Lake Mills Health Services

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 (R1 andR4) of 3 residents reviewed for pressure injuries. * R1 admitted to the facility on [DATE] with a hospital discharge summary that included treatment for R1’s right ischium. This treatment was not picked up by the facility. On 5/14/25, the facility documented a stage 2 pressure injury (PI) to R1’s right buttock. Wound Physician-G’s treatment recommendation for the right buttock was not completed by the facility. On 5/27/25, the right buttock PI was noted to have declined, and Wound Physician-G changed the treatment orders. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure 7 out of 8 staff members reviewed received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. Certified Nursing Assistant (CNA)-Q, CNA-R, CNA-T, CNA-V, Registered Nurse (RN)-Y, Licensed Practical Nurse (LPN)-E, and Housekeeping-Z, did not receive behavioral health training. This deficient practice has the potential to affect all 29 residents residing at the facility that have the potential to experience behavioral health issues.

Inspectors wroteBased on interview and record review, the facility did not ensure the facility that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider or a discharge summary that includes a recapitulation of the resident's stay to ensure a safe and orderly discharge for 2 (R2, R4) or 2 residents.* R2 has no documented discharge summary included recapitulation of R2's stay in the facility in R2's medical record. There was not documentation that R2 was explained or educated on medications, follow up appointments, self-catheterization or therapies that R2 was to receive after discharge home. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents with non pressure wounds received treatment and care in accordance with professional standards of practice for 1 (R1) of 1 residents reviewed with a non-pressure wound. R1 was admitted with a right lower extremity wound on 5/14/25. On 5/21/25, R1's wound treatment was changed. The facility did not recognize the scheduled treatment, only the PRN (as needed) portion of the order was implemented. R1 was not provided with treatment to the right lower extremity wound from 5/21/25 to 5/27/25 when the wound was identified as being healed.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure 1 (R23) of 4 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. R23 had a guided assist to the floor when being transferred with a gait belt and 1 staff member assist. R23 was assessed and the care plan documented R23 required a gait belt and 2 staff members assist with transfers.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 2 (R7 and R23) of 6 residents reviewed. Registered Nurse Unit Manager (RN UM)-H and RN-G did not wear appropriate personal protective equipment (PPE) during a treatment observation for R7. RN UM-H and RN-G were not aware of where PPE is kept for residents requiring enhanced barrier precautions. There was not an enhanced barrier precaution (EBP) sign on R23's door consistent with other residents identified as requiring EBP. Registered Nurse (RN)-I did not wear appropriate personal protective equipment (PPE) during a treatment observation for R23. R23 has a stage 4 pressure injury to the left outer ankle requiring a dressing and did have light serous drainage on 3/25/2025.

Inspectors wroteBased upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the fourth quarter of 2024 (July 1st-September), was accurate. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for low weekend staffing. This had the potential to affect all 27 residents.

Inspectors wroteBased on interview and record review the facility did not have a qualified Infection Preventionist who worked at least part time which had the potential to affect all 24 residents residing in the facility. *The Director of Nursing (DON)-B was serving as the facility's Infection Preventionist and did not have proper credentials.

Inspectors wroteBased on interview, and record review, the Facility did not ensure 1 (R11) of 5 residents were free from unnecessary medications. *R11 was prescribed Seroquel (Quetiapine) without adequate diagnoses, quantitative behavior monitoring and a lack of a timely Abnormal Involuntary Movement Scale (AIMs) assessment.

Inspectors wroteBased on interview, and record review the Facility did not ensure 1 (R6) of 1 residents reviewed were free from significant medication errors. *R6 had an order for Apixaban that was transcribed incorrectly. As a result, R6 only received one dose of Apixaban instead of two from 10/31/23 to 11/27/23.

Inspectors wroteBased on staff and family interview, and record review, the facility did not ensure 2 Residents (R) (R5 and R1) of 10 residents on the COVID-19 unit were allowed to receive visitors. R5 indicated the facility did not allow visitors on the COVID-19 unit during an outbreak in February of 2023. R1's family was not allowed to visit on the COVID-19 unit during an outbreak in February of 2023.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely administration of medication for 1 Resident (R) (R1) of 8 sampled residents. R1 did not consistently receive R1's scheduled morphine (used to treat moderate to severe pain) timely.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene during the provision of cares for 1 Resident (R) (R4) of 2 residents. On 10/10/23, Certified Nursing Assistant (CNA)-C did not consistently perform hand hygiene during the provision of perineal care for R4. In addition, Director of Nursing (DON)-B did not consistently perform hand hygiene during the provision of wound care for R4.

Inspectors wroteBased on observation, interview, record review, the facility did not provide an ongoing program to support Residents in their choice of activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all 2 (R19 and R10) of 4 Resident who attended the Quality of Life Assessment Group interview on 10/11/22 at 10:04 AM. * R19 and R10 confirmed that activities have not been occurring per the posted activity calendar and that their activities of choice have not been met while residing at the facility. Findings Include: Surveyor reviewed the facility Activity Program policy and procedure effective 6/1/17 and notes the following applicable: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident with a pressure injury received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 2 (R277) residents reviewed for pressure injuries. *On 10/4/2022, R277 was admitted to the facility with a stage III pressure injury on their heel and the facility did not initiate the appropriate pressure reducing mattress. Findings Include: The Facility Policy and Procedure, entitled Pressure and Non-pressure Injuries, dated 8/2/21, documents (in part) . Policy This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 (R21) of 4 Residents reviewed who were at risk for falls received the necessary services/interventions and supervision to prevent an injury from a fall. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines policy and procedure effective 2/2017 and notes the following: Policy The facility will maintain a fall prevention and management program. The elderly are at increased risk for falls related to several different factors. The facility will implement a fall program for Residents determined to be a risk for falls in order to better manage these factors and prevent and/or manage as much as is possible the Resident from falling and/or sustaining injuries related to falling. Procedure Fall Prevention and Management Guidelines Objectives: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the necessary care and services to provide respiratory care for 3 (R277, R21 and R128, ) of 4 residents reviewed receiving oxygen care. *R277 was observed during survey with and without oxygen on. R277's medical record did not include a physician's order for oxygen and oxygen was not included on R277's baseline care plan. *R21's medical record included an order for oxygen. R21 was observed during survey without the oxygen on. R21's oxygen tubing and humidifier was not changed per facility policy. R21's care plan did not include oxygen usage. *R128 was observed during survey wearing oxygen. The oxygen humidifier and oxygen tubing was not dated. R128 has a physician order to change oxygen tubing and humidifier bottles weekly and to date tubing one time every Monday. R128's care plan did not include oxygen usage. [...]

Inspectors wroteBased on observation, record review and interview, and the Quality of Life Assessment Group interview, the facility did not always provide orally and in writing, in a language that Residents can understand the notice of rights, rules, regulations and services prior to or upon admission and the facility did not post the full list of Resident rights within the facility for all 33 Residents currently residing in the facility. Findings Include: Surveyor reviewed the facility's Resident Rights policy and procedure effective 9/26/2017 and notes the following: Purpose *To ensure that Resident rights are respected, protected, and promoted *To inform Residents of their rights and provide an environment in which they can be exercised Procedure Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. [...]