Lakeport Post Acute

In the surveyor’s words

From the most serious findings on record at Lakeport Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF760May 13, 2026

  F760 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) The facility must ensure that its- S483.45(f)(2) Residents are free of any significant medication errors. Based on observation, interview and record review, the facility failed to follow facility policies & procedures that required triple-checking of medication before administration which resulted in failure to administer the correct medication prescribed for one of three sampled residents (Resident 1). As a direct result, Resident 1 experienced a life-threatening adverse reaction requiring emergency rescue medications, transfer to a General Acute Care Hospital (GACH), and hospitalization in the intensive care unit for life threatening symptoms. […]

• No harm, potential for more than minimal, widespreadF725Jun 19, 2025

  Based on observations, interviews and record reviews, the facility failed to provide nursing staff based on the 3.5 direct hours per patient day (DHPPD) for 27 out of 39 days reviewed. This failure resulted in two sampled residents, Resident 17 and Resident 37, ability to receive timely nursing care. This failure also had the potential to impact all residents in the facility. Findings: During a review of Resident 17's admission Record dated 6/18/25, the Admissions Record indicated that Resident 17 was admitted to the facility on [DATE] with the diagnosis of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), stroke (damage to brain from lack of blood supply), dementia (impairment of at least two brain function such as memory loss and judgement), and hemiplegia… […]

• No harm, potential for more than minimal, widespreadF574Dec 18, 2023

  Based on observation, interview and record review, the facility failed to ensure that the list of information such as the name and the correct Department of the State Survey Agency, & the State Licensure were accurate and written visibly available to all vulnerable residents, staff and visitors. This failure had the potential to result in unreported and uninvestigated complaint or any incident to the State Agency or State Licensing by a resident/s, staff and visitors who may have had concerns and requires advocacy. […]

• No harm, potential for more than minimal, widespreadF804Dec 18, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure the food was palatable, was served timely and was served at temperatures in accordance with resident preferences for seven out of seven sampled residents (Residents 376, 68, 65, 375, 226, 52 and 50). These failures had the potential to result in residents not eating the food served which could result in weight loss and further compromise their medical status. Findings: During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated he dislike the food at the facility. Resident 376 stated food had no taste and vegetables were soggy. During an interview on 12/11/23 at 1:52 p.m., Resident 68 stated food comes in late, so it was usually cold by the time he gets it. […]

• No harm, potential for more than minimal, widespreadF813Dec 18, 2023

  Based on observation and interviews, the facility failed to ensure 1. residents' food items were labeled with name and dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items. Findings: During an observation on [DATE] at 1:40 p.m., resident's refrigerator was in the staff breakroom. The refrigerator side was broken. During a concurrent observation and interview on [DATE] at 1:47 p.m., Unlicensed Staff AA verified she put the jar of minced garlic for the resident in room [ROOM NUMBER] in the refrigerator. Unlicensed Staff AA stated there was no name to identify who this jar of minced garlic belonged to. […]