Geneva Lake Manor

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent an elopement from occurring for 1 of 3 residents at risk for elopement out of a sample of 12 (R1). R1 has a history of elopement and is at risk of wandering. The facility failed to implement care planned interventions and failed to ensure exits were secured resulting in R1 being able to exit the facility through an exit door without staff knowledge. The facility's failure to supervise a resident and implement care planned interventions allowed R1 to elope from the facility. This created a finding of immediate jeopardy that began on 7/10/26. Surveyor notified Administrator, Director of Nursing (DON), Director of Operations, and the Chief Nursing Officer of the immediate jeopardy on 7/14/26 at 4:10 PM. The immediate jeopardy was removed and corrected on 7/10/26; [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of CNAs (Certified Nursing Assistants) at least every 12 months for 5 of 5 CNAs reviewed. This has the potential to affect all 45 residents. CNA3, CNA4, CNA5, CNA6, and CNA7 did not have a yearly performance review completed. This is evidenced by:The facility's policy Job Descriptions and Performance Evaluations, dated 9/20, includes: Performance evaluations measure the standards against job performance. The objectives of our job descriptions and performance evaluations are to: d. aid management in analyzing and improving the facility's services and structure of its organization; e.and to improve the quality of work performance; CNA3 has a hire date of 2/16/25. CNA3 does not have a yearly performance review completed in the last 12 months. CNA4 has a hire date of 9/21/09. [...]

Inspectors wroteBased on record review and interviews the facility failed to report an allegation of abuse to the state agency (SA) for one of three residents (R8) reviewed for abuse out of 12 sampled residents. R8 reported an allegation of abuse to the NHA (Nursing Home Administrator) this allegation was not reported to the state agency.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R12 & R8) of 3 residents reviewed for pressure injuries. *On 12/9/2025, Surveyor observed R12 in bed without Prevalon boots, per physician orders, for R12's bilateral, heel pressure injuries. *On 12/9/25, Surveyor observed R8 up in her broda chair after breakfast and after lunch. R8's physician order dated 1/28/25 documents R8 is to be laid down after all meals due to pressure injury on coccyx.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure 1 (R2) of 1 resident reviewed for urostomy services, received care consistent with professional standards of practice.*R2's nephrostomy dressing was not applied as ordered. R2's nephrostomy tubing did not have a securement device in place per R2's physician's order.

