Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeport Post Acute during CMS and state inspections, most recent first.
A nurse gave a resident insulin lispro instead of ordered heparin after taking the vial from the wrong location in the med drawer and failing to verify the label against the order. The resident, who had Parkinson’s disease, developed hypoglycemia and was sent to the ER, where records showed insulin overdose, low potassium, low BP, and ICU admission. Facility interviews confirmed the error and that the nurse did not follow the required triple-check medication process.
The facility did not provide the required 3.5 DHPPD on most days reviewed, resulting in delayed care for two residents with significant medical needs, including one with hemiplegia and another who was blind. Staff interviews confirmed frequent understaffing, and records showed that call lights were not answered promptly, impacting residents' ability to receive timely assistance.
Two residents with significant pain needs did not receive timely administration of PRN pain medication or prompt pain reassessment by nursing staff. In both cases, pain medication was administered with substantial delay after the resident's request, and pain reassessments were conducted several hours after administration, contrary to professional standards and facility expectations.
Surveyors found that medications, including expired ointment and undated insulin vials, were not properly labeled or removed from use, and that medications such as nasal spray, eye drops, and insulin were left unsecured at residents' bedsides without required physician orders. Additionally, an LPN disposed of a controlled substance without a witness, violating facility policy. The DON and pharmacy consultant confirmed these actions did not meet established procedures for medication management.
A resident with Type 1 Diabetes Mellitus and left eye blindness was found to be self-administering insulin and eye drops without an assessment by the IDT, as required by facility policy. The DON was unaware of the self-administration, and no documentation or care plan reflected an evaluation of the resident's ability to safely self-administer medications.
A resident's care plan required that cigarettes and lighters be stored in a lock box, but staff left these items unattended in the resident's room with the door open. Both CNA and LVN staff confirmed the items should have been secured, and the DON stated that all staff are responsible for implementing care plan interventions. Facility policy also mandates comprehensive, person-centered care plans.
A resident receiving insulin did not have fasting blood glucose (FSBG) levels monitored or recorded as ordered by the physician. Staff interviews confirmed that daily FSBG checks were not performed, and the resident reported being told by nurses that daily monitoring was unnecessary. Facility policy also required blood glucose monitoring for residents on insulin, but this was not followed.
Surveyors identified a 10% medication error rate after two residents were given enteric coated Aspirin instead of the prescribed chewable form, and another resident with hepatic encephalopathy did not receive a scheduled dose of Lactulose due to nurse omission. In each case, the medications administered did not match physician orders, and facility policy requiring verification of medication details was not followed.
Two fans in the kitchen, both covered in fine white dust, were observed blowing air directly onto food preparation and delivery areas. The Registered Dietitian confirmed the dust and acknowledged the risk of dust particles landing on food, in violation of FDA Food Code and facility policy requiring clean nonfood-contact surfaces.
Surveyors found that both pill crushers on medication carts were coated with powder-like substances, and staff acknowledged they were dirty and should have been cleaned after each use. The DON confirmed that pill crushers should be cleaned between uses, and manufacturer instructions required regular cleaning. This failure resulted in a deficiency in the infection prevention and control program.
A resident with multiple serious medical conditions received more than the prescribed 3000 mg of acetaminophen on 29 out of 34 days, risking liver damage. The DON acknowledged confusion due to concurrent physician orders and stated that nurses should have sought clarification from the doctor. The facility's policy emphasized contacting the prescriber if a dosage was believed to be excessive.
Medication Error Resulted in ICU Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when a nurse administered insulin lispro to a resident instead of the ordered heparin injection. The resident had been admitted with a primary diagnosis of Parkinson’s disease and had an order for heparin sodium 5000 units/mL, 1 mL every 12 hours. According to the record and staff interviews, the nurse obtained the medication vial from the front of the medication drawer where insulin was stored, rather than from the back where heparin was kept, and did not verify the medication label against the physician’s order before giving it. After the medication was given, the nurse later realized a serious error may have occurred and checked the resident’s blood sugar, which was low. The nurse gave the resident food and orange juice, notified the DON and FMD, and the FMD ordered glucagon, frequent blood sugar checks, and transfer to the nurses’ station for monitoring. The nurse also called 911, and the resident was transported to a GACH for evaluation and treatment. Hospital records showed the resident was treated for insulin overdose and had a low potassium level, low blood pressure, and required potassium replacement, Levophed, and IV fluids. The resident was admitted to the ICU. Interviews confirmed the nurse administered insulin lispro instead of heparin and did not follow the facility’s medication administration process requiring the medication label to be checked three times against the order before administration.
