Health inspection·November 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm stated she had been sitting more than an hour and a half now. At 11:39 a.m., CNA-B came to the room to clean and change Resident 1. During an interview on 9/14/23 at 11:40 a.m., Certified Nursing Assistant B (CNA-B) stated she was assigned to care for 12 residents. Residents Affected - Some A review of Resident 1's Minimum Data set (MDS – a federally mandated clinical assessment of a resident's functional capabilities in a Medicare and Medicaid certified nursing home) dated 9/1/23, indicated, Resident 1 was admitted with a diagnosis of a displaced comminuted fracture of the shaft of the right femur (the long portion of the right thigh bone was broken in at least two places and have come out of alignment), cancer with metastases, anemia, malnutrition, and repeated falls among other conditions, had a Brief Interview for Mental Status (BIMS – a tool to screen and identify the cognitive condition of a resident upon admission into a long term care facility) score of 13 indicating Resident 1 is cognitively intact. The MDS indicated Resident 1 requires one-person extensive assistance to transfer and two-person extensive assistance to cleanse self after elimination. Resident 1 is frequently incontinent (inability to control) of bladder and bowel movement. During an interview on 9/14/23, at 11:52 a.m., Resident 2 stated it takes 2 hours for staff to respond to her call light. Resident 2 stated the nurse tells her she will get to her when she can. Resident 2 stated she'd been in her commode alone without assistance because nobody came to respond. Resident 2 cried and asked herself why she is still alive, they do not have to be rude, she felt the nurse purposely made her wait. Today Resident 2 stated she had been waiting for 2 hours to get her Oxycodone (narcotic pain medication). Resident 2 stated she does not feel the respect. She sits in herurine and feces and wait for assistance until they come. Resident 2 stated staff do not come in response to her call light. A review of Resident 2's admission MDS dated [DATE] indicated Resident 2 was admitted to the facility on [DATE] for care following joint replacement surgery for an unspecified cervical disc disorder, chronic pain syndrome, among other conditions. Resident 2 had a BIMS score of 13. A review of the facility document titled: Medication Admin (administration) Audit Report for the period between 9/1/23 to 9/14/23, indicated Resident 2 received oxycodone 5 mg (milligram, a unit of weight) on 9/14/23 at 1:28 a.m. and on 9/14/23 at 10:32 p.m. There was no record she received oxycodone around the time of the interview. During an interview on 9/14/23, at 1:57 p.m., Resident 4 stated staff tell her to wait. Once or twice a day, Resident 4 stated she gets upset because she does not like sitting in the toilet waiting to get cleaned. Resident 4 had experience waiting 2-4 hours sitting on urine and feces. There are days it happened more than twice a day. Resident 4 stated she preferred female CNAs and the male CNAs will tell her they will get someone, but nobody comes, and the male CNA do not come and check back on her. A review of Resident 4's admission MDS dated [DATE] indicated she was admitted on [DATE] with a diagnosis of respiratory failure, atrial fibrillation, congestive heart failure, renal insufficiency, and diabetes among other conditions. Her BIMS score was 13 and she required extensive 1-person assistance to transfer, and toilet use. During an interview on 9/14/23, at 2:33 p.m., Licensed Nurse A (LN-A) stated making residents wait two to five minutes is acceptable and reasonable. It also helps to inform the resident she will assist them after she is done with another resident. LN-A stated the longest wait time maybe 10-12 (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 11/06/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some minutes, but 1-2 hours response is way too long and not acceptable. It will also upset residents, cause skin breakdown, urinary tract infections, and falls. During an interview on 9/14/23, at 2:49 p.m., Certified Nursing Assistant B (CNA-B) stated caring for 8 residents is manageable, but she had been assigned 12 residents for some time. CNA-B stated it was her first time to care for Resident 1. Resident 1 lets them know if she needs a change. CNA-B stated making residents wait three to five minutes is acceptable, over 10 minutes is not acceptable. CNA-B stated residents get distressed, upset, or feel ignored when they are made to wait too long. It can also cause a fall. It is degrading to leave them wet, with feces while waiting. During an interview on 9/14/23, at 3:06 p.m., Licensed Nurse C (LN-C) stated responding to a call in 5 minutes is acceptable, 15-20 minutes is not acceptable unless the call is not urgent. LN-C stated making the residents wait too long can result to a fall, choking, discomfort from pain, and skin breakdown. When asked why calls are not answered soon enough, LN-C stated, staff were either busy, in the middle of another task, assume residents put their call light on all the time, or assume it is nothing urgent. During an interview on 9/14/23, at 3:27 p.m., Resident 5 stated she gets upset when she soils her underwear with urine and feces. She had to be lifted (using a portable total body lift or a patient lift to move or transfer a patient) and had to wait 2-3 hours to get cleaned. She presses her call light when she is going to have a bowel movement but they do not come or respond for 45 minutes. CNAs get mad at her, makes her feel inadequate and dirty because they get wet with her urine without her intention. She does not feel respected. A review of Resident's 5 admission MDS dated [DATE] indicated she was admitted on [DATE] for hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebral infarction (stroke) and heart failure among other disease conditions. Resident 5 required 2-person extensive assistance to transfer and toilet use. Resident 5 also has inability to control her bladder and bowel movement. A review of the facility's Policy titled: Resident Rights revised 12/2016 indicated employees shall treat residents with kindness, respect, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555222 If continuation sheet Page 3 of 3