Inspectors wroteBased on interview and record review, the facility did not ensure residents who require dialysis receive such services consistent with professional standards of practice, including ongoing communication with the dialysis center before and after treatments for 1 (R10) of 1 resident reviewed for dialysis.*R10 had a history of experiencing unresponsive episodes primarily after hemodialysis sessions. R10 did not have a post dialysis assessment completed after receiving hemodialysis on 11/20/2025 and was experiencing symptoms, however there is no documentation staff were aware of R10's history and or that R10 required additional monitoring.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R2 and R7) of 8 residents received their prescribed medications in a timely manner. *On 12/9/2025, R2's morning medications, with a scheduled timeframe of 6AM-10AM, were not given until after 11AM. *R7 is prescribed Ozempic injection weekly for diabetes. R7's August, October and November 2025 MAR (medication administration record) documents weeks when Ozempic injection was not available to administer.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R2) of 8 residents were free of significant medication errors.*On 12/9/2025, R2 did not receive R2's 8 AM ordered dose of Insulin glargine, until after 11 AM.* On 12/9/2025, R2 received R2's Lispro outside of R2's order for special instructions.*On 12/9/2025, R2 did not receive R2's 8 AM scheduled dose of Insulin (Lispro).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R8) of 2 residents observed while being provided wound treatment had the necessary hand hygiene performed. * Surveyor LPN (Licensed Practical Nurse)-I not perform hand hygiene while providing pressure injury treatment to R8.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) based on their comprehensive assessment for 1 (R1) of 3 residents reviewed. On 9/3/2025, R1 experienced a change of condition with increased lethargy, not wanting to eat, having a small emesis, and no bowel movement for three days. No documentation of an assessment by facility staff including vital signs, was found with the change of condition. No assessment or documentation was found from facility nursing staff of R1 having multiple emesis. No assessment or documentation was found from facility nursing staff indicating R1 had received medication to relieve constipation, what medication was administered, and the results from receiving the medication. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of the 47 residents. Dietary Aide (DA)-P did not have an up to date background check completed within the four year time frame.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (CNA-J, MT-E) of 3 nursing staff reviewed had appropriate competencies and skills sets to assure resident safety and respond to resident needs. This has the potential to affect a total of approximately 25 residents who currently reside in zone 2 and the rehab zone in which certified nursing assistant (CNA)-J and med tech (MT)-E are typically assigned. *CNA-J stated they assessed vitals for R1 while R1 was experiencing a change of condition without proof of competency to collect vitals and without a comprehensive assessment being performed by a registered nurse or monitoring by a licensed practical nurse (LPN)*MT-E did not have evidence of completing required pharmacy education for the last 3 calendar years and did not have evidence of certification to perform blood draws defined under State regulations.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 6 (R17, R47, R34, R19, R26, and R36) of 6 residents reviewed with pressure injuries or at risk for developing pressure injuries. *R17 did not have a comprehensive skin assessment on admission on [DATE]. On 7/26/2024, wound documentation included a Deep Tissue Injury (DTI) to the right lateral foot, a DTI to the right Achilles and heel, a DTI to the coccyx, a DTI to the left heel, and a DTI to the left Achilles. The Right lateral foot, and the coccyx pressure injuries progressed to Unstageable, and the right Achilles and heel progressed to a Stage 4. All areas healed. [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to prevent the need for repeated medical interventions. This was discovered with 1 (R13) of 14 residents reviewed for quality of care. In the last 120 days R13 has been sent to the emergency department six times for complications related to nephrostomy tubes (thin, flexible tubes inserted directly into the kidney to drain urine when the natural urinary tract is blocked).

Inspectors wroteBased on interview and record review, the Facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 53 of 53 residents in the Facility. * The Facility did not designate a charge nurse for each tour of duty on each daily nursing schedule.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop an infection prevention and control program that included preventing, identifying, reporting, and controlling infections and communicable diseases potentially affecting all 53 residents, and providing a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 (R47, R34, R17, and R19) of 12 residents in Enhanced Barrier Precautions (EBP). *Facility outbreaks did not have complete surveillance data on the residents and staff affected. *Monthly infection surveillance data did not have infection rates calculated. *The Water Management Plan did not have a detailed description and diagram of the water system in the facility identifying control measures and how the control measures are monitored. *R47 was in EBP. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 53 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic.

Inspectors wroteBased Interview and record review, the facility did not provide transfer notices to 3 (R5, R47, R13) of 4 residents reviewed for discharge. The facility did not provide transfer notice information to the Ombudsman on a consistent basis. *R5 was hospitalized on [DATE] and did not receive a transfer notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive a transfer notice for all 3 hospitalizations. * R13 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information including appeal rights. * Monthly discharge summaries were not sent to the Ombudsman in a timely manner for the months of December and January.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 5 out of 5 residents (R44, R26, R16, R34 and R5) drug regimen was free from unnecessary medications. R44, R26, R16, R34 and R5 received recommendations from the Pharmacy Consultant via the monthly review and the facility did not address the recommendations by having the physician review and sign acknowledge of receiving the recommendations and if they accept or want to modify the recommendation for each individual resident.

Inspectors wroteBased on observation and interview, the facility did not ensure food was stored, prepared and served in a sanitary manner. This practice had the potential to affect a pattern of the facility 53 residents who receive food served in the facility common dining room. * A dietary staff member was observed taking temperatures and serving food in the common dining room for breakfast service on 3/3/25 and not wearing a hair net. * Food temperatures were not obtained prior to providing breakfast service on 3/3/25 and throughout breakfast serving times, in the common dining room.

