Lake Winona Manor

Inspectors wroteBased on observation, interview, and record review the facility failed to reassess the resident's elopement risk and revise the comprehensive person-centered care plan to reflect interventions following an elopement episode for 1 of 1 residents reviewed for elopement risk.

Inspectors wroteBased on interview and record review, the facility failed to maintain and clearly define a full-time director of nursing (DON). This practice had the potential to affect all 66 residents who resided at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance and/or cueing with activities of daily living (ADLs), such as eating, for 2 of 2 residents (R3, R4) observed at a designated table for residents who need staff assistance with meals.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed for 1 of 1 resident (R8) reviewed for self-administration of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 64 residents currently residing in the facility as well as all staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility survey results were posted in an accessible location for residents, staff and visitors. This had the potential to affect all 64 residents residing in the facility as well as staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the turning and repositioning care plan requiring assist of two staff for 1 of 3 residents (R1) which resulted in actual harm when R1 fell off the bed sustaining a right tibia and fibula fracture, and a distal end of left femur fracture. The facility had put corrective measures in place on 11/13/25, prior to the start of the survey, therefore, was issued at past non-compliance

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure proper food safety practices when food service workers (FSW-A and FSW-B) were observed not having hair secured, not properly disinfecting food thermometer, not recognizing need to reheat food when needed, and touching food with contaminated gloves. This practice had the potential to affect all 65 residents who received meals from 2 of 2 dining rooms observed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 of 3 residents (R27,R24,R58) reviewed for wounds, and proper donning and doffing of personal protective equipment (PPE) was completed per standard guidelines for 2 of 3 residents (R20,R27).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess wounds including measurements weekly for 1 of 3 residents (R24) reviewed for pressure ulcers.

Inspectors wroteBased on observations, interview, and document review, the facility failed to complete a comprehensive, person-centered care plan, to promote fecal continence to the extent possible that is dignified, and per resident choice for 1 of 2 residents (R34) who were reviewed for bowel incontinence.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss risks and benefits, and obtain informed consent prior to use of bed rails for 3 of 3 residents (R1, R27, R38), who were observed to have assist bars raised on their beds. This had the potential to affect all 48 residents who utilized an assist bar(s) for mobility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 1 resident (R1) observed during peri care and full body lift transfer.

Inspectors wroteBased on interview and document review the facility failed to ensure continued monitoring and surveillance for efficacy and appropriateness was completed for 2 of 2 residents (R7, R20) who were on long-term, prophylactic antibiotics. In addition, the facility failed to ensure an appropriate antibiotic was administered for 1 of 1 (R9) residents who had an infected wound and were prescribed an ineffective antibiotic.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. In addition the facility failed to ensure concerns brought forward at the resident council meetings were addressed in a timely manner. This deficiency had the potential to affect all 13 residents who attended the monthly resident council meetings.

Inspectors wroteBased on observation, interview, and document review, the facility failed to keep remote to chair within reach for 1 of 1 residents (R31) reviewed for possible restraint.

Inspectors wroteBased on interview, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) within fourteen (14) days after the facility determined, or should have determined, that there had been a significant change in the resident's physical or mental condition for 2 of 2 residents (R15 and R20).

Inspectors wroteBased on interview, and document review, the facility failed to implement the care to provide restorative range of motion (ROM) for 1 of 1 resident (R5) reviewed for range of motion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that reported symptoms of a urinary tract infection (UTI) were assessed and acted upon to reduce the risk of severe infection or complication for 1 of 1 residents (R9) who reported burning and increased frequency with urination.

Inspectors wroteBased on interview, and document review, the facility failed to comprehensively analyze the root cause of falls and promptly incorporate new fall interventions to help prevent future falls and possible injury for 2 of 2 resident (R31, R10) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for 2 of 2 residents (R17, R52) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate and manufacturer-directed steps to prevent post-administration complication (i.e., thrush) of a dry powedered inhaler (DPI) were completed for 1 of 1 residents (R48) observed to receive a DPI during the recertification survey.

Inspectors wroteBased on interview and document review the facility failed to ensure a prophylactic antibiotic without an end date was monitored and evaluated for the appropriateness of its continued use for 1 of 2 residents (R20) reviewed for antibiotic administration.

Inspectors wroteBased on interview and document review the facility failed to ensure psychotropic medications were reviewed for the appropriateness of a gradual dose reduction (GDR) for 1 of 1 residents (R17) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 2 of 5 residents (R25, R39) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nurse staffing information was posted with required information and in a timely manner at the start of the shift. This had potential to affect all 56 residents, staff, and visitors who could wish to review this information.

Inspectors wroteBased on interview, and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the residents' trust fund, which had the potential to affect 50 of 56 residents who kept personal funds with the facility.