Geneva Lake Manor

F-F604).

On 03/04/25, at 09:30 AM, Surveyor interviewed Resident R13 regarding the abdominal binder, Resident R13 stated they are not using it now because it is so tight that Resident R13 got a rash. Resident R13 decided on own that they did not want the rash so have asked staff not to put it on.

On 03/04/25, at 09:39 AM, Surveyor interviewed CNA-K regarding the care used for Resident R13's nephrostomy tubes. CNA-K stated they have gotten a little training from Facility on how to clean around the nephrostomy tubes. It is kinda the same as cleaning the penis. CNA-K stated that when Resident R13 first got the nephrostomy tubes it was discussed at a staff meeting, topics like precautions when transfer with Hoyer, always use a two assist with Resident R13 and both staff should watch the cords. Surveyor asked about Resident R13's abdominal binder and was told ya he wear it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 On 03/04/25, at 09:58 AM, Surveyor interviewed Director of Nursing (DON)-B regarding steps taken by facility to prevent pulling of nephrostomy tubes on Resident R13. Per DON-B the first couple times it happened it was Level of Harm - Actual harm during Hoyer transfers, so DON-B got an abdominal binder and stat locks to hold tubes in place. DON-B admits not being aware Resident R13 is not wearing the binder due to rash, stated will have to talk to Resident R13 about skin Residents Affected - Few protection options. Surveyor asked what type of staff training had occurred since Resident R13 got the nephrostomy tubes. DON-B replied that they had talked to staff verbally about transfers and checking tubing so not in a place where the tubes can get pulled out. Surveyor told DON-B this is a concern because Resident R13 has been sent to ED six times in the last 120 days, with some requiring hospitalization .

Surveyor notes the Facility Assessment was reviewed and there is no staff competency to care for Nephrostomy tubes included as being assessed.

On 03/04/25, at 03:34 PM, Surveyor told DON-B and Nursing Home Administrator-A that there is a serious concern related to Resident R13's nephrostomy tubes and being sent to the ED six times for care issues where Resident R13 developed infections and requiring hospitalization .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42037 potential for actual harm Based on record reviews and interviews, the facility did not adequately address Nutrition needs for 1 (Resident R19) of Residents Affected - Few 1 residents reviewed for Nutrition.

*Resident R19 sustained a 9.2% weight loss from October 2024 to December 2024. The facility did not monitor Resident R19's weight or implement proper interventions per RD (Registered Dietician) recommendations.

Findings include:

*Resident R19 was admitted to the facility on [DATE REDACTED] with diagnoses including left femur fracture, hemiparesis of left side, polyneuropathy and cerebrovascular disease.

Resident R19's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/30/24 indicated that Resident R19 has a Brief Interview for Mental Status (BIMS) score of 12, indicating that Resident R19 is moderately cognitively impaired. Resident R19's Admission MDS with ARD of 10/30/24 indicated that Resident R19 is dependent upon staff for bed mobility, transfers, bathing, dressing and toileting. Resident R19's Admission MDS with

an ARD of 10/30/24 indicates that Resident R19 did not have any pressure injuries or an active risk for pressure injuries.

Resident R19's Quarterly MDS with ARD of 1/13/25 indicated that Resident R19 is dependent upon staff for bed mobility, transfers, bathing, dressing and toileting. Resident R19's Quarterly MDS with an ARD of 1/13/25 indicates that Resident R19 was assessed with a stage 3 pressure injury and at active risk for pressure injuries.

Surveyor reviewed Resident R19's electronic medical record including nursing progress notes, physician orders, Registered Dietician progress notes and comprehensive care plan.

On 10/25/2024, Resident R19's weight was documented at 148.7 lb. On 10/27/2024, Resident R19's weight was documented at 147.9 lb. On 11/7/2024, Resident R19's weight was documented at 149.2 lb. On 12/27/2024, Resident R19's weight was documented at 135.0 lb. On 2/24/2025, Resident R19's weight was documented at 140.4 lb. Surveyor did not identify any documented weight for Resident R19 for January 2025.

From 10/25/2024 to 12/27/2024, Resident R19 sustained a 9.2 % weight loss.

Surveyor reviewed Resident R19's nutrition care plan with an initiation date of 12/20/2024. Resident R19's nutrition care plan documents the following: Problem: I (Resident R19) am on a Regular diet, with thin liquids. No straws. Resident R19's nutritional care plan included the following interventions: House stock supplement beverage daily .Obtain dietary consultation as needed .monitor and record weight, notify the health care provider and family of significant weight change .provide supplements as ordered .

Surveyor reviewed Resident R19's dietary progress notes from Reg (Registered) Dietician-Y from 10/30/2024 to present.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 10/30/2024 at 11:23 AM Reg Dietician-Y documented the following: RD new admit assessment. Ht (Height): not recorded, Wt (Weight)147.9 lb, BMI (Body Mass Index) unable to calculate. Resident admits Level of Harm - Minimal harm or post fall with L (left) hip fx (fracture) . (surgical repair). PMH (Primary Medical History): potential for actual harm hemiplegia/hemiparesis, COPD (Chronic Obstructive Pulmonary Disease, PVD (Peripheral Vascular Disease), HTN (Hypertension, HLD (Hyperlipidemia), polyneuropathy, pre diabetes, CHF (Congestive Heart Residents Affected - Few Failure). Receiving regular diet which is appropriate. PO (by mouth) intake appears to be > (greater than) 50% at meals which is adequate. No reports of any recent significant weight changes .Suggest obtaining height. No further recommendations. Resident (Resident R19) is low nutritional risk. RD to follow as consult.

On 11/21/2024 at 11:28 AM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 149.2 lb, BMI 21.41 . DTI (Deep Tissue Injury) to R (Right)-heel, being treated by wound nurse. He (Resident R19) receives a regular diet w/thin liquids. He (Resident R19) has snacks/food items brought in from family at times. Recorded po intake does varying depending on day/meal. Does tend to have at least 1 smaller meal each day. His (Resident R19) weight is stable without any recent changes. Would suggest offering 30ml pro-source daily for additional protein to support healing of DTIs. Resident is high nutritional risk r/t wounds. RD to follow as consult.

On 12/19/2024 at 12:46 PM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 149.2 lb (11/7/24), BMI 21.41. Most recent weight available from November, unable to assess any recent weight changes. He continues with a DTI to R-heel which has a scab intact .He (Resident R19) is on a general diet order with varying po intake. He is receiving a multivitamin to support wound healing. Would suggest offering a house supplement at least 1x day due to varying po intake and low BMI/wt. Also suggest obtaining recent weight to better assess any weight changes. Resident is high nutritional risk r/t wounds. RD to follow as consult.

On 1/29/2025 at 10:44 AM, Reg Dietician-Y documented the following: RD review. Ht 70, Wt 135 lb (12/27/24), BMI 19.37. Most recent weight available from December and indicates a -9.2% weight loss since October. Receives regular diet w/thin liquids. Po intake appears adequate around 76-100% majority meals. Skin reviewed: PI (Pressure Injury) to R heel, improving. Would suggest offering a house supplement at least 1x day due to varying po intake and low BMI/wt, increased needs for wound healing. Also suggest obtaining recent weight to better assess any weight changes and weekly weights therefore after given significant weight loss. Resident is high nutritional risk r/t wounds and weight. RD to follow as consult.

On 2/27/2025, Surveyor requested to conduct interview with Reg Dietician-Y. Nursing Home Administrator (NHA)-A informed Surveyor that Reg Dietician-Y is no longer employed by the facility. The facility has a newly appointed dietician and offered to ask them to speak to Surveyor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 3/3/2025 at 2:05 PM, the Survey team conducted a group interview with Reg Dietician-W. Surveyor asked Reg Dietician-W what their expectation would be for how often residents should be weighed upon Level of Harm - Minimal harm or admission to the facility. Reg Dietician-W told Surveyor that usually each facility has their own procedure for potential for actual harm obtaining weights for new admissions and that they are not sure what procedure the facility has been following. Surveyor asked Reg Dietician-W if they are familiar with Resident R19. Reg Dietician-W responded that they Residents Affected - Few are not familiar with that resident and that they are currently covering for another dietician who is on vacation. Surveyor asked Reg Dietician-W what their expectation would be regarding the facility's time frame to carry out dietary recommendations by a dietician, such as supplement orders or recommendations for weekly weights. Reg Dietician-W responded that as a dietician that they would expect no more than a 24 hour turn around time for facility to initiate dietician recommendations and share those with resident's physician and power of attorney if applicable. Reg Dietician-W added that they had been made aware by Reg Dietician-Y that the facility was not timely following up on Reg Dietician-Y's recommendations and sometimes not responding to recommendations at all.

On 3/3/2025 at 3:40 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that Resident R19 had sustained a documented 9.2 % weight loss from October 2024 to December 2024. Surveyor shared concerns that Reg Dietician-Y had made recommendations including a liquid protein supplement and weekly weights for Resident R19 that were not carried out by the facility. The facility did not provide any additional information at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011 potential for actual harm Based on interview and record review the Facility did not ensure residents who require dialysis receive such Residents Affected - Few services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments for 1 (Resident R46) of 1 residents reviewed for dialysis.

Resident 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.

Findings include:

The Facility Policy titled Dialysis Policy and Procedure last reviewed 9/17/2024 documents (in part):

Procedure .:

-Communicate with dialysis facility before and after treatment via the Dialysis Communication form .

Resident R46 was admitted to the facility on [DATE REDACTED], pertinent diagnoses include dementia, pleural effusion, end stage renal disease, and dependence on renal dialysis.

Resident R46's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/7/25 indicated Resident R46 had a Brief Interview for Mental Status score of 99, which indicates severe cognitive impairment. Resident R46 uses a wheelchair for mobility. Dialysis was selected in Section O of the MDS.

On 02/27/25, at 08:27 AM, Surveyor reviewed the electronic medical record and for January and February only found two dialysis communication forms dated 1/25/25 and 1/28/25. Surveyor requested January and February communication forms regarding dialysis for Resident R46.

On 02/27/25, at 09:47 AM, Surveyor interviewed Director of Nursing (DON)-B who stated that the Nursing Home Administrator (NHA)-A had talked to dialysis regarding a hiccup in getting communication forms back from dialysis, NHA-A would be in to discuss.

Surveyor reviewed Dialysis Communication forms provided. None were provided for: 1/4/25, 1/7/25, 1/9/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 2/8/25, and 2/22/25.

On 02/27/25, at 01:27 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q regarding the process of sending Resident R46 to dialysis. LPN-Q stated that when transportation gets here, they are given an orange folder. There is a paper inside that has who is doing transport along with vitals etc. about Resident R46. The nurse signs the form and sends it with Resident R46. (Name of dialysis center) will send pertinent information back on that form. LPN-Q states this happens each time Resident R46 goes out.

On 02/27/25, at 03:00 PM, Surveyor interviewed NHA-A who stated they talked to (name of dialysis center)

before Christmas regarding the missing forms, will get Surveyor an exact date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 On 03/03/25, at 08:15 AM, NHA-A followed up with Surveyor that they spoke with (name of dialysis center) originally on [DATE REDACTED] then followed up with them on January 6, 2025. Level of Harm - Minimal harm or potential for actual harm Surveyor notes eight dialysis communication forms were not on record after the NHA-A followed up with dialysis. Residents Affected - Few No additional information was provided regarding the missing dialysis communication forms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 49011

Residents Affected - Many Based 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.

Findings include:

On 02/27/25, at 10:58 AM, Surveyor reviewed 30 days of nursing staff schedules. Surveyor noted that the Facility's nursing staff schedules did not designate who the charge nurse was for each tour of duty.

On 02/27/25, at 01:25 PM, Surveyor interviewed Nursing Scheduler-R regarding how to know who the charge nurse is at any given time. Nursing Scheduler-R replied that during the day the Director of Nursing (DON) or Assistant DON are in the building. On PM shift the Nurse Educator is usually in the building otherwise there is an on-call person listed at the bottom of the schedule page who is reachable by phone. Surveyor then asked who is in the building that is labeled as charge nurse during each shift, the answer was staff know to call the on-call person.

On 02/27/25, at 03:08 PM, Surveyor informed the Nursing Home Administrator-A, DON-B and Assistant Nursing Home Administrator-D of the concern related to the Facility's schedules not designating who the Facility charge nurse would be for each shift on the Facility's nursing staff schedules.

The Facility did not provide any additional information as to why it did not ensure there was a designated charge nurse for each tour of duty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 49011 minimal harm Based on observation, interview, and record review the Facility did not ensure they posted the nurse staffing Residents Affected - Many 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.