Inspectors wroteBased on observation, interview and record review, the Facility did not provide written notice including the reason for the room change to a resident and offer a choice in a change of room for 1 (R13) of 1 residents reviewed for room change. R13 returned from the hospital on 2/24/2025 and was placed into a different room, the Facility did not take resident preference into account or offer to show possible rooms to the resident/resident representative prior to the change. There is no documentation R13 received prior written notice for the reason for the transfer.

Inspectors wroteBased on observation, interview and record review, the Facility did not promote or facilitate the resident's choice for a sleep schedule. This was observed with 1 (R13) of 14 residents reviewed. * R13's morning preference of time to get up was not followed by staff.

Inspectors wroteBased on interview and record review the Facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 (R13) of 1 residents reviewed for restraints. R13 has an abdominal binder in place which cannot be removed easily by R13 and restricts R13's freedom of movement or normal access to body. The Facility did not have a Physician order or signed consent form, did not provide evidence that the use of the abdominal restraint is the least restrictive alternative, did not document scheduled time binder should be on and did not document on-going evaluation of the need for the abdominal binder.

Inspectors wroteBased on Interview and Record Review, the facility did not provide bed hold notices to 3 (R5. R47, R13) of 3 residents reviewed for hospitalization. *R5 was hospitalized on [DATE] and did not receive a bed hold notice. *R47 was hospitalized on [DATE], 12/24/24 and 1/19/25. R47 did not receive bed hold notices for all 3 hospitalizations. *R13 was hospitalized on [DATE] and did not receive a bed hold notice.

Inspectors wroteBased on interview and record review, the facility did not complete a Pre-admission Screening & Resident Review (PASARR) assessment for 1 (R37) of 1 residents reviewed. R37 was admitted to the facility on [DATE], and did not have a PASARR Level I completed at time of admission.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R50) of 1 residents reviewed for discharge received a thorough discharge summary in order to communicate necessary information to care for the resident. *R50 discharged from the facility on 1/13/25. The facility did not complete a discharge summary or a recapitulation of their stay that was available to R50.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 1 (R44) out of 3 residents reviewed for accident hazards, received the care and services to prevent a further accident from happening. R44 had a history of swallowing difficulties and experienced a choking episode. The facility did not get a referral for R44, immediately following the incident, to identify the cause of the choking and provide supervision and assistance devices to prevent further choking incidents from happening.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received appropriate treatment to restore continence to the extent possible for 1 (R47) of 2 residents reviewed for bladder incontinence. R47 had an indwelling urinary catheter that was removed while at the facility. The facility did not comprehensively assess R47's bladder pattern to develop a toileting program to restore R47's urinary continence. R47's Care Plan was not revised when the catheter was removed.

Inspectors wroteBased on record reviews and interviews, the facility did not adequately address Nutrition needs for 1 (R19) of 1 residents reviewed for Nutrition. *R19 sustained a 9.2% weight loss from October 2024 to December 2024. The facility did not monitor R19's weight or implement proper interventions per RD (Registered Dietician) recommendations.

Inspectors wroteBased on interview and record review the Facility did not ensure residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments for 1 (R46) of 1 residents reviewed for dialysis. R46 has a physician order for dialysis on Tuesday, Thursday and Saturday. Communication between the Facility and the dialysis center was not being shared with each visit.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R13) of 1 residents were free from significant medication errors. R13 had a physician order to receive one 100 mg Amantadine HCl capsule (Per Drugs.com Amantadine is used to treat Parkinson's disease and Parkinson-like symptoms such as stiffness or tremors, shaking, and repetitive uncontrolled muscle movements that may be caused by the use of certain drugs) one time a day. It was documented that R13 did not receive three administrations of Amantadine between 2/28/2025 and 3/3/2025.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure they posted the nurse staffing data to include the date, resident census, and the total actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, on a daily basis. This has the potential to affect all 53 residents currently residing in the Facility. * The Facility did not have Nurse Staff Posting forms posted daily in a visible location in the Facility and has no record of Nurse Staff Postings being completed or maintained for 18 months.

