not being able to hear adequately without the use of hearing aid device.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient and appropriate social services were provided to meet the needs of Resident 1, Resident 14, Resident 51, Resident 38, Resident 35, Resident 52 & Resident 37, when: 1. The facility did not conduct and document an Interdisciplinary Team Meeting and Care Conference for the last two quarters for Resident 1, Resident 14, Resident 51, Resident 38, Resident 35. 2. The facility did not ensure that Resident 52 had the Level II PASARR evaluation by a Medical Doctor's scheduled in 9/23. Failure to attend the scheduled Medical Doctor's appointment for Level II PASARR evaluation resulted in cancellation, and therefore Resident 52 needed to begin with the entire process for PASARR evaluation. Level II PASARR evaluation will determine the proper care and home placement. 3. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the development of a plant-based menu. This failure had the potential for vegetarian residents to not meet the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins which could further compromise their medical status .

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the kitchen walls were in good repair when holes on the walls were noted. This failure could result in rodents and pest accessing the kitchen area through these holes which could put residents at risk for harmful diseases. During a concurrent observation and interview on 12/14/23 at 6:44 a.m., when asked about the multiple holes on the kitchen wall by the dish sanitizing machine, the Registered Dietician (RD) stated she could not identify what those holes were, but it could possibly be screw holes. When asked if those kitchen holes should be covered, she stated she does not know how deep those were, but she would notify maintenance today. The RD stated she conducted environmental rounds in the kitchen monthly. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident's, Resident 230's, responsible party, act on behalf of Resident 230 in order to support her in decision-making regarding her care, when the facility did not explain the risks and benefits of bed rails to the responsible party, and did not ask for her consent, before installing the bed rails. This failure had the potential to result in injuries to Resident 230 related to entrapment due to her cognitive impairment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident, Resident 71, was provided her medical records within the accepted timeframes after she made an oral request to the Administrator in Training (AIT). This failure had the potential to result in mismanaged care if Resident 71 was not provided her medical records that would help with decision-making with regards to her healthcare and could have a negative impact on her health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat 4 of 6 residents (Resident 1, Resident 2, Resident 4, and Resident 5) with respect, dignity, and kindness when: 1. Resident 1 for waited in pain while seated in her wheelchair in soiled underwear for a half hour or more before she was assisted back to bed and cleaned. 2. Resident 2 sat on the commode or in her soiled underwear for long periods waiting for assistance and waited 2 hours for her pain medication. 3. Resident 4 waited in the toilet once or twice a day or waited 2-4 hours sitting on her soiled or wet adult diapers to get cleaned. 4. Resident 5 laid in her soiled underwear for 45 minutes or more waiting for assistance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were free from accidents for one out of two sampled residents (Resident 1) when there were no new interventions in place when Resident 1 fell on [DATE] and again on 11/10/22 and the nurses did not follow up with the physician regarding a request for X-ray on 1/11/22 to rule out fracture. This failure resulted in Resident 1 complaining of rib pain on 11/11/22 and subsequent hospitalization on 11/14/22 due to a fractured (broken) rib.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievance forms and complaints information were visually accessible and attainable by residents in the Facility without retaliation or fear of discrimination. This failure had the potential to result in violation of resident's rights, maltreatment, neglect, and loss of personal items. During an interview on 6/21/2022 at 2:30 p.m., at the Resident Council meeting in the Dining room, Resident 52 stated, he did not know where to get the grievance form. Resident 70 stated she did not know where the grievance forms was located. Resident 12 stated, he did not know where to get the grievance forms. Residents 52, 26, 70 ,12 & 34 stated they did not know where to find the phone number for the State Agency and how to file complaints. Resident 26 stated he did know where the forms were located. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for four sampled residents (Resident 75, Resident 22, Resident 32, and Resident 48), that were individualized and updated to show residents specific care related to their medical needs. These failures could possibly result in residents decline in health, harm, and negatively impact the residents' quality of care and services.

Inspectors wroteResident 24 During an interview on 6/21/22 at 11:15 p.m., Resident 24 was sitting up at the side of the bed. When asking questions about her care she stated, the care was ok and the food was not that good. Resident 24 stated that her upper dentures were not fitted correctly and she has no lower dentures making it hard for her to eat solid foods. Resident 24 stated she liked her breakfast which was eggs and toast. Resident 24 stated I mash up the egg on the toast and I can eat that. Resident 24 stated she had asked to see a social worker to help her schedule a dentist appointment for her dentures but no one has come. Resident 24stated I cannot eat the food because of my dentures. I cannot chew a lot of the foods and I do not like the pureed foods. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Adequately supervise one of four sampled residents, Resident # 33, when he was observed smoking unsupervised in an area of the facility which was not the designated smoking area, and with an oxygen tank that was strapped at the back of his wheelchair. This failure had the potential to result in a burn injury to Resident # 33. 2. Implement interventions and actions to prevent one of six residents (Resident 75) from falling, after she fell and fractured her right ankle at the facility. This had the potential to result in another fall with injury to Resident 75.