Findings include:

On 02/27/25, at 10:58 AM, Surveyor reviewed 30 days of nursing staff schedules provided by Facility. However, noted that there were no Nurse Staff Postings included which had been requested.

On 02/27/25, at 12:30 PM, Surveyor observed no Nurse Staff Postings in the reception area of the Facility when looking around for the posting.

On 02/27/25, at 01:25 PM, Surveyor interviewed Nursing Scheduler-R and asked where the Nurse Staff Posting is located, which the response was it is posted in the nurses' stations to keep confidential. Nursing Scheduler-R then walked with Surveyor to one of the nurse stations where we had to enter a room through a closed door to see the posting. What Nursing Scheduler-R showed Surveyor was the nursing staff schedule.

On 02/27/25, at 01:36 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding the Nurse Staff Posting. ADON-F stated putting the posting in the nurse station is not the correct way, it should be on

the outside of both nurses' stations and in the receptionist desk area.

On 02/27/25, at 03:08 PM, Surveyor discussed with the Director of Nursing-B, Nursing Home Administrator (NHA)-A and Assistant Nursing Home Administrator-D the concern of no Nurse Staff Posting displayed daily

in a visible spot for visitors and residents to see. Surveyor explained what is needed on the form and which tag to refer to. It was also explained that the nursing staff schedule that is posted in the nurse stations is not visible and lacks pertinent information.

On 03/03/25, at 10:52 AM, NHA-A shared they have a form they used to use, will start using again and it will be posted on the scheduler's door which is adjacent to the lobby area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16584 potential for actual harm Based on record review and staff interviews, the facility did not ensure that 5 out of 5 residents (Resident R44, Resident R26, Residents Affected - Some Resident R16, Resident R34 and Resident R5) drug regimen was free from unnecessary medications.

Resident R44, Resident R26, Resident R16, Resident R34 and Resident 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.

Findings include:

Policy review: Medication Regimen Reviews , revised 5/2019

Policy statement: The consultant pharmacist reviews the medications regimen of each resident at least monthly.

Policy Interpretation and Implementation:

8.) Within 24 hours of the MRR (medication regimen review), the consultant pharmacist provides a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. The report contains the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation.

11.) If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator.

12.) The attending physician documents in the medical record that the irregularity has been reviewed an what (if any) action was taken to address it.

14.) The consultant pharmacist provides the director of nursing services and medical director with a written, signed copy of all medication regimen reports.

15.) Copies of the medication regimen review reports, including physician responses, are maintained as part of the permanent medical record.

1. ) Resident R44 was originally admitted to the facility on [DATE REDACTED] with diagnoses that included dementia, anxiety disorder, and depression.

Surveyor conducted a review of the monthly pharmacy consultant reviews and noted the following:

On 11/27/2024 at 10:54 a.m., med review complete; see report.

On 12/28/2024 at 08:56 a.m. med review complete; see report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 On 01/24/2025 at 10:33 a.m., med review complete; see report.

Level of Harm - Minimal harm or On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she potential for actual harm does not have any of them signed off or notations if they followed up on them.

Residents Affected - Some On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for Resident R44, dated 11/27/24, and 12/28/24 These reports had to be downloaded and printed prior to being available for review and were not part of Resident R44's medical record.

The 11/27/24 pharmacy consultation report indicated that Resident R44's PRN (as needed) order for Desitin paste has not been used within the previous 60 days. Recommendation is to consider discontinuing due to lack of use.

The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response.

The 12/28/24 pharmacy consultation report states that Resident R44 receives 2 or more medications known to prolong

the QT interval (length of time it takes for the ventricles of the heart to depolarize & repolarize as measured

on an electrocardiogram): Ondansetron ODT (Zofran-anti-nausea), Escitalopram Oxalate (Lexapro), quetiapine (Seroquel). Recommendation to reevaluate continued use of these medications and consider decreasing dose of the escitalopram from 20 mg each day to 10 mg each day. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response.

On 03/04/25 at 08:00 AM Surveyor interviewed DON (Director of Nursing)-B who stated that the facility did not respond to the pharmacy recommendations for Resident R44 for those dates. DON- B stated that there was a break in the system and not all of the communication was made to the physician.

2.) Resident R26 was originally admitted to the facility on [DATE REDACTED] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood.

Surveyor conducted a review of the monthly pharmacy consultation reports and noted the following:

On 10/26/2024 at 01:20 p.m., med review complete; see report.

On 12/28/2024 at 09:23 a.m., med review complete; see report.

On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she does not have any of them signed off or notations if they followed up on them.

On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for Resident R26, dated 10/26/24 and 12/28/24. These reports had to be downloaded and printed prior to being available for review and were not part of Resident R26's medical record.

The 10/26/24 pharmacy consultation report documented that Resident R26 receives a medication containing an inhaled corticosteroid, Wixela Inhub. The recommendation is to reduce the risk of thrush, please update the order to include the directions: Rinse mouth with water after use. Do not swallow. The facility was unable to provide evidence that they followed-up on this recommendation by obtaining the Physician's response.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 On 12/28/24, the same recommendation was made as on 10/26/24. Resident R26 receives a medication containing an inhaled corticosteroid, Wixela Inhub. Recommendation to reduce the risk of thrush, please update the order Level of Harm - Minimal harm or to include the directions: Rinse mouth with water after use. Do not swallow. The facility was unable to potential for actual harm provide evidence that they followed-up on this recommendation by obtaining the Physician's response.

Residents Affected - Some On 3/4/25 at 10:30 a.m., Administrator-A confirmed that there is no behavior monitoring for Resident R26. In addition, there has been no follow-up on the pharmacy recommendations. Administrator- A stated that they are going to start having behavior meetings to discuss these types of issues.

3.) Resident R16 was originally admitted to the facility on [DATE REDACTED] with diagnoses that included major depressive disorder and anxiety.

Surveyor conducted a review of the monthly pharmacy consultation reports and noted the following:

On 11/29/2024 at 12:28 p.m., med review complete; see report.

On 01/26/2025 at 03:35 p.m., med review complete; see report.

On 03/03/25 at 08:31 a.m., DON- B stated that she will need to print the pharmacy recommendations but she does not have any of them signed off or notations if they followed up on them.

On 03/03/25 09:05 a.m., Surveyor was provided with the pharmacy consultation report/ recommendations for Resident R16, dated 11/29/24 and 1/26/25. These reports had to be downloaded and printed prior to being available for review and were not part of Resident R16's medical record.

The 11/29/24 pharmacy consultation/ report documented that Resident R16's PRN (as ordered) orders below have not been used within the previous 60 days- miconazole powder. Recommendation: Please consider discontinuing due to lack of use. The facility was unable to provided evidence that they followed-up on this recommendation by obtaining the Physician's response.

The 1/26/25 pharmacy consultation/ report; (Resident R16) receives two antiplatelets, Aspirin low dose and Plavix and does not have a CBC (complete blood count) documented in the medical record within the previous 6 months. Recommendation: Please monitor a CBC on the next convenient lab day and every 6 months thereafter. Consider fecal occult blood tests if clinically indicated. Ongoing surveillance for bleeding is recommended. The facility was unable to provided evidence that they followed-up on this recommendation by obtaining the Physician's response. Further review of Resident R16's electronic record did not show an order for CBC drawn following the 1/26/25 recommendation.

On 03/04/25 at 08:00 AM Surveyor interviewed DON (Director of Nursing)- B who stated that the facility did not respond to the pharmacy recommendations for Resident R16 for those dates. DON- B stated that there was a break in the system and not all of the communication was made to the physician.

42037

4.) Resident R34 was admitted to the facility on [DATE REDACTED]. Resident R34's current diagnoses include Atrial Fibrillation, Cerebral Infarction and Hyperlipidemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Resident R34's Quarterly MDS (Minimum Data Set) Assessment with ARD (Assessment Reference Date) of 2/17/25 indicates that Resident R34 is receiving a Antidepressant and Anticoagulant medication. Level of Harm - Minimal harm or potential for actual harm Surveyor reviewed Resident R34's electronic medical record including physician orders, and comprehensive care plans. An anticoagulant care plan with an initiation date of 8/6/24 documents: (Resident R34) is at risk for bleeding and Residents Affected - Some bruising d/t (due to) use of Eliquis (an anticoagulant medication). The following interventions are documented: Administer anticoagulants as ordered by MD .Monitor for bruising .monitor lab work as ordered by MD .Observe for signs of active bleeding.

A psychosocial care plan with an initiation date of 8/6/24 documents: (Resident R34) receives Fluoxetine (an antidepressant medication) d/t depression. The following interventions are documented: Assess/record effectiveness of drug treatment, Monitor (Resident R34's) mood and response to medication, Pharmacy consultant review. Surveyor could not identify monitoring for Resident R34's anticoagulant or antidepressant medications in Resident R34's medical record.

On 2/27/25 at 2:47 PM, Surveyor requested Resident R34's monthly pharmacy reviews from Director of Nursing (DON)-B. DON-B told Surveyor that they do not have resident's pharmacy recommendations available at the facility and have requested additional documentation from the pharmacy. DON-B told Surveyor that they are unable to verify if Resident R34's pharmacy recommendations have been followed up upon.

On 3/3/25 at 3:24 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that Resident R34 does not have any documented evidence of monitoring for anticoagulant medication, antidepressant medication and no evidence of monthly pharmacy reviews. No additional information was given by the facility at this time.

5.) Resident R5 was admitted to the facility on [DATE REDACTED]. Resident R5's diagnoses include aphasia, diabetes mellitus and traumatic brain injury.

On 2/27/25 at 2:47 PM, Surveyor requested Resident R5's monthly pharmacy reviews from Director of Nursing (DON)-B. DON-B told Surveyor that they do not have resident's pharmacy recommendations available at the facility and have requested additional documentation from the pharmacy. DON-B told Surveyor that they are unable to verify if Resident R5's pharmacy recommendations have been followed up upon.

On 3/3/25 at 3:24 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that Resident R5 does not have any documented evidence of monthly pharmacy reviews. No additional information was given by

the facility at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011 potential for actual harm Based on interview and record review the Facility did not ensure 1 (Resident R13) of 1 residents were free from Residents Affected - Few significant medication errors.

Resident 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 Resident R13 did not receive three administrations of Amantadine between 2/28/2025 and 3/3/2025.

Findings include:

The Facility's Policy and Procedure titled, Adverse Consequences and Medication Errors, last revised February 2023 documents, in part:

Medication Errors

1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services .

2. Examples of medication errors include:

a. Omission - a drug is ordered but not administered .

Resident R13 was originally admitted to the facility on [DATE REDACTED] and most recently readmitted [DATE REDACTED] after a hospital stay. Resident R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder.

Resident R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents Resident R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating Resident R13 is cognitively intact for decision making. Resident R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are documented. Resident R13 is assessed as making self understood and understands others. Per MDS Resident R13 has a catheter bladder function and an ostomy for bowel function.

Resident R13 has a care plan with diagnosis of Parkinsonism, start date 6/26/2024. A pertinent intervention is provide medications as ordered by MD (medical doctor) Start date 6/26/2024.

Resident R13 has a physician order that started 11/19/2024 for Amantadine HCl 100mg, once a day for Parkinsonism.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Surveyor reviewed Resident R13's Medication Administration Record (MAR) and saw that Amantadine HCl was documented as not given three times between 2/28/25 to 3/3/25. Surveyor notes on 3/1/25 the medication Level of Harm - Minimal harm or was signed out as given, however, the three missed doses are coded as drug/item unavailable so unsure potential for actual harm how it was available to be given on 3/1/25.

Residents Affected - Few On 03/03/25, at 01:06 PM, Surveyor interviewed Resident R13 and was told that at least three times a week the improper medication or dose is given. Resident R13 must be vigilant and watch each medication given.

On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding the missed doses of Amantadine HCl. ADON-F stated they will look into this. Surveyor asked if the Facility has a contingency supply of medications and was told they do, ADON-F will see if Amantadine HCl is included in contingency.

On 03/03/25, at 02:25 PM, ADON-F followed up with Surveyor and stated that the Amantadine HCl medication was delivered and put into overflow, the nurses did not look there for the medication. ADON-F moved the medication to the medication cart. Also, Amantadine HCl is not available in contingency. ADON-F had contacted the Nurse Practitioner (NP) and was waiting to hear from NP if ok to give Amantadine HCl now.

Surveyor notes an order was entered as once-one time for Amantadine HCl on 3/3/2025 to be given between 3:00 PM and 11:00 PM.