Inspectors wroteBased on record review and interviews, the facility did not ensure resident's experiencing a medical change in condition, received appropriate treatment and care, per standards of practice consistent with N6 Wisconsin Nurse Practice Act. This was discovered with 2 (R13 and R6) of 5 residents reviewed with a medical change in condition. * On [DATE], at 3:15 PM, R13 developed a high fever that was not resolved with medication. R13's blood sugar was to high to register on a testing meter. Their pulse and oxygen saturations were erratic. They had rapid gargled breathing. There is no evidence their symptoms were communicated to a medical provider for consultation and treatment. They experienced a cardiac arrest and passed away in the facility on [DATE], at 7:35 PM. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not address and resolve grievances conveyed on behalf of 4 (R2, R5, R10 and R12) of 4 residents reviewed for grievances. * R2's dialysis social worker contacted the Facility on numerous occasions with concerns that were not recorded or investigated. * R5's Power of Attorney (POA) filed a grievance related to medication administration that was not thoroughly investigated. * R10 expressed care concerns. There was not documentation they the concerns were thoroughly investigated, along with appropriate resolution. * A grievance was filed on behalf of R12 by Hospice for neglect when R12 was found in bed soiled and wet. The grievance was not thoroughly investigated.

Inspectors wrote2.) R9 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, poly neuropathy, hypertension and atrial fibrillation. The significant MDS (minimum data set) dated 8/30/24 indicate R9 is cognitively impaired. Surveyor reviewed the facility self report dated 8/17/24 which indicated on 8/17/24 R9 was observed with bruising to the left side of her face. The investigation indicate on 8/17/24 at 12:30 a.m. CNA (certified nursing assistant) DD observed R9 in bed with facial bruising to the left side of the head. It indicates CNA-DD notified RN (registered nurse) EE regarding the bruising and RN-EE Stated R9 had a fall on 8/13/24. The investigation indicates it wasn't until the first shift staff came on shift that R9 was assessed and was discovered to have bruising to the left side of her face. The nurses note dated 8/17/24 at 6:21 a.m. [...]

Inspectors wroteBased on interview and record review, the facility did not allow the resident representative the right to exercise their rights as delegated to the representative for 1 (R7) of 2 residents reviewed with an activated power of attorney. R7's power of attorney was not present for the admission of R7 into the facility and did not sign any admission consents or contracts. R7 had been deemed incapacitated by a physician and a psychologist prior to admission. R7 signed all admission consents and contracts while assessed to be incapacitated.

Inspectors wroteBased on interview and record review, the Facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R5) of 2 allegations of abuse or neglect reviewed. * R5 had an injury of unknown origin that was not thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a baseline care plan that includes the instructions needed to provide effective and person centered care for 2 (R16 and R7) of 2 residents reviewed. * R16 was admitted to the facility on [DATE] and did not have a baseline care plan initiated. * R7's baseline care plan did not include individualized, person-centered interventions.

Inspectors wroteBased on interview and record review, the facility did not ensure a discharge plan was in place to effectively transition the resident to post-discharge care for 1 (R7) of 2 residents reviewed for discharge. R7 was discharged to home while incapacitated with no appointed decision maker. R7 did not receive home health services upon discharge due to no appointed Power of Attorney (POA) to sign contracts for services and no medications were available for R7 upon return to home.

Inspectors wroteBased on interview and record review, the facility did not ensure medically related social services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (R7) of 2 residents reviewed for discharge. R7 had an activated Power of Attorney (POA) on admission that was not included in the admission process, social services did not assist R7 in obtaining a decision-maker or guardian prior to R7 revoking the POA, R7 was not assisted in applying for Medicaid after changing payor sources from Medicare, and social services did not ensure R7 had a safe discharge.

Inspectors wroteBased on record review and interview, the facility did not ensure a medication administration errors were thoroughly investigated to prevent reoccurrence. This was observed with 2 (R6 and R2) of 4 residents reviewed with medication administration errors. * R6 received potassium 40 (milliequivalents) meq that was not prescribed for R6. There is not documentation to how this occurred and preventative action. * R2 did not have a reported medication error investigated by the Facility.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R17) of 1 resident were free of significant medication errors. R17 did not receive various medications from September 2024 through November 2024 because the medication was not available. The medications that were not administered were Trulicity (diabetic medication), losartan hydroclorothiazide 100/25 mg (milligrams) (blood pressure medication), allopurinol 300 mg (medication to treat gout), latanoprost (eye drops for glaucoma), sertraline 50 mg (depression), toprol xl 100 mg (blood pressure medications), pantoprazole EC 40mg (for GERD-gastro-esophageal reflux disease), and fluticasone (treat asthma).

