Health inspection·February 25, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 nursing staff failed to give acetaminophen (generic for Tylenol, a medication for mild pain and fever reducer) as ordered to one of two sampled residents (Resident 1) when Resident 1 was given more than 3000 mg (milligrams) of acetaminophen on 29 days of 34 days at the facility. This failure to follow Resident 1 ' s physician ' s orders had the potential to cause liver damage in a vulnerable resident who had several serious medical problems. Residents Affected - Some Finding: During a record review of Resident 1 ' s electronic medical record on 2/20/25 at 1:20 p.m., Resident 1 ' s face sheet (demographic information) revealed Resident 1 was admitted to the facility on [DATE] with multiple medical diagnoses including heart transplant, end-stage kidney disease, Type 2 diabetes mellitus (a chronic disease characterized by high blood sugar), broken right hip with surgical repair, and Covid-19. Further review of Resident 1 ' s face sheet revealed he was discharged on 1/6/25. Review of Resident 1's care plan revealed a focus area, dated 12/4/24, At risk for pain or discomfort due to fracture of the right femur and recent surgical repair of the right hip, [right] side rib pain. Interventions included, Administer medication as ordered. Review of Resident 1 ' s physician ' s orders revealed a physician ' s order dated 12/3/24 for Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet [sic] by mouth three times a day for PAIN NTE (not to exceed) 3000mg of acetaminophen in 24h/day. Further review of Resident 1 ' s physician orders revealed a physician ' s order dated 12/3/24 for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Generalized Discomfort Not to Exceed 3000 mg in 24 hours. Review of Resident 1 ' s medication administration record (MAR) for December 2024 and January 2025 indicated Resident 1 received 3650 mg of acetaminophen on 17 days during his stay, 4300 mg of acetaminophen on 10 days during his stay, and 4950 mg of acetaminophen on 2 days during his stay. During a record review and concurrent interview on 2/25/25 at 1:56 p.m., Director of Nursing (DON) reviewed Resident 1 ' s physician orders during his stay 12/3/24 to 1/6/25, and Resident 1's December 2024 MAR. DON verified Resident 1 had concurrent physician orders for acetaminophen 1000 mg three times a day, for a total of 3000 mg daily, and acetaminophen 650 mg every six hours as needed. DON stated the fact that both orders indicated the acetaminophen should not exceed 3000 mg in 24 hours could be confusing to the nurses. DON verified Resident 1 ' s December 2024 MAR indicated Resident 1 was administered more than 3000 mg of acetaminophen on most days in December 2024. DON stated it was (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 02/25/2025 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)