On 03/04/25, at 10:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding the missed doses of Amantadine HCl and was told that ADON-F talked to DON-B and it was decided to reach out to doctor to update and get order to give late since it is a once a day medication.

On 03/04/25, at 01:29 PM, Surveyor interviewed Agency Licensed Practical Nurse (LPN)-T regarding the Amantadine HCl not being administered on 3/3/24 and that it was coded as drug/item unavailable. Per LPN-T they worked [PHONE NUMBER] AM yesterday, then left. LPN-T does not remember this medication.

On 03/04/25, at 01:38 PM, Surveyor interviewed LPN-Q who gave the once-one time dose of Amantadine HCl on 3/3/25. LPN-Q stated they had to call the pharmacy and ask them to resend the order so could be given.

No further information was provided as to why the Facility did not ensure that Resident R13 was free from this significant medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 48391

Residents Affected - Some Based 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.

Findings include:

The facility Policy and Procedure titled, Food Preparation and Service with no date, documents:

Policy Statement:

Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices.

Food Distribution and Service:

2. The temperature of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.

8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

On 3/3/25, at 8:08 AM, Surveyor entered the common dining room and reviewed the clip board containing food temperature logs, hanging on the wall next to the warming station. Surveyor notes food temperature entries on 3/1/25 and 3/2/25 with no missed entries or concerns with temperatures. Surveyor notes there are not food temperatures noted for breakfast on 3/3/25 and residents currently eating breakfast in the common dining room.

Surveyor observed Dietary Aide-H enter the common dining room with her hair loosely pulled back with a hair tie and no hair net on. Surveyor observed Dietary Aide-H serve food from the warming trays to a resident in the common dining room without a hair net on. Dietary Aide-H returned to the warming tray station and Surveyor asked if staff record food temperatures. Dietary Aide-H responded yes and directed Surveyor to the food temperature clip board hanging on the wall. Surveyor noted to Dietary Aide-H there were no temperatures recorded for breakfast today on 3/3/25. Dietary Aide-H then grabbed the thermometer and proceeded to temp the food in the warming trays. Surveyor asked Dietary Aide-H if food temperatures should be tested prior to serving food and Dietary Aide-H responded, yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On 3/3/25, at 8:43 AM, Surveyor observed Dietary Aide-H with hair loosely pulled back in a hair tie and a hair net on. Dietary Aide-H was observed in the common dining room assisting residents with food and requests. Level of Harm - Minimal harm or potential for actual harm On 3/3/25, at 9:16 AM, Surveyor interviewed Dietary Aide-H who states she is supposed to wear a hair net at all times while serving food and throughout the common dining room while serving food. Surveyor noted to Residents Affected - Some Dietary Aide-H she was not wearing a hair net when temping food and serving residents food from the warming trays earlier at breakfast. Dietary Aide-H states she was returning from using the restroom and was caught off guard which is why she didn't have a hair net on. Surveyor observed Dietary Aide-H wearing a hair net at the time of the interview.

On 3/3/25, at 11:09 AM, Surveyor went back into the common dining room to review the clip board containing food temperatures. Surveyor notes there was one temperature log from 3/3/25 breakfast that was obtained earlier with Dietary Aide-H and Surveyor. No further temperatures for 3/3/25 breakfast were noted. Cook- G walked into the common dining area where Surveyor was reviewing the food temperature log. Surveyor asked Cook- G if he serves food in the common dining room and if temperatures of food are obtained. Cook- G states yes, he serves lunch from the warming trays in the common dining room and food temperatures are to be completed and documented on the clip board, prior to serving food and in the middle of passing lunch. Cook- G pointed to the food temperature log on the clip board and states this is where temperatures are recorded. Surveyor asked Cook- G if he would expect additional entries for 3/3/25 breakfast time and Cook- G indicates yes.

On 3/3/25, at 3:05 PM, Surveyor notified Nursing Home Administrator (NHA)- A of concerns listed above. NHA- A acknowledged concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38253 potential for actual harm Based on observation, interview, and record review, the facility did not develop an infection prevention and Residents Affected - Many 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 (Resident R47, Resident R34, Resident R17, and Resident 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.

*Resident R47 was in EBP. Observations were made of staff not wearing appropriate Personal Protective Equipment (PPE) when performing cares and wound care.

*Resident R34 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care.

*Resident R17 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care.

*Resident R19 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care.

Findings include:

The facility policy and procedure titled Surveillance for Infections from MED-PASS (C) 2001 revised 9/2017 documents: Policy Interpretation and Implementation:

1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections.

2. The criteria for such infections are based on the current standard definitions of infections.

Gathering Surveillance Data:

1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of the data.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 5. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; Level of Harm - Minimal harm or for example, focused surveillance data may be gathered for residents with a high risk for infection or those potential for actual harm with a recent hospital stay.

Residents Affected - Many Data Collection and Recording:

1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information .; b. Diagnoses; c. admitted , date of onset of infection .; d. Infection site .; e. Pathogens; f. Invasive procedures or risk factors .; g. Pertinent remarks Also,

record if the resident is admitted to the hospital, or expires; and h. Treatment measures and precautions .

4. For targeted surveillance sing facility-created tools, follow these guidelines: a. DAILY (as indicated):

Record detailed information about the resident and infection on an individual infection report form b. MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (e.g., Line Listing of Infections by Resident or similar form). c. MONTHLY: Summarize monthly data for each nursing unit by site and by pathogen d. MONTHLY/QUARTERLY: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends . e. MONTHLY/QUARTERLY: Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period (for example, over the past 12 months) as the baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates.

Calculating Infection Rates:

1. Obtain the month's total resident days from the business office. The following data is used as the denominator to calculate the monthly infection rate: a. Total resident days (daily census of each day in the designated time period added together).

2. To determine the incidence of infection per 1000 resident days, divide the number of new healthcare associated infections for the month by the total resident days for the month (obtained from the business office) X 1000.

Interpreting Surveillance Data:

1. Analyze the data to identify trends. a. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. b. Consider how increases or decreases might relate to recent process changes, events, or activities in the facility

2. Surveillance data will be provided to the infection control committee regularly.

3. The infection control committee will determine how important surveillance data will be communicated to

the physicians and other providers, the administrator, nursing units, and the local and state health departments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The facility policy and procedure titled Enhanced Barrier Precautions from MED-PASS (C) 2001 revised 8/2022 documents: Level of Harm - Minimal harm or potential for actual harm 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. Residents Affected - Many 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.

3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bating/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing).

5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

1.) On 2/26/2025 at 8:00 AM, Surveyor entered the facility and observed a sign on the front door stating the facility was in a COVID-19 outbreak and anyone entering the facility needed to wear a mask. Surveyor asked for a list of residents in COVID-19 isolation and was told by facility staff that no residents currently have any positive COVID-19 tests, and the facility staff and visitors are wearing masks for the ten days beyond the last symptom to prevent future spread of COVID-19.

On 2/26/2025 at 3:00 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (Don)-B all outbreak summaries and line lists since the last recertification survey. DON-B stated Assistant DON (ADON)-F is the facility infection preventionist and would provide that information to Surveyor.

On 2/27/2025, ADON-F provided Surveyor with two COVID-19 outbreak packets consisting of resident and staff line lists and a summary of the outbreak, two respiratory line lists, and two gastrointestinal line lists. Surveyor noted the gastrointestinal line lists each had one resident listed and therefore did not meet the definition of an outbreak. Surveyor noted the respiratory line list that had current dates of infection was an Influenza outbreak and not a COVID-19 outbreak as was documented on the sign at the facility entrance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Surveyor reviewed the outbreak packet for COVID-19 that started on 10/26/2024 when a staff member tested positive. Another staff member and one resident tested positive on 10/28/2024. Per the line lists, 7 Level of Harm - Minimal harm or staff members tested positive and 17 residents tested positive totaling 24 individuals being affected by potential for actual harm COVID-19. The last positive collected sample was on 11/4/2024. The summary of the outbreak documented

the outbreak began on 10/29/2024 with a total of 20 residents and 7 staff members testing positive. Surveyor Residents Affected - Many noted the number of residents on the summary did not match the number of affected residents on the line list.

Surveyor reviewed the outbreak packet for COVID-19 that started on 12/4/2024 when three staff members tested positive. Two staff members tested positive on 12/5/2024. A resident tested positive on 12/18/204, thirteen days after the last staff member tested positive. The outbreak should have been concluded on 12/15/2024, ten days after the last staff member tested positive. 1/6/2025-1/22/2025 had two staff members and eight residents positive. The Outbreak Summary Report documented 17 individuals were affected in the outbreak with testing of residents and staff from 12/4/2024-1/6/2025 with the outbreak conclusion being 1/6/2025. The conclusion date does not match the last resident testing positive on 1/22/2025.

On 3/3/2025 at 11:14 AM, Surveyor met with DON-B and ADON-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor shared with ADON-F the concern the outbreak summaries did not match the information on the line lists. ADON-F agreed.

2.) Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. The monthly sections included line lists and plot maps of the facility. In an interview on 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if monthly rates of infection were calculated. ADON-F stated no. Surveyor asked ADON-F what information was brought to Quality Assessment and Assurance (QAA) meetings for the infection prevention program. ADON-F stated ADON-F brings the binders with the line lists to QAA. Surveyor shared the concern trends in infection could not be determined if rates of infection were not calculated monthly to compare to previous months/years. ADON-F agreed.

On 3/3/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern rates of infection were not calculated per infection monthly. DON-B agreed the rates should be calculated.

3.) On 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if ADON-F is part of the Water Management Plan (WMP). ADON-F stated Maintenance Director (MainDir)-L is in charge of the WMP and would have any information Surveyor needed. Surveyor requested ADON-F contact MainDir-L to provide the WMP to Surveyor for review.

The facility policy and procedure titled Legionella Water Management Program from MED-PASS (C) 2001 revised 7/2017 documents:

1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The Level of Harm - Minimal harm or director of environmental services. potential for actual harm 3. The purposes of the water management program are to identify areas in the water system where Residents Affected - Many Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease.

4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program.

5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c.

The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP machines, hydrotherapy equipment; etc. d. The identification of situations that can lead to Legionella growth, such as: (1) Construction; (2) Water main breaks; (3) Changes

in municipal water quality; (4) The presence of biofilm, scale or sediment; (5) Water temperature fluctuations; (6) Water pressure changes; (7) Water stagnation and; (8) Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program.

6. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: a. The control limits are consistently not met; b. There is a major maintenance or water service change; c. There are any disease cases associated with the water system; or d. There are changes in laws, regulations, standards or guidelines.

On 3/3/2025 at 11:36 AM, MainDir-L provided to Surveyor the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L for the WMP, which should include diagrams of

the water system, control measures, and logs of flushes. MainDir-L stated MainDir-L thought Surveyor just wanted the policy for the WMP. MainDir-L stated MainDir-L would get more information for Surveyor.

On 3/3/2025 at 1:34 PM, MainDir-L provided to Surveyor a second copy of the facility Legionella Water Management Program policy and procedure, a checklist for developing a legionella water management program that was not dated, a facility policy and procedure titled Legionella Water Management dated 1/10/2024, and a hand-drawn diagram of the facility with no control measures designated.

-The facility policy and procedure titled Legionella Water Management dated 1/10/2024 documented:

I. OBJECTIVE: The purpose of this policy is to reduce the risk associated with the control of Legionella to the lowest practical level.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 II. DEFINITION: Legionella-the bacterium that causes legionnaires' disease, flourishing in air conditioning and central heating systems. Level of Harm - Minimal harm or potential for actual harm III. POLICY: The Legionella Team consisting of the Administrator, Director of Nursing, Maintenance Director, Dietary Manager and Housekeeping Supervisor are to achieve by improving the standard of existing water, Residents Affected - Many implementing safe operational procedures, and ensuring that the design and installation of all new systems conform to the current standards.

IV. PROCEDURES: A. NURSING 1. Make sure medical devices such as CPAP and BIPAP machines are cleaned and sanitized on a daily basis. B. HOUSEKEEPING 1. DAILY TASKS: a. Clean and sanitize all showerheads for a minimum of 3 minutes. b. Clean and sanitize all facets [sic] regardless of use. 2. WEEKLY TASKS a. Run water through every showerhead for a minimum of 3 minutes. b. Run water through every facet [sic] for a minimum of 3 minutes. C. DIETARY 1. Clean/drain and sanitize all steam tables daily. 2. Monitor ice machine filters and notify Maintenance when the filter needs to be replaced. 3. Check water temperatures and chemical dispensers on Dishwasher daily. 4. Notify vendor of and repairs. [sic] D. MAINTENANCE 1. Insure [sic] the water heaters are running within the required WI State code guidelines. 2. Flush when required. Surveyor noted the policy did not include the infection preventionist as part of the team and no documentation showed the appropriate time to flush shower heads and faucets to be 3 minutes.