Inspectors wrote2. R300 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Dysphagia, Dyspnea, and Adjustment Disorder with Depressed Mood. R300 is currently R300's own person. Surveyor noted physician orders dated 8/3/17 for the use of prevalon boots on at all times while in wheelchair. R300's Quarterly Minimum Data Set (MDS) dated [DATE] documents R300's Brief Interview for Mental Status(BIMS) score to be 15, indicating R300 is cognitively intact for daily decision making. R300's MDS also documents for mobility that R300 requires partial to moderate assistance for rolling left to right and substantial to maximum assistance for sit to lying and sit to stand. Bed rails are not documented on R300's MDS. [...]

Inspectors wroteBased on observation, interview and record review the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection. This had the potential to affect all 53 of the 53 residents residing in the facility at the the time of the survey. -The facility did not maintain surveillance data to monitor communicable diseases within the facility. -Registered Nurse (RN) performed wound care for resident (R31) who was on transmission-based precautions (TBP), without wearing appropriate personal protective equipment (PPE). - Dietary staff were observed not wearing their PPE appropriately. Dietary staff were observed wearing their mask below their nose and mouth. - The December 2023 monthly infection control log does not include baseline rates by infection. [...]

Inspectors wroteBased on observations, record review and interviews, the facility did not ensure Residents had an individualized comprehensive plan of care. This was observed with 5 (R15, R20, R40, R300, and R2) of 21 Residents comprehensive care plan reviews. *R15 has a repositioning bar on R15's bed and has an active history of refusing showers. There was no comprehensive plan of care with individualized interventions to address the repositioning bar or the refusal of showers. *R20 has bilateral half side rails on R20's bed and there was no comprehensive plan of care with individualized interventions to address the half side rails. *R40 is a smoker and there was no comprehensive plan of care with individualized interventions to address smoking safety. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, and did not have evidence the risks and benefits of bed rails were discussed with the resident and/or resident representatives and informed consent was obtained prior to installation for 4 (R15, R20, R300 and R38) of 4 Residents reviewed for repositioning bars. *R15 does not have a completed assessment done quarterly which documents that risks and benefits were discussed with the Resident and/or Resident representatives and informed consent was obtained prior to the installation, or a care plan was in place for R15's repositioning bars. [...]

Inspectors wroteBased on observation and interview the Facility did not ensure insulin was dated when opened, eye drops were dated when opened & labeled with a Resident's name, medications belonging to residents who no longer resided in the facility were disposed of properly, and pharmacy labels were not removed from medications. This has the potential to affect R6, R8, R349, R21, R14, R39, R249, R28, R250, R251, R403, R252, R253, and a pattern of residents residing on the rehab unit who utilize metamucil.

Inspectors wroteBased on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 5 residents reviewed (R42). * R42 is prescribed Seroquel, an antipsychotic medication for agitation related to Alzheimer's disease and dementia diagnosis. The facility did not have a written, signed consent explaining the risks and benefits of to R42's power of attorney (POA). This is evidenced by: Surveyor reviewed R42's physician orders and noted that R42 is currently prescribed Seroquel 25 mg tablet twice a day with start date of 11/22/23 and ending on R42's date of discharge 01/09/24. R42 has an activated power of attorney (POA) for health care decisions. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 2 resident-to-resident incidents of physical abuse involving R36 towards R32 and R7 were reported to the State Agency within 2 hours, when the allegation involves abuse, and did not submit the results of their investigation within 5 working days to the State Agency. * On 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not report this resident-to-resident physical abuse incident between R36 and R32 to the State Agency within 2 hours. The facility did not provide their investigation results within 5 working days to the State Agency. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 resident-to-resident incidents (involving R32 and R7) of 2 incidents of physical abuse by a resident (R36), had a thorough investigation completed. * The facility self-report Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 1/4/24 indicates, on 12/26/23 at 2:00 pm, R36 struck R32 on the hand, when R32 wheeled past R36's wheelchair. The facility did not complete a thorough investigation of this incident. * On 12/27/23, R36 struck R7 on the shoulder when R36 was being wheeled past R7. The facility did not report this resident-to-resident physical abuse incident to the State Agency and did not complete a thorough investigation.

