Health inspection·October 5, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few broken ribs, fracture, punctured lungs or even death. Licensed Staff D stated, if a resident was complaining of persistent and severe pain, an X-ray to check for fracture should be requested to the physician. Licensed Staff D stated she was not sure of the process for follow up if the physician did not reply to request for treatment. Licensed Staff D stated, if a resident continued to complain of persistent pain, this could be indicative of a fracture. Licensed Staff D stated, if the resident was left in pain, it could lead to emotional and physical distress. Licensed Staff D further stated, residents would feel neglected, like nobody cared. During a concurrent interview, and record review of physician ' s orders, fall risk assessment and fall care plan on 2/1/23 at 2 p.m., the Director of Nursing (DON) verified Resident 1 fell on [DATE] and 11/10/22. The DON stated the facility ' s policy was to complete a fall risk assessment upon admission and after every fall. The DON verified the fall risk assessment on 11/4/22 was missed. The DON stated the fall risk assessment needed to be completed so it could be used to track falls and its risks and to prevent further falls.The DON stated all fall incidents were care planned per facility protocol, and a short-term care plan should be created after every fall with new interventions. The DON stated if there were no specific care plan interventions to address falls, resident could be at risk for further falls or injury. The DON stated it was also the facility ' s policy to complete an Interdisciplinary note (IDT, a group of dedicated healthcare professionals who work together to provide you with the care you need) anytime there was a fall. The DON verified an IDT note was completed for the fall on 11/4/22, but there was no IDT for the fall incident on 11/10/22. The DON stated, if there were no IDT notes completed, Resident 1 would continue to be at risk for further falls and injuries. The DON verified, based on the fall risk assessment completed on 11/5/22, Resident 1 scored 26, indicating high fall risk. The DON verified nurses would notify the physician after a fall incident. The DON stated nurses would report to the physician if there were complaints of pain following a fall. The DON verified an X-ray was requested by a nurse on 11/11/22, but the physician did not respond until 11/13/23. When asked what the expected turnaround time was for when to expect the physician to respond for a treatment request, specifically, Resident 1 ' s X-ray, the DON was silent. The DON stated, if Resident 1 was experiencing severe and persistent pain, he could be sent to the hospital for further evaluation. The DON was not aware on how staff should follow up with the physician when there was no response to request for treatments. Although the physician had ordered an X-ray on 11/13/22, the DON was not able to provide a documentation that an X-ray was completed prior to Resident 1 ' s discharge to the hospital on [DATE]. The DON stated the X-ray company only comes every Tuesday ' s and Thursday ' s, so the X-ray probably was not done at the facility. During an interview on 2/1/23 at 2:21 p.m. the regional consultant verified it was the facility ' s fall policy to ensure a fall risk observation was completed upon admission, and after every fall. The regional consultant stated if this was not completed, the facility was not in compliance. The regional consultant stated, per the facility policy, long-term care plans for falls would be initiated upon admission and a short-term fall care plan would be initiated after every fall incident. The regional consultant stated it was expected there would be new interventions implemented with every fall. The regional consultant verified the fall care plan for 11/4/22 and 11/10/22 did not have any specific interventions that will prevent the risk for future falls. The regional consultant stated, without any new interventions, Resident 1 could be at risk for further falls. During a review of the facility ' s policy and procedure (P&P), titled Fall and Fall Risk, Managing, revised 3/2018, the P&P indicated, staff will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls .if falling recurs, staff will implement additional or different interventions .staff will re-evaluate the situation and whether it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 2 of 3 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 10/05/2023 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)

F 0689 appropriate to continue or change current interventions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 3 of 3