Surveyor reviewed with MainDir-L the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L if there was a more detailed drawing or description of the water system showing where control measures were in the building. Surveyor went through each item listed in 5. The water management program includes the following elements: to clarify with MainDir-L what information Surveyor needed to see to assess the facility WMP that was in place. MainDir-L stated the information provided to Surveyor, the policies, the checklist, and the hand-drawn diagram, was the information provided to MainDir-L by the previous maintenance director. MainDir-L stated MainDir-L would get logs that have been completed by kitchen and housekeeping.

In an interview on 3/3/2025 at 1:47 PM, Surveyor asked Nursing Home Administrator (NHA)-A who was part of the Water Management team. NHA-A stated the Regional Maintenance Director, MainDir-L, and ADON-F. Surveyor asked NHA-A if NHA-A was part of the team. NHA-A stated no. Surveyor shared the concern with NHA-A that NHA-A should be part of the team per their policy, and the information provided by MainDir-L was not complete or thorough.

On 3/3/2025 at 1:52 PM, MainDir-L provided logs that showed six rooms a week were tested for water temperature coming out of the faucets. Surveyor noted the temperatures logged ranged from 94 degrees to 112 degrees. The Centers for Disease Control and Prevention (CDC) guidelines document Legionella grows best between 77-113 degrees; hot water should be stored at temperatures above 140 degrees and hot water

in circulation should not fall below 120 degrees. MainDir-L provided logs from the kitchen that documented daily draining and sanitizing steam tables. Surveyor noted not all the boxes had been filled in indicating the task had been completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview on 3/4/2025 at 8:04 AM, Surveyor asked NHA-A to explain the water temp logs for resident rooms. NHA-A stated temperatures are gotten from six different rooms every week and the rooms are listed Level of Harm - Minimal harm or on the logs. Surveyor noted it takes about one and a half months to get the temperatures of every room in potential for actual harm the facility. Surveyor shared with NHA-A the concern the temperatures taken in resident rooms were below

the recommended 120 degrees by the CDC. Surveyor asked NHA-A if they had a policy to show what Residents Affected - Many temperature should be reached and if there was a measure in place to follow if the temperatures were not at

the level indicated. NHA-A provided a facility policy and procedure titled Water Temperatures, Safety of dated MED-PASS (C) 2001 revised 12/2009 that documented: 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 115 degrees F. Surveyor noted 115 degrees was hand-written in the policy where a blank had been left.

On 3/4/2025 at 10:57 AM, Surveyor measured the temperature of the water coming out of the faucet in room [ROOM NUMBER]. The temperature measured 124 degrees.

On 3/4/2025 at 3:32 PM, Surveyor shared with NHA-A and DON-B the concern staff measuring the temperature of the running water did not keep the thermometer in the water for a long enough period of time to come up with an accurate measurement. Surveyor shared the observation of the temperature of the water coming from the faucet in room [ROOM NUMBER]. Surveyor shared the concern NHA-A was not a member of the WMP team and the WMP 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.

4.) Resident R47 was admitted to the facility on [DATE REDACTED] and was in EBP due to wounds to the right heel, right lateral foot, and coccyx.

On 2/27/2025 at 11:14 AM, Surveyor was with Registered Nurse (RN)-M who was preparing to provide wound care to Resident R47. A sign was observed outside of Resident R47's room indicating Resident R47 was in EBP. RN-M knocked

on Resident R47's door prior to entering and told Resident R47 RN-M was there to do wound care. RN-M did not put on a gown prior to entering Resident R47's room. RN-M brought the treatment cart into Resident R47's room rather than leaving it in the hallway and bringing in only the treatment items needed to provide wound care. Resident R47 informed RN-M that Resident R47 had a bowel movement and needed to be cleaned up. RN-M told Resident R47 RN-M would return after Resident R47 had been cleaned. RN-M pushed the treatment cart back into the hallway. Surveyor observed Certified Nursing Assistant (CNA)-K enter Resident R47's room to provide incontinence care. CNA-K did not put on a gown prior to entering the room. CNA-K came out of Resident R47's room with a bag of garbage which CNA-K deposited into a garbage container in the hallway. Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to Resident R47. RN-M stated yes.

In an interview on 2/27/2025 at 11:27 AM, Surveyor asked CNA-K if any special PPE needed to be put on when doing incontinence care for Resident R47. CNA-K stated CNA-K did not think any PPE needed to be worn when caring for Resident R47, but maybe for Resident R47's roommate. CNA-K looked at the sign posted on Resident R47's door and stated Resident R47 was in EBP and next time, CNA-K will wear a gown to do cares with Resident R47.

On 2/27/2025 at 11:28 AM, Surveyor observed RN-M put on a gown prior to entering Resident R47's room. RN-M pushed the treatment cart into Resident R47's room. Resident R47 asked RN-M why RN-M was wearing a gown since RN-M had never had a gown on to do wound care before.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern CNA-K did not wear a gown when performing cares on Resident R47 and RN-M put on Level of Harm - Minimal harm or a gown after a discussion was had regarding Resident R47 being in EBP. Surveyor shared the concern RN-M brought potential for actual harm the treatment cart into the room when providing wound care.

Residents Affected - Many 5.) Resident R34 was admitted to the facility on [DATE REDACTED] and was in EBP due to a wound to the right heel.

On 2/27/2025 at 10:39 AM, Surveyor was with RN-M who was preparing to provide wound care to Resident R34. A sign was observed outside of Resident R34's room indicating Resident R34 was in EBP. RN-M knocked on Resident R34's door and entered the room pushing the treatment cart into Resident R34's room. RN-M did not put on a gown prior to providing wound care to Resident R34's right heel. After RN-M completed the wound treatment and pushed the cart into the hallway, Surveyor asked RN-M if RN-M should have worn PPE when doing Resident R34's wound treatment. RN-M stated yes.

On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M did not wear a gown when performing wound care on Resident R34 and the concern RN-M brought the treatment cart into the room when providing wound care.

6.) Resident R17 was admitted to the facility on [DATE REDACTED] and was in EBP due to wounds to the left and right buttocks.

On 2/27/2025 at 10:57 AM, Surveyor was with RN-M who was preparing to provide wound care to Resident R17. A sign was observed outside of Resident R17's room indicating Resident R17 was in EBP. CNA-O accompanied RN-M to help position Resident R17 during wound care. RN-M and CNA-O did not put on a gown prior to entering the room to provide wound care. RN-M pushed the treatment cart into Resident R17's room. When RN-M completed Resident R17's wound treatments, RN-M pushed the cart out of Resident R17's room and CNA-O followed. Surveyor asked CNA-O when a resident is in EBP, what PPE should be worn. CNA-O stated they should wear a gown. CNA-O showed Surveyor the bin outside of Resident R17's room that had PPE in the drawers. Surveyor asked CNA-O what would cause a resident to be in EBP. CNA-O stated if a resident has a wound or a catheter, then they are in EBP. Surveyor asked CNA-O if Resident R17 was in EBP. CNA-O stated CNA-O did not know if Resident R17 was on precautions or not so did not wear a gown.

On 2/27/2025 at 11:14 AM, Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to Resident R17. RN-M stated yes.

On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M and CNA-O did not wear a gown when performing wound care on Resident R17 and the concern RN-M brought the treatment cart into the room when providing wound care.

42037

7.) Resident R19 was admitted to the facility on [DATE REDACTED] and was in EBP due to a heel wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/27/2025 at 10:29 AM, Surveyor was with RN-M who was preparing to provide wound care to Resident R19. A sign observed outside of Resident R19's room door indicated Resident R19 was in EBP. RN-M knocked on Resident R19's door and Level of Harm - Minimal harm or entered the room pushing the treatment cart into Resident R19's room. RN-M did not don a gown prior to providing potential for actual harm wound care to Resident R19's heel wound. After RN-M completed the wound treatment RN-M pushed the cart back into the hallway, Residents Affected - Many

On 2/27/2025 at 3:10 PM, Surveyor shared with NHA-A and DON-B the concern that RN-M did not don a gown prior to performing Resident R19's wound care. Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care for Resident R19 who is in EBP. No additional information was supplied by

the facility at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 38253 potential for actual harm Based on interview and record review, the facility did not ensure they implemented their antibiotic Residents Affected - Many 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.

Findings include:

The facility policy and procedure titled Surveillance for Infections from MED-PASS (C) 2001 revised 9/2017 documents: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections.

On 3/3/2025 at 11:14 AM, Surveyor met with Assistant Director of Nursing (ADON)-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. Surveyor asked ADON-F what standard of practice for antibiotic stewardship was used. ADON-F stated they use McGeer, and they are trying to get it in place more frequently. (The McGeer criteria are a set of clinical guidelines used for infection surveillance in long-term care facilities, focusing on identifying potential infections and guiding antibiotic stewardship.) Surveyor asked ADON-F what was meant by that. ADON-F stated they are trying to complete the McGeer form for each resident on an antibiotic and then scanning it into the resident record. Surveyor asked ADON-F if each resident has had a McGeer form completed prior to

the use of an antibiotic. ADON-F stated that was their goal, but that had not been done for everyone at that time.

Surveyor reviewed the monthly line lists for 1/2025, 2/2025, and 3/2025. 1/2025 had 36 resident entries on

the line list, 2/2025 had 29 resident entries on the line list, and 3/2025 had 24 resident entries on the line list. Examples from the line list review:

-Resident R1 was diagnosed with a urinary tract infection on 3/1/2025 with a culture taken on 3/1/2025; the antibiotic Macrobid was started on 3/2/2025. No documentation was found of a McGeer criteria review being completed prior to the use of the antibiotic.

-Resident R151 was diagnosed with a urinary tract infection on 2/17/2025 with a culture taken on 2/17/2025; the antibiotic ciprofloxacin was started on 2/23/2025. On 2/22/2025 at 9:52 AM in the progress notes, nursing documented a call was received from Resident R151's physician regarding the urine culture results and to stop Keflex immediately and start ciprofloxacin. Surveyor noted Resident R151 had not received Keflex, and no documentation was found of a McGeer criteria review being completed prior to the use of any antibiotic.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern residents are put on antibiotics without documentation that the use of the antibiotic Level of Harm - Minimal harm or meets the McGeer criteria. Antibiotic stewardship relies on the use of a standard of practice to prevent potential for actual harm unnecessary antibiotic usage. Surveyor shared with NHA-A and DON-B resident records were reviewed and no documentation was found in the medical record of the McGeer criteria checklist being completed prior to Residents Affected - Many the use of antibiotics.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 525565

F-F684).

Residents Affected - Few On 03/04/25, at 09:30 AM, Surveyor interviewed Resident R13 regarding the abdominal binder, Resident R13 stated they are not using it now because it is so tight that Resident R13 got a rash. Resident R13 decided on own that they did not want the rash so have asked staff not to put the binder on.

On 03/04/25, at 09:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who finished helping Resident R13 get ready that morning and asked about Resident R13's abdominal binder to which CNA-K responded ya he wear it.

On 03/04/25, at 09:58 AM, Surveyor interviewed Director of Nursing (DON)-B regarding steps taken to prevent pulling of nephrostomy tubes by Facility. Per DON-B the first couple times it happened it was during Hoyer transfers so DON-B got an abdominal binder to hold tubes in place. DON-B admits not being aware Resident R13 is not wearing the binder due to rash, stated will have to talk to Resident R13 about skin protection options.

On 03/04/25, at 03:34 PM, Surveyor asked DON-B if the abdominal binder was assessed and was told that it was not assessed or considered a restraint. The Nursing Home Administrator was also in the room. Surveyor reiterated that this is a concern.

As of the time of exit, no additional information was provided as to why the Facility did not comprehensively assess the use of the physical restraint (abdominal binder) and then develop a plan of care based on the outcome of the assessment for its continued use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48391 potential for actual harm Based on interview and record review, the facility did not complete a Pre-Admission Screening & Resident Residents Affected - Few Review (PASARR) assessment for 1 (Resident R37) of 1 residents reviewed.

Resident R37 was admitted to the facility on [DATE REDACTED], and did not have a PASARR Level I completed at time of admission.

Findings include:

The facility's Policy and Procedure titled Admission Criteria, not dated, documents:

All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process.

a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD.