Inspectors wroteBased on interview and record review the facility did not ensure that the PASARR (Pre-admission Screen and Resident Review) for 1 (R5) of 2 Residents reviewed was completed accurately upon admission to the Facility and was appropriately referred for a Level II screen. R5 has a diagnosis of bipolar disorder and being treated with antidepressants of Trazadone & Effexor. The Facility did not complete Section C Questions pertinent for an abbreviated Level II screen and did not refer R5 for a Level II screen on or before the 30th day of stay at the Facility as required. A required Level II screen which would indicate if R5 needs nursing home placement and if R5 needs specialized service related to developmental disability and/or serious mental illness which is defined by federal PASARR regulations.

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure residents who are dependent on staff for personal hygiene/showering were provided the necessary care. This was observed with 1 (R15) 2 Residents reviewed who were dependent on staff for personal hygiene/showering. * On 1/9/24 at 9:58 AM, R15 informed Surveyor that R15 has not been getting showers on a regular basis and is scheduled for Tuesdays and Fridays. There is no documentation or comprehensive care plan of R15 refusing showers. The facility was not able to provide documentation that R15 has received showers. Findings Include: Surveyor reviewed the facility's Bath, Shower/Tub policy and procedure revised February 2018 and notes the following: .Purpose The purposes of this procedure are to promote cleanliness, provide comfort to the Resident and to observe the condition of the Resident's skin. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure the resident's record reflected the accurate resuscitation code status as identified in the resident's advanced directive for 2 of 2 residents (R3 and R40) reviewed for a Do Not Resuscitate (DNR) code status. * R3's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R3's current physician orders for [DATE]-[DATE] documents that R3 is a full code with a start date of [DATE]. * R40's Emergency Care Do Not Resuscitate Order (DNR) was signed [DATE]. R40's current physician orders for [DATE]-[DATE] documents that R40 is a full code with a start date of [DATE]. Surveyor requested during the survey process the facility's policy and procedure for documenting a Resident's preference for CPR but did not receive a policy and procedure. Findings Include: 1. [...]

Inspectors wroteBased on interview, and record review the Facility did not ensure quality of care was provided for 2 (R5 & R300) of 3 Residents reviewed for neurological checks. * R5's neurological checks were not completed after unwitnessed falls on 12/8/23, 12/20/23, 12/28/23, & 12/30/23. * R300's neurological checks were not completed after unwitnessed falls on 9/13/23 & 10/4/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure daily diabetic foot inspections was provided in accordance with professional standards of practice for 1 Resident (R) (R20) of 2 Residents reviewed with a diagnosis of Diabetes. * R20 who has Type 2 Diabetes Mellitus with diabetic neuropathy. R20's care plan and care card does not address performing daily foot care and inspection. R20 reported R20 has been taught to do diabetic foot checks but is not able to physically check his own feet. R20 reported staff do not check his feet daily. According to Director of Nursing (DON)-B foot checks are not completed daily but are completed weekly. Findings Include: According to the American Medical Directors Association (AMDA), Diabetes Management in the Post-Acute and Long Term Care Setting Clinical Practice Guideline. [NAME], MD: AMDA 2015 page 32-33 states in part: [...]

Inspectors wroteBased on interview and record review, the Facility did not ensure ongoing communication with a dialysis facility for 1 (R24) of 1 resident who received dialysis care and services. * R24 received dialysis three times per week. The Facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R24's dialysis appointments.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure self-administration assessments were completed prior to leaving medication at the bedside to ensure safe medication delivery for 1 of 1 resident (R403) reviewed for self-administration. * R403 was observed to have medication left at bedside to self-administer and did not have a physician order or an assessment to self-administer medications. This is evidenced by: The facility's Medication Self-Administration of Medications policy states in part . Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. [...]

