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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 555222 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeport Post Acute 1291 Craig Avenue Lakeport, CA 95453 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)