Failure to Meet Required Nursing Staff Hours Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the required 3.5 direct care service hours per patient day (DHPPD) for 27 out of 39 days reviewed. This deficiency was evidenced by observations, interviews, and record reviews, which showed that residents did not receive timely nursing care. For example, one resident with cerebral palsy, stroke, dementia, and hemiplegia was observed unable to reach his call light and stated that it took a long time to get help. Another resident, who was completely blind and had diabetes and retinopathy, reported that it often took between thirty minutes to an hour to receive assistance, especially at night and on weekends, sometimes requiring him to call out or go to the nursing station himself despite his blindness. Certified Nursing Assistants (CNAs) interviewed confirmed that staffing was often insufficient, with one CNA responsible for up to 15 residents and feeling unable to provide adequate care. The Director of Nursing verified that the facility's DHPPD was below the required level on most days reviewed, and acknowledged that call lights were not being answered within the expected 15-minute timeframe. The facility's staffing waiver also required a minimum of 3.5 DHPPD, which was not met on numerous days as documented in the reviewed records.
Failure to Provide Timely Pain Management and Reassessment
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents with significant medical needs. In the first instance, a resident with an open wound and acute osteomyelitis of the right foot requested pain medication for the first time since admission. After the resident pressed the call light and informed a CNA of the pain, the CNA promptly notified an LVN. However, the LVN did not administer the prescribed acetaminophen until one hour and seven minutes after the request, despite acknowledging that pain should be addressed within 15-20 minutes. Furthermore, the LVN did not reassess the resident's pain level until two hours and thirty-five minutes after medication administration, contrary to professional standards and facility expectations. In the second case, a resident admitted with a femur fracture received PRN oxycodone for severe pain on two occasions. On both occasions, the pain reassessment was conducted more than three hours after medication administration, significantly exceeding the expected timeframe of 30 minutes to one hour. Interviews with facility leadership confirmed that there was no policy specifying the required timeframe for pain reassessment after PRN oral pain medication, and that timely response and reassessment are necessary to ensure effective pain management. These lapses were documented through record reviews, staff interviews, and direct observation.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and biologicals. An expired box of hemorrhoid ointment was found in a medication cart, and the LVN confirmed it should have been removed. Additionally, an opened multi-dose vial of insulin for a resident with diabetes was not labeled with the date it was opened, contrary to facility policy and manufacturer instructions, which require insulin vials to be dated and discarded after 28 days. The DON confirmed that staff are expected to inspect medication carts weekly and ensure expired medications are removed, and that insulin vials must be labeled with the opened date. Observations also revealed that medications were not securely stored as required. One resident had a Fluticasone Propionate nasal spray on their bedside table without a physician's order for bedside storage, and another resident had multiple eye drops and two vials of insulin on their bedside table. Both residents stated that staff had provided the medications, and the DON confirmed that medications should not be kept at the bedside unless there is a physician's order and care plan for self-administration. Facility policy requires all medications to be kept in locked compartments unless otherwise ordered and documented. A further deficiency was noted when an LVN discarded a tablet of Oxycodone, a controlled substance, into a medication waste bin without a witness after it was dropped. Both the DON and pharmacy consultant confirmed that controlled substances must be wasted in the presence of another licensed nurse, as per facility policy. The lack of proper witnessing and documentation for the disposal of controlled substances was a direct violation of the facility's procedures.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A resident admitted with Type 1 Diabetes Mellitus and left eye blindness was observed to have five bottles of eye drops and two vials of insulin on her bedside table. The resident reported that a nurse provided these medications at 6 AM for her to self-administer, and she confirmed that she had been self-administering both her insulin and eye drops since admission. The resident also stated she refilled her insulin pump and administered her eye drops before attending physical therapy that morning. Upon review, the Director of Nursing (DON) stated she was unaware that the resident had been self-administering medications. The facility's policy requires the Interdisciplinary Team (IDT) to assess a resident's ability to self-administer medications and document this in the medical record and care plan if deemed safe and appropriate. The DON confirmed that the IDT had not conducted this assessment for the resident prior to the survey, resulting in a failure to follow facility policy regarding self-administration of medications.