Inspectors wroteBased on record review and interview, the Facility did not keep 1 (R5) of 1 Residents reviewed for antibiotic use free from unnecessary drugs. * On 11/3/23 R5 was ordered & received Macrobid 100 mg (milligrams) BID (twice daily) x (times) 5 days for UTI (urinary tract infection) when R5 did not have/ appropriate signs and symptoms for use of the antibiotic.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 33 opportunities which resulted in a medication error rate of 6.06%. Medication errors were identified for R351 & R38. * R351 did not receive PreserVision AREDS-2 on 1/10/24 as this medication was not available. * R38 did not receive Colchicine 0.6mg on 1/11/24 as this medication was not available.

Inspectors wroteBased on observation, interview and record review the facility did not provide adequate supervision and interventions to prevent accidents for 4 (R17, R300, R32 and R5) of 4 sampled Residents identified by the facility to be at risk for falls. *On 1/19/24, R17 was not transferred per plan of care (including the care card), which indicates the use of 2 staff assist when transferring with the hoyer lift. *R300 had 4 falls all from R300's recliner on 9/13/23, 10/4/23, 11/12/23, and 12/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R300's falls. *R32 had 2 falls on 7/29/23 and 11/30/23. The facility did not complete a thorough investigation and determine a root cause analysis for R32's falls. *R5 had 5 six falls in December 2023: 12/4/23, 12/8/23, 12/20/23, 12/27/23, 12/28/23, & 12/30/23. [...]

Inspectors wroteBased on observation, the facility did not ensure the privacy and confidentiality of protected health information (PHI) for 2 of 2 residents (R2 and R9). This is evidenced by: On 01/09/24, at 10:37 AM, Surveyor observed a medication cart in hallway in front of R2's room. The computer screen was up with R2's medication administration screen viewable. R2's door was closed, and Licensed Practical Nurse Q (LPNQ) was in R2's room. LPNQ was observed coming out of R2's room and started setting up R2's medications. At 10:40 AM, LPNQ completed R2's medication set up. LPNQ locked the medication cart and went back into R2's room. LPNQ left the medication cart computer screen up with R2's PHI visible. At 10:45 AM, Surveyor observed LPNQ pushing the medication cart throughout the hallways with the computer screen up and R9's PHI viewable. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 3 (CNA (Certified Nursing Assistant)-N, CNA-O, & CNA-Q) of 5 randomly selected CNAs had a performance (competency) review at least once every 12 months. This has the potential to affect all 48 Residents residing in the Facility as staff work throughout the facility. A performance (competency) review was not completed for CNA-N, CNA-O, & CNA-Q in 2021.

Inspectors wroteBased upon observation and interview, the Facility did not ensure Facility equipment was maintained in proper working order potentially impacting 48 of 48 Residents residing in the Facility. Surveyor observed the left dryer in the laundry and observed the top flat surface and wires above the dry screen had a large accumulation of lint, which is a potential fire hazard.

Inspectors wroteBased on interview and record review the Facility did not ensure 4 (CNA (Certified Nursing Assistant)-O, CNA/Med Tech-P, CNA-Q, & CNA-R) of 5 randomly sampled CNA's (Certified Nursing Assistant) who had been employed for over a year received dementia management & resident abuse prevention training. This has the potential to affect all 48 Residents residing at the Facility as staff work throughout the facility.

Inspectors wroteBased on record review and interview the Facility did not ensure 4 (R2, R12, R41, & R43) of 5 Residents reviewed for COVID-19 vaccination had documented risk and benefits.

Inspectors wroteBased on record review and interview, the facility did not notify the resident or resident's representative in writing of the transfer and the reasons for the move including the effective date of transfer, the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form as well as the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman for 1 (R22) of 1 residents reviewed for transfer to the hospital. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a transfer notice was provided to R22 or R22's representative. [...]

