Health inspection·April 17, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a care plan to manage and respond to behavioral disturbances for two residents (Resident 1 and Resident 2) of five sampled residents. These failures decreased the facility ' s potential to provide supervision to prevent resident altercations. Findings: A review of Resident 1 ' s admission record indicated he was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances. A review of Resident 1 ' s medical record indicated no documented evidence care plans regarding Resident 1 ' s aggressiveness toward others. During an interview on 1/20/23 at 1:55 p.m., Licensed Nurse A stated Resident 1 had a history of aggression toward other residents. During an interview on 1/20/23 at 2:05 p.m., the Activities Director stated Resident 1 had a history of being aggressive toward other residents. During an interview on 1/20/23 at 2:28 p.m., the Quality Assurance Nurse (QAN) stated Resident 1 had a history of aggression towards other residents. The QAN reviewed Resident 1 ' s care plans and confirmed no care plans had been created to manage and respond to Resident 1 ' s aggressiveness towards other residents. A review of Resident 2 ' s admission record indicated he was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances. A review of Resident 3 ' s admission record indicated she was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a chemical imbalance in the blood which can affect the brain). A review of a Minimum Data Set (MDS, an assessment tool), dated 11/1/22, indicated Resident 3 had mild memory problems. During an interview and observation on 1/20/23 from 2:28 p.m. to 2:58 p.m., with the QAN in her office, with the door closed, the Department heard Resident 2 continuously yelling, help me. At 2:58 Page 1 of 3 555222 555222 04/17/2023 Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453

F 0656 p.m. the Department observed Resident 3 yell at Resident 2 to be quiet across the hallway. Level of Harm - Minimal harm or potential for actual harm In an interview and record review on 1/20/23 at 3:03 p.m., the QAN stated Resident 2 did not need help when he yelled, help me. The QAN stated it was a behavior he manifested, which usually stopped once he was redirected. A review of Resident 2 ' s care plans did not indicate a care plan to manage and respond to Resident 2 behavior of continuously yelling for help. Residents Affected - Few During an interview on 1/23/23 at 3:10 p.m., Resident 3 stated Resident 2 ' s behavior of continuously yelling for help had been occurring for several weeks. Resident 3 stated it bothered her and disturbed her sleep. Resident 3 stated she could hear Resident 2 from her room even with her room door closed and with headphones on. During an interview on 1/20/23 at 3:15 p.m., Nursing Aide B verified Resident 2 had a history of continuously yelling for help even when he did not need anything. A review of facility policy and procedure titled Care Planning - Interdisciplinary Team, dated March 2022, indicated, The interdisciplinary team is responsible for the development of resident care plans . [which are] Comprehensive, person-centered .[and] are based on resident assessments . 555222 Page 2 of 3 555222 04/17/2023 Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453

F 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to provide annual dementia management training to two of three sampled nurse aides. Residents Affected - Few This failure decreased the facility ' s potential to ensure residents with dementia received adequate care and services. Findings: A review of Resident 1, 2, 4 and 5 ' s admission records indicated diagnoses of dementia. During an interview on 1/20/23 at 8:35 a.m., the Administrator was asked for records of dementia management training provided to staff during the last year. The Administrator provided a dementia training in-service sign-in sheet dated 1/21/21. During an interview on 1/20/23 at 11:47 a.m., Certified Nursing Assistant C (CNA C) stated she had worked for the facility for about one year. The CNA C was asked which training and/or in-services she received during this period. The CNA C did not mention dementia management training. During an interview on 1/20/23 at 11:53 a.m., Certified Nursing Assistant E (CNA E) stated she had worked for the facility for about one year. The CNA E was asked which training and/or in-services she had received during this period. The CNA E did not mention dementia management training. During an interview on 1/20/23 at 1:35 p.m., the Administrator provided the Department a dementia training sign-in sheet dated 12/15/22. A review of this record verified CNA C and E had not received dementia management training. A review of facility policy titled Dementia – Clinical Protocol, dated November 2018, indicated, Nursing Assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. 555222 Page 3 of 3