Failure to Secure Smoking Materials as Directed in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident when the intervention to store cigarettes and a lighter in a lock box was not followed. During observations, it was noted that the resident's room door was open while the resident was not present, and cigarette lighters and packs of cigarettes were left unattended on the bed and nightstand. Staff interviews confirmed that cigarettes and lighters should have been secured in a lock box as per the resident's care plan to prevent unauthorized access by other residents. Record review showed that the care plan specifically required cigarettes and lighters to be stored in the resident's lock box. Both a CNA and an LVN acknowledged that the care plan was not implemented as directed, and the Director of Nursing confirmed that all staff are responsible for following care plan interventions. The facility's policy also requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Failure to Monitor and Record Fasting Blood Glucose for Insulin-Dependent Resident
Penalty
Summary
The facility failed to follow physician orders for a resident on insulin therapy by not monitoring and recording fasting blood glucose (FSBG) levels as directed. The physician's order, dated 5/20/25, specified that FSBG should be checked every morning. However, a review of the resident's chart revealed that no FSBG values had been recorded since the order was written. Interviews with the Infection Preventionist and a Licensed Vocational Nurse confirmed that the monitoring was not performed as required. Additionally, the resident reported being told by nursing staff that daily blood sugar monitoring was unnecessary. The facility's own diabetes protocol also indicated that blood glucose should be monitored twice daily for residents on insulin, further highlighting the deviation from both physician orders and facility policy.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 10 percent, exceeding the acceptable threshold of less than 5 percent, based on three identified errors out of 30 observed opportunities. Two residents were administered Aspirin 81 mg enteric coated tablets without a physician's order specifying this formulation. In both cases, the physician's order required Aspirin 81 mg chewable tablets, but the nurse administered the enteric coated version instead. The nurse confirmed during interviews that the correct chewable form was not available in the medication cart at the time of administration, and the pharmacy consultant verified that the two formulations are not interchangeable. Another incident involved a resident with hepatic encephalopathy who did not receive a scheduled dose of Lactulose, a medication prescribed to be given four times daily. The nurse prepared and administered the resident's other morning medications but omitted the Lactulose, later confirming that it was forgotten. The physician's order for Lactulose was clear, and the facility's policy required medications to be administered within one hour of the scheduled time. The pharmacy consultant noted that missing a dose could affect the intended treatment. In all three cases, the facility's policy and procedure for administering medications required staff to verify the right resident, medication, dosage, time, and method of administration, and to follow prescriber orders. The observed errors demonstrated a failure to adhere to these policies, resulting in the administration of incorrect medication formulations and the omission of a prescribed dose.
Unsanitary Kitchen Fans Lead to Food Contamination Risk
Penalty
Summary
During an observation in the kitchen, a stand-up fan and a floor fan were found to have fine white colored particles, identified as dust, on their surfaces. Both fans were actively blowing air into areas where food was being prepared and delivered, specifically directing airflow toward the food delivery cart, tray-line, and food preparation area. The Registered Dietitian confirmed the presence of dust on both fans and acknowledged that dust particles could land on food. Review of the FDA Food Code and the facility's own sanitization policy indicated that nonfood-contact surfaces, such as fans, must be kept clean to prevent contamination and maintain a sanitary environment. The failure to keep these fans clean resulted in a deficiency related to the safe and sanitary maintenance of kitchen food preparation and storage areas.
Failure to Maintain Clean Pill Crushers Compromises Infection Control
Penalty
Summary
Surveyors observed that both pill crushers on separate medication carts were coated with powder-like substances of various colors, including white, black, and brown. During interviews, both LVNs acknowledged that the pill crushers were dirty and should have been cleaned to prevent cross contamination. The DON confirmed that the pill crushers should be cleaned after each use, with any residue removed using bleach wipes before crushing another medication. Review of the manufacturer's cleaning instructions indicated that the pill crushers should be regularly cleaned with a damp cloth and detergent, then wiped dry. The failure to clean the pill crushers as required led to the deficiency in the facility's infection prevention and control program.
Excessive Acetaminophen Administration to Resident
Penalty
Summary
The facility nursing staff failed to administer acetaminophen as ordered to a resident, resulting in the resident receiving more than the prescribed 3000 mg limit on 29 out of 34 days during their stay. The resident, who had multiple serious medical conditions including a heart transplant, end-stage kidney disease, Type 2 diabetes, a broken hip, and Covid-19, was at risk for liver damage due to this oversight. The resident's care plan included administering medication as ordered, but the medication administration record showed that the resident received 3650 mg on 17 days, 4300 mg on 10 days, and 4950 mg on 2 days. The Director of Nursing (DON) acknowledged that the concurrent physician orders for acetaminophen could be confusing, as both orders specified not to exceed 3000 mg in 24 hours. The DON confirmed that the resident was administered more than 3000 mg of acetaminophen on most days and stated that nurses should have contacted the doctor for clarification if the resident requested more than the prescribed amount. The facility's policy on administering medications emphasized the importance of contacting the prescriber if a dosage was believed to be inappropriate or excessive.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Point Care Center | 1.2 mi | ★★★★★ | 13 | 0 |
| Ukiah Post Acute | 16.3 mi | ★★★★★ | 9 | 0 |
| Redwood Cove Healthcare Center | 16.5 mi | ★★★★★ | 18 | 0 |
| Meadowood Nursing Center | 17 mi | ★★★★★ | 32 | 0 |
| Cloverdale Healthcare Center | 17.4 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.