Inspectors wroteBased on record review and interview, the facility did not notify at the time of transfer the resident or resident's representative in writing the state bed-hold policy, the duration of the bed hold, the reserve bed payment policy, and the return to the facility for 1 (R22) of 1 residents reviewed for bed hold notice. *R22 was transferred and admitted into the hospital on [DATE], 2/26/2022, 5/10/2022, and 7/9/2022. No documentation was found indicating a bed hold notice was provided to R22 or R22's representative.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice after an unwitnessed fall for 2 (R22 and R8) of 4 residents reviewed for falls. *R22 had unwitnessed falls on 12/16/2021, 1/29/2022, 2/9/2022, 2/16/2022, 2/21/2022, 2/26/2022, 3/3/2022, and 7/9/2022. Neurological checks were not completed following the fall to assess for a change in mentation. *R8 had unwitnessed falls on 2/23/2022, 4/28/2022, and 6/4/2022. Neurological checks were not completed following the fall to assess for a change in mentation.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receives appropriate care, treatment, & preventative measures to promote healing for 1 (R99) of 2 Residents with pressure injuries reviewed. R99 was admitted to the facility on [DATE] with a right buttocks Stage 2 pressure injury. There was no assessment of the pressure injury until after Surveyor spoke with ADON (Assistant Director of Nursing)-C on 9/12/22. The physician order dated 8/26/22 documents may apply medseptic cream to areas of concern every shift - PRN (as needed). There is no documentation in R99's Treatment Administration Record (TAR) from 8/26 to 9/11/22 of R99 receiving the medseptic cream, even though the Assistant Director of Nursing (ADON) -C informed Surveyor staff had been applying it. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents received adequate supervision to prevent falls for 3 (R9, R8, and R22) of 4 residents reviewed for falls. *R9 had a fall on 7/4/2022 due to staff not following interventions per the Falls Care Plan. *R8 had six falls in eight months. R8's Falls Care Plan was not revised timely after falls to prevent future falls, interventions were not implemented as stated per the Fall Care Plan, and no documentation was found in R8's medical record of having a fall yet staff statements of a fall were provided. *R22 had eleven falls in eight months. R22's Falls Care Plan was not revised timely after falls to prevent future falls with resident-centered interventions.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R36) of 1 residents reviewed received dialysis services consistent with professional standards of practice. R36 did not have a physician's order documenting the frequency of dialysis treatments, the location of the dialysis center in the community, the care, monitoring, and location of the dialysis access site. R36's care plan did not document the location of the dialysis access site or the monitoring of the dialysis site for complication such as bleeding.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 (R35) of 1 residents reviewed for mood and behavior received appropriate treatment and the services to attain the highest practicable mental and psychosocial well-being. The facility did not ensure that R35 received a psychiatric consult as requested by R35's POA (Power of Attorney).

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 2 (R31 & R35) of 6 Residents reviewed. * R31 receives metoprolol tartrate 25 mg (milligrams) with instructions to hold the medication if R31's systolic blood pressure is less than 100. R31's PM (evening) blood pressure was not taken before administering the medication on 8/12/22, 8/18/22, 8/19/22, 8/20/22, 8/21/22 & 9/3/22. * R35 receives a prophylactic antibiotic for UTI (urinary tract infection) without adequate indications for its use.

Inspectors wroteBased on interview and record review, the Facility did not ensure that 1 (R31) of 4 Resident's medications reviewed were free from unnecessary drugs. * R31 receives Risperidone (Risperdal) 0.5 mg twice a day. The Facility is not monitoring R31's behavior and an AIMS (Abnormal Involuntary Movement Scale) was not completed.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure 1 (R16) of 5 residents reviewed for medication administration were free of significant medication errors. R16 was administered an extra 4 units of long-acting insulin before lunch time instead of the prescribed 4 units of short-acting insulin.

Inspectors wroteBased on interview and record review the Facility did not ensure 2 (CNA-V & CNA-H) of 5 unvaccinated Facility staff including individuals providing services under arrangements were tested for COVID 19 according to Facility's outbreak protocol and [NAME] County community transmission rates. This had the potential to affect all 48 Residents residing at the Facility.