Resident R37 was admitted to the facility on [DATE REDACTED] with a diagnosis that includes Bipolar disorder, Depression, Anxiety, and Post Traumatic Stress Disorder (PTSD).

Resident R37's hospital documentation dated 12/20/24, documents Resident R37 with a history of chronic bipolar, depression, anxiety, and PTSD.

On 2/27/25, at 1:39 PM, Surveyor interviewed Medicaid Pending Manager (MPM)- C who states she is notified by the facility of new admissions and will read through the referral to see if there are any medications or diagnoses to fill out the Level I PASARR. MPM- C indicates a Level I PASARR is required on every resident, and she will download in the Electronic Medical Record (EMR). MPM- C states she will complete a Level 2 PASARR if it is required and will send a notification to the facility's Director of Nursing (DON) if a Level 2 PASARR is required. Surveyor asked MPM- C if a Level I PASARR was completed on Resident R37 and MPM- C states she completed the Level I PASARR today on 2/27/25. Surveyor notes Resident R37 was admitted on [DATE REDACTED]. Surveyor asked why the Level I PASARR was completed on 2/27/25 and MPM- C states she works

in 6 other facilities and sometimes doesn't catch everything. MPM- C indicates Resident R37's Level I PASARR was completed and submitted on 2/27/25 and the Level 2 PASARR is not completed but is requested.

On 2/27/25, at 3:02 PM, Surveyor notified Nursing Home Administrator (NHA)- A, Assistant Nursing Home Administrator (ANHA)- D, and DON- B of concerns with Resident R37 not having a Level I PASARR completed on admission. NHA- A, ANHA- D, and DON- B acknowledge concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38253

Residents Affected - Some Based 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 (Resident R17, Resident R47, Resident R34, Resident R19, Resident R26, and Resident R36) of 6 residents reviewed with pressure injuries or at risk for developing pressure injuries.

*Resident R17 did not have a comprehensive skin assessment on admission on 7/19/2024. 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. Resident R17 developed a DTI to the right medial foot on 8/2/2024 that progressed to a Stage 3 and healed. Resident R17 developed Moisture Associated Skin Damage (MASD) on 2/7/2025 to the right and left buttocks that worsened with pressure and are still present. The pressure injury documentation was not accurate, and

the wounds were not comprehensively assessed weekly. The Registered Dietician recommendations were not implemented for 2 months.

*Resident R47 did not have a comprehensive skin assessment on admission on 10/18/2024. On 10/25/2024, wound documentation included a Stage 2 pressure injury to the right lateral ankle, an Unstageable pressure injury to

the right lateral foot, and MASD to the sacrum and medial thighs. Documentation was conflicting as to the right lateral ankle and right lateral heel being assessed as the same area or two separate areas. Resident R47 was readmitted after hospitalization four times with skin assessments not being completed upon return to the facility. The sacrum and medial thighs MASD healed. The right lateral ankle/heel progressed to Unstageable.

On 2/7/2025, Resident R47 developed MASD to bilateral buttocks that worsened with pressure and was not staged as

a pressure injury. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. The Registered Dietician recommendations were not implemented for 2 months.

*Resident R34 developed a Stage 3 pressure injury to the right heel on 11/26/2024 that was not comprehensively assessed on discovery. Interventions to prevent the pressure injury to the heel were not in place. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. Observations were made of Resident R34's heels on the mattress and the air mattress was not plugged in.

The Registered Dietician recommendations were not implemented.

*Resident R19 developed a DTI to the right heel on 11/1/2024 that progressed to an Unstageable pressure injury. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. Observations were made of interventions not in place.

*Resident R26 developed wounds to the abdominal fold that were not comprehensively assessed.

*Resident R36 was admitted to the facility on [DATE REDACTED] with limited mobility related to a left femur fracture. Resident R36 was Non-Weight-Bearing (NWB) to Left Lower Extremity (LLE). Resident R36 was prescribed an immobilizer brace to her LLE to be worn at all times. There is no evidence the facility was removing Resident R36's immobilizer brace and performing skin checks to prevent injuries to the skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Findings include:

Level of Harm - Actual harm The facility policy and procedure titled Prevention of Pressure Injuries from MED-PASS (C) 2001 revised 4/2020 documents: Purpose: The purpose of this procedure is to provide information regarding identification Residents Affected - Some of pressure injury risk factors and interventions for specific risk factors.

Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Risk Assessment:

1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly for one month a total of 4 assessments, upon any changes in condition and with each MDS assessment.

2. Under observations use the standardized assessment titled Skin Risk Assessment with Braden Scale to determine and document risk factors, help you identify and initiate preventive interventions and initiate plan of care.

3. Supplement the use of a risk assessment tool with assessment of additional risk factors.

Skin Assessment:

1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge.

2. During the skin assessment, inspect: a. Presence of erythema. b. Temperature of skin and soft tissue; and c. Edema.

3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan.

4. A weekly skin prevalence will be conducted each week over a 24-hour period. See Skin Prevalence process and form. Skin prevalence should be completed the day prior to wound rounds.

5. Weekly RN assessment and documentation completed. Wound rounds must be completed at a minimum of at least once every 7 days.

6. Measurements and documentation to support treatment, interventions, type of wound must be part of the weekly documentation.

7. There must be a current PI care plan in place to support the wound status and all interventions and goals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 8. MD must be notified with any changes in wound.

Level of Harm - Actual harm 9. Residents and or their representative must be notified of the status of the wound and current interventions at least weekly and as needed. Residents Affected - Some Prevention: .

Nutrition:

1. Conduct nutritional screenings for residents at risk.

2. Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition, and for all adult residents with a pressure injury.

5. Monitor the resident for weight loss and intake of food and fluids.

6. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning:

1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by

the interdisciplinary care team.

Support Surfaces and Pressure Redistribution:

1. Select appropriate support surfaces based the [sic] resident's risk factors, in accordance with current clinical practice.

Device-Related Pressure Injuries:

1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device.

2. Monitor regularly for comfort and signs of pressure-related injury.

3. For prevention measures associated with specific devices, consult current clinical practice guidelines.

Monitoring:

1. Evaluate, report and document potential changes in the skin.

2. Review the interventions and strategies for effectiveness on an ongoing basis.

1.) Resident R17 was admitted to the facility on [DATE REDACTED] with diagnoses of cellulitis of the right and left lower limbs, chronic obstructive pulmonary disease, venous insufficiency (peripheral), congestive heart failure, adult failure to thrive, and xerosis cutis (a skin condition characterized by excessive dryness, roughness, and flaking).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Resident R17's Significant Change Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented Resident R17 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had no impairment to the Level of Harm - Actual harm arms or legs. Resident R17 was always incontinent of bowel and bladder, had one Unstageable pressure injury due to

a non-removable dressing or device that was present on admission, and four Unstageable pressure injuries Residents Affected - Some that were present on admission.

The Pressure Ulcer/Injury Care Area Assessment (CAA) associated with the MDS documented Resident R17 had recently transitioned to hospice care and remains bed bound most of the time. Resident R17 transfers with a Hoyer lift and is dependent in the wheelchair. Resident R17 had skin concerns on the coccyx that was present on admission and the wound nurse continues to monitor. Resident R17 was rotated every two hours and lays on a pressure relieving mattress. Resident R17 had a BIMS of 15 and could state any concerns or needs. Resident R17 did not have an activated Power of Attorney.

Prior to admission to the facility, Resident R17 was hospitalized from 7/15/2024 to 7/19/2024 with failure to thrive and worsening bilateral foot wounds. On 7/15/2024, Resident R17 was evaluated by the hospital wound Registered Nurse (RN) and documented Resident R17 had an Unstageable pressure injury to the coccyx that measured 1.3 cm x 0.4 cm x unable to determine with 100% slough, a venous ulceration to the right lateral ankle that was red and moist with a few scattered open areas, and a venous ulceration to the left posterior ankle that was red and moist with one small open area. The RN documented Resident R17 reported not being able to cleanse the legs and only has

a bathtub so has not showered in quite some time. Resident R17 had thick build up of epithelial cells and drainage on bilateral ankles/lower extremities; hair was cleansed from the right leg wound. Thick scaly skin was removed with mechanical debridement with cleansing and cocoa butter was applied to help moisten the areas that could not be removed. An Unstageable pressure injury was discovered on the coccyx. Resident R17 was positioned to

the right side lying with pillow support as well as placement of a waffle cushion. Resident R17 should be turned every two hours left to right and limit supine/sitting position as much as possible. A photograph of the right lateral ankle wound was included in the hospital documentation.

On 7/19/2024 (date of admission to the facility) on the Head-to-Toe Assessment form, the nurse hand wrote See RN document under the skin section for pressure ulcer. The form was not signed. The Skin Condition on

the Admission form documented Resident R17 had a bruise to the top of the right hand, a bruise to the left wrist, and a bruise to the left antecubital from blood draws. No areas were circled on the body diagram. This form was not signed.

On 7/20/2024 at 3:19 PM in the progress notes, an RN documented Resident R17 was admitted on [DATE REDACTED] with diagnoses of venous stasis dermatitis with infected ulceration to the right foot and a wound to the coccyx. No documentation of an assessment was found.

On 7/22/2024 at 6:00 PM in the progress notes, an RN documented an admission skin assessment was done by the RN and Director of Nursing (DON)-B and Resident R17 had bilateral lower extremity venous stasis dermatitis. The wounds were cleansed with normal saline, patted dry, and xeroform was applied to the affected areas. No measurements or description was documented, and no assessment of the coccyx was documented.

On 7/22/2024, Resident R17 got a treatment order to cleanse area with warm water and soap daily. Surveyor noted no location was documented as to where the treatment was to be applied and, if this was for the coccyx wound,

the coccyx wound was not treated for three days since admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Resident R17's At Risk for Skin Breakdown Care Plan was initiated on 7/25/2024 with interventions:

Level of Harm - Actual harm -Assess for presence of risk factors; treat, reduce, eliminate risk factors to the extent possible.

Residents Affected - Some -Avoid shearing skin during positioning, transferring, and turning.

-Check for incontinence episodes often.

-Conduct a systemic skin inspection on admission, with cares, and on bath days.

-Cushion in wheelchair for protection.

-Document episodes of refusals to reposition in progress notes.

-Educate on the risk vs benefits of sleeping in recliner vs bed for off loading and pressure relief if indicated.

-Educate on the risk vs benefits of staying in bed vs getting up for offloading and position changes to prevent breakdown if indicated.

-Encourage fluids every shift.

-Encourage physical activity, mobility, and range of motion to maximal potential.

-Encourage/assist to make frequent position changes while in chair.

-Encourage/assist to turn and reposition frequently.

-Float heels to reduce the risk of pressure and friction.

-Heel boots on at all times while in bed.

-Keep clean and dry as possible; minimize skin exposure to moisture.

-Keep linen clean, dry, and wrinkle free.

-Provide cushion in recliner if (Resident R17) prefers to sleep in recliner to reduce the risk of skin breakdown.

-Report any signs of skin breakdown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 7/26/2024 at 8:46 AM in the progress notes, an RN documented wound rounds were done with Nurse Practitioner (NP)-N and Resident R17 did not have any open areas to bilateral lower extremities. The RN documented Level of Harm - Actual harm Resident R17 had multiple deep tissue injuries (DTIs): 1.) the right heel measured 8.5 cm x 1 cm with intact skin that was deep purple and appeared to be an old injury unseen related to the thick covering of stasis dermatitis; 2. Residents Affected - Some ) the right Achilles measured 14 cm x 5 cm with intact skin that was deep purple and an old wound as stated above; 3.) the coccyx had an open wound measured 4 cm x 9 cm that was 90% dark purple and 10% slough; 4.) the left heel had a DTI that measured 1 cm x 1 cm; 5.) skin discoloring 1.5 cm x 12 cm related to Resident R17 lying on catheter tubing. Surveyor noted the coccyx wound was not staged and did not have a depth measurement, and no location was identified where the skin was discolored from the catheter tubing.

On 7/26/2024 at 12:21 PM in the progress notes, DON-B documented an alternating air mattress had been ordered for Resident R17 due to Resident R17's condition.

On 7/27/2024, Resident R17 got a treatment order for the coccyx wound to be cleansed with warm water and soap, pat dry, and apply zinc cream to the area twice daily and to turn Resident R17 every two hours to relieve pressure.

On 8/4/2024 at 10:44 AM in the progress notes, an RN documented wound rounds were completed on 8/2/2024 with NP-N and Resident R17 had Prevalon boots on but refused to have them Velcro closed. Resident R17 had DTIs to the right thigh, the left heel, the left thigh, the left Achilles and the right thigh (listed twice).

