Health inspection·May 25, 2023

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents ' (Resident 1) rights were upheld when it failed to honor an agreement made with Resident 1 ' s health care agent (FM 1) regarding his choice of excluding involvement of Licensed Staff A in Resident 1 ' s care. This failure resulted in FM 1 to experience anger, distrust, and undermined his confidence in the nursing care rendered to Resident 1 for 14 months, from the agreement date of 1/17/22, until her discharge from the facility on 3/11/23. Residents Affected - Few Findings: A review of Resident 1 ' s admission Record (a summary of important information about a patient) indicated she was admitted to the facility on [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1 ' s Advance Health Care Directive, dated 3-13-2015, designated FM 1 as her health care agent. During an interview on 5/24/23 at 2:40 p.m., FM 1 stated he met with facility staff back in January 2022 to express his concerns regarding Licensed Staff A. FM 1 stated he had been assured by the facility that Licensed Staff A would no longer be involved in Resident 1 ' s care per his request. FM 1 stated it was not until March 2023, 14 months after the agreement was made, when he found out that Licensed Staff A had continued to be part of Resident 1 ' s care, after noting numerous Progress Notes (records of the medical care a patient receives, along with details of the patient's condition) in 2022 and 2023, that were authored by Licensed Staff A. FM 1 stated the facility knew of the agreement but had broken its word. Upon discovery of the Progress Notes, FM 1 stated he was angry and distrustful of the facility and added that it had undermined his confidence in the nursing care that Resident 1 had received in the past year. A review of Resident 1 ' s Progress Notes revealed an IDT Note, dated 01/17/2022, which indicated, IDT had conference call with [FM 1] to discuss his concerns . [FM 1] mentions a specific nurse he wishes to not be involved in his mother ' s care and [FM 1] was reassured this nurse would no longer be involved at his request . Further review of Resident 1 ' s Progress Notes indicated 26 entries authored by Licensed Staff A throughout Resident 1 ' s facility admission until her discharge date on 3/11/23, with majority of the notes as IDT (Interdisciplinary Team) Note type. During an interview on 5/25/23 at 9:50 a.m., Licensed Staff A stated the IDT was a team that met to identify and discuss resident concerns and collaborated on interventions that could be done for them. Licensed Staff A stated the IDT included members from nursing, therapy, Social Services, and other departments involved in the resident ' s care. Licensed Staff A stated part of her role as the (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 2 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 05/25/2023 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)