Inspectors wroteBased on interview, and record review, the facility failed to ensure sufficient staff were available to provide care and services to residents for each shift and ensure that resident needs were met when the facility did not have sufficient staff to assign to the Red Zone (Covid 19 positive residents who were potentially infectious), and resident reported long wait times for call light responses. This failure had the potential to affect infection control, and the quality of care provided and safety to the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer a palatable meal to the residents of the facility on regular and pureed consistencies. This had the potential to cause a negative dining experience, loss of appetite and a decrease in caloric intake for the residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare meals in a sanitary manner, when: 1. Expired dairy was found in one of the facility's refrigerators, 2. Flies were observed in the kitchen sitting in the beverage cart, during tray line observation, and; 3. A Dietary Aid (Dietary Aid L) was observed serving beverages, and pulling up his pants in the process without washing his hands before serving more beverages. These failures had the potential to cause foodborne illness and spread of infections to the resident population.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure documentation for 2 of 6 sampled residents (Resident 22 and Resident 79) was complete and accurate, when: 1) Resident 22's documentation on urinary catheter (a tube placed in the body to drain and collect urine from the bladder) care for the month of June, 2022, had several empty boxes, making it unable to determine if he received the care ordered by the physician. 2) Resident 79's closed record did not contain a discharge summary and comprehensive care plan These failures had the potential to result in inability for the interdisciplinary team to determine if required nursing care and services were provided to Resident 22 and Resident 79 as per physician orders, and for the physicians to be aware if their orders had been implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when staff did not follow the facility's policy and procedures for infection control when entering Person Under Investigation (PUI) rooms without appropriate PPE (Personal Protective Equipment), and when residents were not cohorted, and staff moved between Red, Yellow and [NAME] zones (Red zone: residents confirmed positive test for Covid-19; Yellow zone: residents suspected of developing Covid-19 and exposed to Covid-19; [NAME] zone: residents who were not exposed and had negative test for Covid-19) potentially increasing the spread of infections. These failures had the potential to spread COVID-19 infections to other residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide 1 of 6 sampled residents (Resident 179), the opportunity to participate in care planning when no care conference meetings (A meeting between healthcare professionals and the resident to decide the resident's needs, discuss the medical team's goals, and discuss the resident's ideas for meeting those needs) were held inviting her to develop her plan of care. This failure had the potential to result in inability for Resident 179 to advocate for her needs, receive information regarding her care, and begin to develop a discharge plan with the interdisciplinary team.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman for one discharged resident to the Community, Resident 80. This failure had the potential to result in unsafe discharge, accidents and worsening mental and health care.

Inspectors wroteBased on interview and record review, the facility failed to follow the recommendations by the State of California when they did not perform a PASARR (Pre-admission Screening and Resident Review-A federal program implemented to prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facilities for long-term care, and ensure these individuals receive specialized services) II (Level 2) screening after 1 of 6 sampled residents (Resident 35) tested positive for a PASARR I (Level 1, initial screen)screening. This finding had the potential to result in Resident 35's inability to obtain specialized services to manage her mental illnesses, which could have resulted in incapacity to attain or maintain her highest practicable physical, mental, and psychosocial well-being

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide care in accordance with professional standards of practice to one out of three sampled residents, Resident # 66, when Resident # 66's Controlled Drug Record for Oxycodone/APAP (A combination preparation of the analgesic and antipyretic acetaminophen and the semisynthetic opioid agonist oxycodone with analgesic and antitussive properties) 5/325 MG (milligram) tablet indicated that Licensed Staff A did not sign-out the Controlled Drug Record when she prepared, and after she administered the medication to Resident # 66, and the pharmacy instruction on the medication label indicated that the frequency of the administration of this as needed pain medication was not followed. These failures had the potential to result in physical harm to Resident # 66.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process plan for one sampled Resident (Resident 80) when Resident 80 was discharged home without proper discharge planning and without arrangements for potentially needed follow -up services. This failure had the potential to result in undetected worsening medical and mental health conditions, and potential preventable readmissions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 178) received appropriate respiratory care when: 1. Physician orders were not followed for supplemental oxygen (The use of oxygen as a medical treatment) administration, and; 2. A Licensed Nurse (Licensed Staff M) left Resident 178 alone and unsupervised during the administration of a nebulizer (A device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) treatment. These findings had the potential to result in respiratory failure, harm and death to Resident 178.

Inspectors wroteResident 48 Based on interview and record review, the facility failed to ensure resident's medical supervision such as weight loss was assessed and monitored by a Physician to one of four residents, Resident 48. This failure had the potential to results in malnourish, electrolyte imbalance and dehydration. A [AGE] year-old female with history of Parkinson's disease, Dementia without behavioral disturbance, cognitive communication deficit with a BIMS (Brief Interview for Mental Status) score of 4, (Not cognitively intact). During a record review titled Weekly Weights for Resident 48 revealed, on 5/8/2022 weighed 112 lbs., on 5/10 weighted 110.2 lbs., on 6/5 weighed 107 lbs., 6/19 weighed 104.8 lbs. Resident 48 loss 7.2 lbs. approximately within one month. A record review of Resident 48's food intakes revealed 51- 75% most of the time. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its policy and procedure in ordering and receiving non-controlled medications (Pharmaceutical preparations that can only be obtained through a practitioner's prescription dispensed by a pharmacist and are not considered controlled substances under the Controlled Substances Act) for one of nine sampled residents, Resident # 33, when four (4) prescription medications scheduled to be administered on 6/23/22, at 8 a.m., were not available for administration to Resident # 33. Due to this incident, Resident # 33 refused to take the rest of his medications scheduled for 8 a.m., until the facility could provide the missing prescription medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor 1 of 6 sampled residents (Resident 32) for episodes of anxiety and depression, for which she was given medications with significant adverse effects. This had the potential to result in administration of unnecessary medications, which could have caused Resident 32 serious harm.