-The right heel/Achilles DTI measured 15 cm x 5 cm.

-The wound to the coccyx measured 5 cm x 7 cm with 50% epithelial tissue, 10% granulation tissue, and 40% deep purple.

-The right medial foot DTI measured 4 cm x 1 cm.

-The right calf DTI measured 0.7 cm x 15 cm.

-The left lateral foot/Achilles DTI measured 8.5 cm x 7 cm and was boggy and blanchable.

Surveyor noted the right heel wound and the right Achilles wound were combined to one measurement, the coccyx pressure injury was not staged and did not have a depth measurement, and multiple new areas had deep tissue injuries that did not include measurements: the right thigh, the left heel, and the left thigh. Surveyor noted the right medial foot wound and the right calf wound were new DTIs.

On 8/9/2024 at 5:05 PM in the progress notes, an RN documented wound rounds were done with NP-N and Resident R17 had the following pressure injuries:

-The right heel/Achilles DTI measured 13 cm x 4 cm and was now Unstageable with 50% eschar and 50% epithelial tissue. Surveyor noted no depth measurement was documented.

-The Coccyx DTI measured 2.5 cm x 2.5 cm and was now Unstageable with slough. Surveyor noted no depth measurement or percentage of slough was documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -The right medial foot DTI measured 3 cm x 0.9 cm.

Level of Harm - Actual harm -The right posterior calf DTI, related to the catheter tubing, measured 0.5 cm x 12 cm.

Residents Affected - Some -The left Achilles DTI measured 0.5 cm x 0.5 cm.

-The left heel DTI measured 1 cm x 1 cm.

-The right lateral foot DTI measured 7.9 cm x 0.5 cm.

Surveyor noted the right thigh and the left thigh DTIs from the previous week were not documented on, the left Achilles wound did not include the left lateral foot wound as it did from the previous week, and the left heel wound and right lateral foot wound were new DTIs.

On 8/16/2024 at 4:38 PM in the progress notes, an RN documented wound rounds were done with NP-N and Resident R17 had the following pressure injuries:

-The right heel/Achilles DTI measured 12 cm x 3.5 cm with eschar. Surveyor noted the pressure injury did not meet the definition of DTI, and no depth measurement or percentage of eschar was documented.

-The Coccyx pressure injury measured 3.5 cm x 2 cm with slough. Surveyor noted the pressure injury was not staged, and no depth measurement or percentage of slough was documented.

-The right medial foot DTI measured 1.5 cm x 0.4 cm.

-The right posterior calf DTI measured 0.5 cm x 10 cm.

-The left Achilles DTI resolved.

-The left heel DTI resolved.

-The right lateral foot DTI measured 2 cm x 0.5 cm.

On 8/23/2024 at 3:48 PM in the progress notes, an RN documented wound rounds were done with NP-N and Resident R17's wounds to the left lateral ankle, the left heel, and the left Achilles/heel, and the left lateral ankle had healed. Resident R17 had the following pressure injuries:

-The right heel/Achilles pressure injury measured 12 cm x 3.5 cm x unable to determine with 50% eschar and 50% epithelial tissue. Surveyor noted the pressure injury was not staged.

-The Coccyx pressure injury measured 2.5 cm x 1.5 cm with 50% slough and 50% epithelial tissue. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

-The right medial foot DTI measured 1 cm x 0.3 cm and was now Unstageable with 100% eschar. Surveyor noted no depth measurement was documented.

-The right posterior calf DTI measured 0.5 cm x 10 cm with 100% epithelial tissue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -The right lateral foot DTI measured 2 cm x 0.5 cm and was now Unstageable with eschar. Surveyor noted no depth measurement or percentage of eschar was documented. Level of Harm - Actual harm No documentation for wounds was found from 8/23/2024 until 9/6/2024, two weeks later. Residents Affected - Some Resident R17's Moisture Associated Skin Damage (MASD) on Bilateral Buttocks Care Plan was initiated on 9/2/2024 with the interventions:

-Turn every two hours to off load wound area.

-treatment to the wound will be done according to provider orders.

Surveyor noted no documentation was found in Resident R17's record of having MASD to the buttocks.

A timeline of the wound progression is listed for each pressure injury site: the right heel/Achilles, the coccyx,

the right medial foot, the right posterior calf, and the right lateral foot.

RIGHT HEEL/ACHILLES

On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and

the right heel pressure injury measured 2.7 cm x 4 cm x unable to determine with dry eschar. Surveyor noted

the pressure injury was not staged, and no percentage of eschar was documented. The right Achilles pressure injury measured 5 cm x 1.5 cm x unable to determine with 90% dry eschar and 10% epithelial tissue. Surveyor noted the pressure injury was not staged.

On 9/13/2024 on the Wound Management Detail Report, RN-M documented the right Achilles/heel pressure injury measured 11 cm x 3.5 cm x 0 cm with 40% epithelial tissue, 30% eschar, and 30% slough. Surveyor noted the pressure injury was not staged. The right heel and the right Achilles were measured as one.

NP-N assessed Resident R17's right heel/Achilles Unstageable pressure injury and documented weekly from 9/20/2024 - 10/11/2024.

On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 11.5 cm x 4 cm with 40% epithelialization, 20% eschar, and 20% slough. Surveyor noted the pressure injury was not staged, and no depth was documented. The percentage tissue type did not equal 100%.

On 10/25/2024 at 6:00 PM in the progress notes, RN-M documented wound rounds were done with NP-V and Resident R17 had a venous stasis ulcer to the right lateral calf that measured 3.5 cm x 2 cm x 0.1 cm. No pressure injuries were assessed or documented.

No wound documentation of the pressure injury was found from 10/18/2024 until 11/8/2024.

On 11/8/2024, NP-N assessed Resident R17's right heel/Achilles Unstageable pressure injury and documented the wound measured 11 cm x 3.2 cm x unable to determine with 40% epithelial tissue, 20% slough, and 40% granulation and the measurements are post-debridement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 11/15/2024, NP-N assessed Resident R17's right heel/Achilles Stage 4 pressure injury and documented the wound measured 10.4 cm x 3.2 cm by unable to determine with 40% epithelial tissue, 10% tendon, and 50% Level of Harm - Actual harm granulation. NP-N had debrided the area by removing the eschar on the heel.

Residents Affected - Some On 11/22/204 on the Wound Management Detail Report, RN-M documented the pressure injury measured 10.3 cm x 3.0 cm with 40% epithelialization, 50% granulation, and 10% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

No wound documentation of the pressure injury was found from 11/22/2024 until 12/11/2024.

On 12/11/2024 on the Wound Management Detail Report, RN-M documented the pressure injury measured 10.4 cm x 2.9 cm x 0 cm with slough. Surveyor noted the pressure injury was not staged, and no percentage of slough was documented.

On 12/13/2024 on the Wound Management Detail Report, RN-M documented the Stage 2 pressure injury measured 10 cm x 2.4 cm x 0 cm with 30% epithelialization tissue, 60% granulation, and 10% slough. Surveyor noted the pressure injury was not staged appropriately. NP-N documented the pressure injury was

a Stage 4.

On 12/20/2024 and 12/27/2024 on the Wound Management Detail Report, RN-M did not document the stage of the pressure injury.

On 1/3/2025 on the Wound Management Detail Report, RN-M documented the pressure injury was Unstageable Deep Tissue injury with 100% granulation tissue. The staging did not match the wound description.

On 1/10/2025 on the Wound Management Detail Report, RN-M documented the pressure injury was a Stage 3 which was not appropriate staging; a wound cannot get downgraded.

RN-M assessed and documented on Resident R17's Stage 4 pressure injury on 1/17/2025.

Resident R17's Stage 4 pressure injury was not assessed or documented on from 1/17/2025 until 1/31/2025.

RN-M assessed and documented on Resident R17's Stage 4 pressure injury weekly from 1/31/2025 until 2/21/2025 when the wound healed.

COCCYX

On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and

the Stage 3 pressure injury measured 2.5 cm x 2.5 cm x 0.1 with 50% slough and 50% epithelial tissue. Surveyor noted this was the first comprehensive assessment of the wound since admission on 7/19/2024.

On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the Stage 3 pressure injury measured 0.7 cm x 0.5 cm with dry slough. Surveyor noted no depth measurement or percentage of slough was documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation tissue. Surveyor noted no Level of Harm - Actual harm depth measurement documented.

Residents Affected - Some On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation tissue. Surveyor noted no depth measurement documented.

On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the Buttock/Coccyx pressure injury measured 3 cm x 2 cm. Surveyor noted the pressure injury was not staged, and no depth measurement or description of the wound bed was documented.

On 10/11/2024 at 6:25 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Buttock/Coccyx pressure injury measured 0.7 cm x 1 cm with 100% smooth pink tissue. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Buttock/Coccyx pressure injury resolved.

RIGHT MEDIAL FOOT

On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and

the pressure injury measured 0.3 cm x 0.3 cm with dry eschar. Surveyor noted the pressure injury was not staged, and no depth measurement or percentage of eschar was documented.

On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the pressure injury measured 1 cm x 0.7 cm with 100% granulation. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation. Surveyor noted no depth measurement was documented.

On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the right medial/anterior foot pressure injury measured 1 cm x 0.7 cm with 100% granulation. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the medial/anterior foot pressure injury was not assessed or documented. NP-N documented the right medial/anterior pressure injury resolved.

RIGHT POSTERIOR CALF

On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and

the pressure injury measured 1 cm x 12 cm and was determined to no longer be a DTI, even though the description of the area was dark purple.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the Stage 3 pressure injury healed. Surveyor noted this was the first documentation of the pressure Level of Harm - Actual harm injury being a Stage 3.

Residents Affected - Some RIGHT LATERAL FOOT

On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and

the pressure injury measured 2 cm x 0.6 cm x unable to determine was scabbed over with 100% eschar. Surveyor noted the pressure injury was not staged.

On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the pressure injury was not assessed or documented.

On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the pressure injury measured 2.4 cm x 1.3 cm with 80% eschar and 20% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the right lateral foot pressure injury measured 2.4 cm x 1.3 cm with 80% eschar and 20% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the pressure injury measured 2.4 cm x 1.7 cm x 1.1 cm. Surveyor noted the pressure injury was not staged, and no description of the wound bed was documented.

On 10/11/2024 at 6:25 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.4 cm x 1.4 cm x 1.1 cm. Surveyor noted the pressure injury was not staged, and no description of the wound bed was documented.

On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.5 cm x 1.5 cm. Surveyor noted the pressure injury was not staged, and no depth measurement or description of the wound bed was documented.

On 10/25/2024 at 6:00 PM in the progress notes, RN-M documented wound rounds were done with NP-V and Resident R17 had a venous stasis ulcer to the right lateral calf that measured 3.5 cm x 2 cm x 0.1 cm. No pressure injuries were assessed or documented.

No wound documentation of the pressure injuries was found from 10/18/2024 until 11/8/2024.

On 11/8/2024 at 6:34 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the Stage 3 pressure injury measured 1.6 cm x 0.9 cm. Surveyor noted no depth measurement or description of the wound bed was documented.

On 11/15/2024 at 4:17 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 1.4 cm x 0.8 cm with granulated tissue throughout. Surveyor noted the pressure injury was not staged, and no depth measurement was documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 11/22/204 at 4:42 PM in the progress notes, RN-M documented wound rounds were done with NP-N and

the pressure injury was not assessed or documented. Level of Harm - Actual harm

On 12/13/2024, NP-N assessed Resident R17's right lateral foot Stage 3 pressure injury. NP-N assessed Resident R17 weekly, Residents Affected - Some and the pressure injury resolved on 1/10/2025. This documentation was not available to facility staff and was not in Resident R17's medical record until Surveyor requested a copy of NP-N's notes on 2/27/2025 at 3:01 PM.

NUTRITION

On 8/8/2024 at 7:54 AM in the progress notes, the Registered Dietician (RD) documented a nutritional assessment was completed and due to the coccyx wound, multiple DTIs, and foot ulceration, Resident R17 had increased nutrient needs and suggested a wound healing supplement like Arginaid daily. Surveyor noted Arginaid was not initiated.

On 9/11/2024 at 11:25 AM in the progress notes, the RD documented at previous review, RD recommended Arginaid for wound healing. RD continued to suggest Arginaid to support wound healing. Surveyor noted Arginaid was not initiated.

On 10/9/2024 at 11:17 AM in the progress notes, the RD documented a recommendation for Arginaid daily would aid in wound healing. Surveyor noted this was the third month in a row the RD had made that recommendation, and it was not followed up on.

On 10/30/2024, Resident R17 had an order for Arginaid initiated. Surveyor noted this was initiated greater than two and a half months after it had been recommended by the RD.

In a phone interview on 3/3/2025 at 2:02 PM, Surveyor asked Registered Dietician (RD)-W, the regional supervisor for the dieticians, how the RD was notified of residents with pressure injuries. RD-W stated the RD would receive a wound report form the DON or the wound nurse, and depending on the severity of the situation, the RD would put in a progress note within 24 hours of the notification. Surveyor asked RD-W how often the RD documented in resident records. RD-W stated the RD would document once a month with the weight status and how much the resident was eating as well as the status of the wounds. RD-W stated the RD would make a recommendation to address the nutrition and wound status and then would follow up to see if the recommendation was in place within 48 hours. RD-W stated the RD would be in person at the facility two to three times a month, so their voice was not always being heard. Surveyor shared with RD-W

the concern the RD recommendations for Resident R17 were not followed up for over two months. RD-W stated the RD that had been assigned to the facility did not have confidence in getting their recommendations in place.

CURRENT WOUNDS - MASD

On 2/3/2025 at 4:02 PM in the progress notes, RN-M documented Resident R17 was assessed due to a report of MASD to bilateral buttocks. Inspection revealed two areas of denuded skin bilaterally with a dermatitis related ulcer at the twelve o'clock position of the left MASD wound. The ulcer has 80% granulated tissue with 20% slough, wound edges are irregularly shaped, however firmly attached to the wound bed. Surrounding skin is MASD, denuded, partial thickness wound with blanchable erythema. MASD wound edges are rolled back measuring 3 cm x 2.5 cm, no exudate noted. The right buttock has a partial thickness MASD wound measuring 4 cm x 3.3 cm with irre [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16584

Residents Affected - Few Based on record review and staff interviews, the facility did not always ensure that 1 (Resident R44) out of 3 residents reviewed for accident hazards, received the care and services to prevent a further accident from happening. Resident R44 had a history of swallowing difficulties and experienced a choking episode. The facility did not get a referral for Resident 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.

Findings include:

Resident R44 was originally admitted to the facility on [DATE REDACTED] with diagnoses that included neuropathy, dementia, muscle weakness, hypothyroidism, gastroesophageal reflux disease (GERD), anxiety disorder and depression,

The most recent significant change of condition MDS (Minimum Data Set) dated 1/14/25, indicates that Resident R44 does not have any swallowing disorders or oral concerns. Resident R44 did not participate in the BIMs (brief interview for mental status) assessment but is documented to have long and short-term memory concerns. The MDS indicates Resident R44 is assessed as needing supervision or touching assistance by staff while eating, no signs or symptoms of a swallowing disorder, but is on a mechanically altered diet as a resident.

Resident R44's 11/17/24 quarterly MDS indicates Resident R44 requires set up assistance from staff for eating. Resident R44 shows signs and symptoms of coughing and choking while eating or taking medications and is on a mechanically altered diet as a resident.

Resident R44's 8/17/24 quarterly MDS indicates Resident R44 requires set up assistance for eating, has no signs or symptoms of swallowing issues, and is on a mechanically altered diet.

A nursing note dated 11/12/24 at 10:03 a.m. indicates; (Resident R44) was in main dining room eating breakfast and c/o (complained of) having chest discomfort, (Resident R44) sounded nasally, (Resident R44) has hx (history of) gerd and receives scheduled Famotidine q (every) am which writer administered (Resident R44's) meds this am. (Resident R44) did eat her whole breakfast and drank most fluids. (Resident R44) had a coughing spell in dining room and a copious amount of clear phlegm came up on (sic) (Resident R44) stated she had felt better, and her nose did not feel as stuffed up. Writer performed COVID test on (Resident R44) and it is negative for COVID. (Resident R44) currently sleeping in recliner in back lounge. Writer to update MD and ask for CXR (chest Xray) to rule out URI (upper respiratory infection).

Nursing note dated 11/22/2024 at 8:38 a.m. indicates; Staff called for nursing to the dining room. (Resident R44) complaining of feeling full in her throat or like something is stuck. Writer noting mucous production, (Resident R44) making attempts to clear throat. Denies heart burn, however states pain. Tablemate stated that this has been happening every so often, and (Resident R44) confirmed. Updated NP (nurse practitioner) and requested ST (speech therapy) eval/treat.

On 11/22/2024 the NP approved ST eval/treat and notified therapy staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R44 did receive speech therapy from 11/25/24 to 12/2/24. Upon discharge from therapy, the recommendations were for thin liquids and regular texture solids. The recommendation was to also give Level of Harm - Minimal harm or appropriate redirection with Resident R44 and pre-cut large solids. Resident R44's plan of care was updated at this time. potential for actual harm

A nutrition note dated 12/05/2024 at 9:41 a.m.; Wt. (weight) has been stable past 3 months. Wt. gain over Residents Affected - Few past 6 months is desirable given that BMI (body mass index)/wt. were low for age. Her (Resident R44) current BMI is now indicative of overweight but remains appropriate for advanced age. She (Resident R44) had recent episode for concern for difficulty w (with)/swallowing and getting food stuck. She was evaluated by SLP (speech language pathologist) with recommendations for continued general diet w/regular texture and thin liquids. Her po (by mouth) intake is typically at 76-100% majority of meals which is appropriate. She does receive house supplements at all meals which is appropriate to keep weight stabilized at approp (appropriate) amount given advanced age. No new recommendations. Surveyor noted the nutrition note did not include ST recommendations to pre-cut large solids.

Nursing note date 12/19/2024 at 2:51 p.m.; During breakfast (Resident R44) started to choke on her sausage as she could not swallow it or chew it all the way. (Resident R44) had a small emesis after choking on the sausage, vitals were taken and were stable. At lunch time (Resident R44) was complaining of feeling like her chest way full (sic) resident was given Mylanta to see if that would clear up some of the full feeling in her chest. Writer called the doctor, and the doctor said to call the POA (Power of Attorney) and ask if they would like (Resident R44) to go to the emergency room to get a workup. The resident's (Resident R44) POA said to call him back after a while to see if the Mylanta would settle some of the discomfort. Writer checked back after an hour and (Resident R44) said that her chest did not hurt anymore, and she seems much more relaxed and calmed down.

Surveyor conducted further review of Resident R44's medical chart and noted that there was no additional follow-up about the choking incident on the morning of 12/19/24. The facility staff did not notify the physician immediately following the incident. There was no update to the plan of care for further supervision and no referral to the Dietician regarding concerns with meal textures. In addition, there was no follow-up by the facility to ensure that Resident R44's breakfast meal which consisted of larger food items (breakfast sausage) were cut-up before consumption.

Nursing note dated 12/21/2024 at 3:56 p.m.; no issues with swallowing noted this shift.

On 12/26/2024 at 10:34 a.m., the IDT (interdisciplinary team) spoke with NP and requested video swallow study due to Dysphagia, oropharyngeal phase. Voicemail left for POA to return phone call. Scheduling staff made aware of need for appointment.

On 12/27/24 the facility obtained a physician order for Resident R44 to have a Video Swallow Study.

On 12/30/24, an order was written to monitor Resident R44 for swallowing complications at every meal followed up with documentation. With Meals 08:00 AM, 12:00 PM, 05:00 PM

On 1/8/25, Resident R44 received a speech therapy evaluation for the treatment of swallowing dysfunction and /or oral function for feeding. Patient (Resident R44) goals to reach least restrictive diet needs. The reason for the referral was

a change in overall status since a recent fall. Resident R44 was presenting with decreased awareness and ability to self-feed, reason, and swallow itself marked. The assessment noted that Resident R44 was seen by Speech Therapy

in the fall of 2024 and able to be discharged on regular thin liquids and self-feeding after set-up for help with cutting of foods.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Surveyor noted that there was a Notice of care plan change, dated 1/8/25, from Speech Therapist that Resident R44 is to have a dietary change: downgraded to puree. Advise increased supervision and support at mealtimes. Level of Harm - Minimal harm or Copies given to nurse on unit, DON (Director of Nursing), CNA (Certified Nursing Assistants), Binder. potential for actual harm Nursing note dated 01/14/2025 at 5:21 p.m.; CARE PLAN UPDATE: Dietary change: downgrade to puree, Residents Affected - Few advise increased supervision and support at mealtimes.

On 1/17/25, an additional Notice of Care Plan Change from Speech Therapist to upgrade to mech (mechanical) soft and ground meats. Continue thin liquids. Nurse to remind CNA's that Resident R44 needs quiet setting, pre-cut large items to finger food size. Indirect supervision after set-up.

Nursing note dated 01/21/2025 at 10:20 a.m.; (Resident R44) continues to be monitored for diet change to mech soft, (Resident R44) ate all her scrambled eggs and toast, and about half of her oatmeal, drank all fluids offered, no coughing or choking present during breakfast.

Nursing note dated 01/30/2025 at 03:36 p.m.; (Resident R44) was seen by Speech therapy and new orders to upgrade diet to regular solid texture. Continue swallow guidelines per order. POA called and updated.

A physician order was obtained on 1/30/25 ; DIET: Regular solid diet and thin liquids. Instructions: Nurse to remind CNAs that Resident R44 needs quiet setting, pre-cut large items to finger food size. Indirect supervision after set-up. Before Meals 08:00 AM, 12:00 PM, 04:00 PM

On 03/04/25 at 08:00 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding Resident R44's choking incident on 12/19/24. DON- B stated that she verified that the nurse on that shift did not notify the physician of the incident. DON- B stated she would have expected the nurse to call the physician immediately and discuss the need for further evaluation and treatment.

On 03/04/25 at 11:01 a.m., Surveyor interviewed RD-W (Registered Dietician) regarding Resident R44's choking incident on 12/19/24. RD-W stated the previous RD was at the facility that day and upon her review of the progress notes, there was no documentation that she was alerted of Resident R44's choking incident. RD-W stated that she definitely would want to get the referral to Speech Therapist, make dietary changes if needed and add supervision at meals. RD-W stated that the Dietician or any nurse can downgrade a diet until we can get them a swallow evaluation and diagnosis. RD-W stated that she would expect that facility staff would have notified Dietary just so we can look at weights and if resident has had trouble eating previously and needs diet consistency changes.

On 03/04/25 at 01:12 p.m., Surveyor interviewed SP (Speech therapist)-X regarding Resident R44's choking episode

on 12/19/24. SP-X stated that she was not made aware of that incident and had previously worked with Resident R44. Surveyor went over the nursing notes and the time it took for Resident R44 to get an order for a swallow study and for Speech Therapy to evaluate and treat her. SP-X stated that it seems like odd intervals in between the incident and the orders, and she cannot say where communication broke down. SP-X stated that she has been treating Resident R44 since January and she has been doing well. SP-X stated that she was the staff that wrote

the referral for speech services as she noticed a change in Resident R44's cognition, it was not due to the choking incident in December 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident R44 was noted to have a history of swallowing concerns and after the choking incident on 12/19/24 nursing staff did not ensure Resident R44 received additional assessments of her swallowing to ensure Resident R44's safety. It was Level of Harm - Minimal harm or not until SP-X noted a change in Resident R44 that led to the 1/8/25 evaluation of Resident R44's swallowing and changes to potential for actual harm Resident R44's diet were initiated until further assessments and therapies could be completed related to Resident R44's swallowing abilities. The facility did not do a thorough review to determine if Resident R44 received the correct sized Residents Affected - Few food when she had swallowing concerns. The lack of assessment immediately following the choking incident caused a potential for Resident R44 to choke again without further assessment of her capabilities to eat safely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38253

Residents Affected - Few Based on observation, interview, and record review, the facility did not ensure residents received appropriate treatment to restore continence to the extent possible for 1 (Resident R47) of 2 residents reviewed for bladder incontinence.

Resident R47 had an indwelling urinary catheter that was removed while at the facility. The facility did not comprehensively assess Resident R47's bladder pattern to develop a toileting program to restore Resident R47's urinary continence. Resident R47's Care Plan was not revised when the catheter was removed.

Findings include:

The facility policy and procedure titled Behavioral Programs and Toileting Plans for Urinary Incontinence from MED-PASS (C) 2001 revised 10/2010 documents: The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence.

Preparation:

1. Review the resident's care plan to assess for any special needs of the resident.

2. Conduct a thorough assessment of the resident and his or her environment to determine factors that may have contributed to any recent decline in urinary continence.

3. Provide treatment and services to address factors that are potentially modifiable. For example: a. managing pain; b. providing adaptive equipment for residents with mobility problems; c. removing or improving environmental impediments (lighting, distance to toilet or commode, etc.); and d. reviewing medication regimen and notifying the physician with any concerns.

4. Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including: a. voiding patterns .; b. associated pain or discomfort .; c. type of incontinence (stress, urge, mixed, overflow, functional, etc.); d. level of incontinence .; and e. response to specific interventions.

5. Assess the resident for appropriateness of behavioral programs which promote urinary continence.

General Guidelines:

1. Options for managing urinary incontinence include primarily behavioral programs, toileting plans and medication therapy.

3. Toileting Plans that are relatively more dependent on staff involvement and assistance as opposed to resident function include: a. prompted voiding; and b. habit training/scheduled voiding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Toileting Plans:

Level of Harm - Minimal harm or 1. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence potential for actual harm and/or behavior modification, the staff will initiate a toileting plan.

Residents Affected - Few 2. As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence.

Documentation:

1. The staff will document the results of behavioral/toileting trial in the resident's medical record.

2. If the resident responds well, behavioral/toileting programs will be continued.

1. Resident R47 was admitted to the facility on [DATE REDACTED] with diagnoses of left femur fracture, right pubis fracture, diabetes, congestive heart failure, lumbar disc degeneration, and morbid obesity.

Resident R47's Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented Resident R47 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and had an indwelling urinary catheter. Resident R47 did not have an activated Power of Attorney.

Resident R47's Indwelling Catheter Care Plan was initiated on 10/29/2024.

On 2/15/2025 at 11:22 AM in the progress notes, nursing documented Resident R47 was voiding freely with no difficulty in urination after the indwelling urinary catheter was removed on 2/14/2025.

Resident R47's Indwelling Catheter Care Plan was not resolved or revised after the catheter was removed. Resident R47 did not have a care plan in place to address urinary incontinence.

On 2/26/2025 at 10:08 AM, Surveyor observed Resident R47 lying in bed. Resident R47 had on a nightgown that was pulled up exposing Resident R47's abdomen and incontinence brief. Surveyor noted an odor of urine. Surveyor asked Resident R47 if Resident R47 had been provided incontinence care recently. Resident R47 stated Resident R47 had urinated in the incontinence brief, and no one had changed her since the previous night. Resident R47 stated Resident R47 had just urinated in the brief and was waiting until Certified Nursing Assistant (CNA)-K was done helping Resident R47's roommate with cares. Resident R47 stated Resident R47 wanted a bedside commode in the room so Resident R47 could get up to use it instead of urinating in the incontinence brief.

On 3/3/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern Resident R47 did not have a comprehensive bladder assessment completed after the indwelling catheter had been removed and Resident R47's Care Plan still indicated Resident R47 had an indwelling urinary catheter in place.

In an interview on 3/4/2025 at 10:49 AM, Surveyor asked Certified Nursing Assistant (CNA)-J how often Resident R47 had incontinence cares completed. CNA-J stated Resident R47 tells staff when Resident R47 is wet and needs to be changed. CNA-J stated staff also check Resident R47 as well to see if Resident R47 had been incontinent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 In an interview on 3/4/2025 at 8:07 AM, Surveyor asked Director of Nursing (DON)-B if Resident R47 had a bladder assessment completed after the indwelling urinary catheter was removed on 2/14/2025. DON-B provided Level of Harm - Minimal harm or CNA documentation that was completed hourly from 2/14/2025 to 3/4/2025 to establish if Resident R47 had voided potential for actual harm and had incontinence care provided. Surveyor asked DON-B if a nurse or nurse manager had reviewed the documentation to establish a toileting program such as prompted voiding. DON-B stated nothing was done Residents Affected - Few with the information and no toileting program had been developed.

In an interview on 3/4/2025 at 8:16 AM, Surveyor asked Resident R47 if Resident R47 was aware of the need to urinate before voiding. Resident R47 stated Resident R47 knows when Resident R47 has to go but the staff do not offer Resident R47 anything to go to the toilet. Resident R47 stated Resident R47 uses a mechanical lift so it does not fit in the bathroom, but the staff could put a bedside commode next to the bed and Resident R47 could be lifted to the commode. Surveyor asked Resident R47 if the staff offered Resident R47 a bed pan. Resident R47 stated they tried to use a bed pan once, but it caused Resident R47 pain because the bed pan was not straight underneath Resident R47.

On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern Resident R47 did not have a comprehensive bladder assessment completed after the urinary catheter was removed to determine a toileting program to meet Resident R47's needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011 Residents Affected - Few Based 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 (Resident R13) of 14 residents reviewed for quality of care.

In the last 120 days Resident 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).

Findings include:

Resident R13 was originally admitted to the facility on [DATE REDACTED] and most recently readmitted [DATE REDACTED] after a hospital stay. Resident R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder.

Resident R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents Resident R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating Resident R13 is cognitively intact for decision making. Resident R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are noted. Resident R13 is assessed as making self understood and understands others. The MDS indicates Resident R13 has a catheter for bladder and an ostomy for bowel function.

Resident R13 has a care plan for indwelling catheter which started on 06/26/2024. The problem reads Resident R13 requires an indwelling catheter (Bilateral Nephrostomy Tubes) r/t (related to) Neuromuscular dysfunction of bladder and BPH (benign prostate hyperplasia) with the following pertinent interventions:

-Abdominal Binder to maintain placement of tubes Created: 01/07/2025

-Assess drainage. Record amount, type, color, odor. Observe for leakage. Keep closed system as much as possible to reduce the risk of infection. Created: 06/26/2024

-Monitor output q (per)/ shift. Flowsheet: I&O (intake & output). Created: 06/26/2024

-Observe for s/s (signs/symptoms) of infection. Document and promptly report s/s. Follow McGeer's unless

specified per MD (medical doctor) order with education. Created: 06/26/2024

-Provide catheter care Q shift and as needed. Created: 06/26/2024

-Provide education to reduce the risk of trauma. Created: 06/26/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 Surveyor notes the following interventions remained on the care plan and should have been updated/removed: Level of Harm - Actual harm -16 FR foley with 10mL balloon. Created: 06/26/2024 Residents Affected - Few -Attempt voiding trial per facility protocol or MD order, unless otherwise specified per MD. Created: 06/26/2024

-Change catheter per facility protocol or MD order. Created: 06/26/2024

Surveyor reviewed the electronic medical record (EMR) and found the following orders related to Resident R13's nephrostomy care: Bilateral Nephrostomy Tubes. Special Instructions: Assess bandages and change if soiled. Imperative to be changed if soiled. Once An Evening 03:00 PM - 07:00 PM start date 01/06/2025. Nephrostomy tubes: Cleanse with NS (normal saline), pat dry, cover with spilt gauze. Change Q 2-3 days and PRN (as needed). Once A Day Every Other Day 06:00 PM - 10:00 PM start date 11/19/2024.

Surveyor reviewed the EMR for past 120 days and found six occurrences when Resident R13 was sent out for complications with Nephrostomy tubes.

1st time sent out

On 11/28/2024, at 12:34 AM, a progress note was written ambulance arrived to take resident to (name of) hospital for R (right) nephrostomy tube placement. VSS (vital signs stable). No signs of pain at this moment. No s/s of infection from nephrostomy tube insertion site.

A second progress note gives more details to the dislocation written on 11/28/2024, at 12:46 AM, writer entered room to perform wound care to find that resident's Nephrostomy had been torn from the stop-cock

during transfer via Hoyer lift. Leaving urine to leak freely from the Neph (nephrostomy)-tube. Writer attempted to identify a resolution and without success, called . DON (Director of Nursing). DON had suggested to contact (name of nurse practitioner group) to update and ask to advise. (Name of nurse practitioner group) had advised patient go to the ED (emergency department) for eval (evaluation) and treat. To stop the urine from freely flowing on to patient, a Foley catheter was cut and attached to a leg bag to allow the Nephrostomy tube to be inserted directly inside the Foley to drain into the collecting bag until patient could be transported to the ED for eval and treat .

On 11/28/2024, at 04:00 AM, a progress note was written resident returned from (name of) hospital. Hospital stated resident will need to go to (name of different) hospital for new nephrostomy tube. Tube remains to drain but is partially dislodged. VSS (vital signs stable) .

The After Visit Summary dated 11/28/24, reads right sided nephrostomy tube partially dislodged internally, but still functional. Continue to empty the bag as per normal protocol. Use caution in transferring the patient to prevent further dislodgement or tubing .

An After Visit Summary dated 11/29/2024, contains discharge instructions for the procedure of percutaneous nephrostomy being completed.

2nd time sent out

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 A progress note written on 12/29/2024, at 08:54 AM, reads left nephrostomy tubing stick line is 2 Inches off

the insertion site, no c/o (complaints of) pain to site, blood is noted to the tubing about 50 cc of sanguinis Level of Harm - Actual harm (sic) drainage noted, notified (nurse practitioner group) gave order to send out to (name of hospital) in [NAME] to be reinserted ., paramedics arrive at 0916 . Residents Affected - Few

On 12/29/2024, at 01:30 PM, a progress note reads pt (patient) back from ED for nephrostomy displacement vitals stable and charted no complaints, IR (interventional radiology) could not place nephrostomy today but referral to IR in place they will be calling us tomorrow but call back tomorrow if they don't reach out, stated to keep it covered, N.O. (new order) for cephalexin 500mg cap (capsule), take 1 cap PO (by mouth) in the AM, noon and evening x10 days per paperwork appear pt received first dose at ED, pt does not meet UTI (urinary tract infection) McGeer criteria, called (nurse practitioner group) to clarify if she would like to continue with ABT (antibiotic) due to pt not meeting criteria . (nurse practitioner group) gave order to continue with ABT prophylactic due to pt having leukocyte in UA (urinary analysis) and for upcoming procedure tomorrow, all order in. pt placed on 24 hour board to keep insertion site covered and to call IR tomorrow .

The After Visit Summary dated 12/29/2024, has a diagnosis for visit of nephrostomy tube displacement.

The After Visit Summary dated 12/30/2024, shows the nephrostomy tube being replaced.

3rd time sent out

A progress note written on 01/28/2025, at 10:18 AM, reads at 0745 (am) CNA (Certified Nursing Assistant) called RN (Registered Nurse) to look at nephrostomy bag. Left nephrostomy tubes attached to the patient and dressing dry and intact. Adaptor where tubing is attached to intact but catheter tubing was out and looks like its clogged with a white object. No other tubing available .

On 01/28/2025, at 01:26 PM, the return from ED progress note reads patient returned from (hospital location) BL (bilateral) nephrostomy tubes in place with clear yellow urine. Per patient replaced both tubes .

The After Visit Summary dated 1/28/2025, has diagnosis of malfunction of nephrostomy tube.

4th time sent out

A progress note written on 02/11/2025, at 02:04 PM, reads CNA found left nephrostomy tube out. RN applied dressing no drainage noted at this time some redness noted. Call placed to NP (nurse practitioner) order to send to (hospital location) ED.

The After Visit Summary dated 2/11/2025, has diagnosis listed as nephrostomy tube displacement.

5th time sent out

On 2/16/2025, at 01:08 PM, a progress note was written that reads blood tinged urine noted in nephrostomy as well as unequal output. Urine leaking through penis as well with strong foul odor. (Name of medical group) gave orders for resident to be sent to ED for evaluation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 58 525565 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525565 B. Wing 03/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0691 Surveyor notes Resident R13 was hospitalized on the 16th and returned to the facility on [DATE REDACTED]. Resident R13 was kept at the hospital to receive intravenous antibiotics due to a urinary tract infection. Level of Harm - Actual harm

The After Visit Summary dated 2/24/25, has a diagnosis of urinary tract infection associated with Residents Affected - Few nephrostomy catheter. A right nephrostomy catheter exchange was ordered on 2/17/25.

6th time sent out

A progress note written on 03/01/2025, at 05:57 AM, reads resident returned from hospital this shift. Sent out

on PMs for dislodged urostomy tube. Tube remains dislodged. Left tube functioning properly. Instructions sent to make an appointment to schedule urostomy placement.

The After Visit Summary dated 3/1/2025 has diagnosis of nephrostomy tube displacement.

On 02/26/25, at 12:35 PM, Surveyor interviewed Resident R13 and learned that Resident R13 returned from the hospital Monday (2 days before). Resident R13 was there over a week due to nephrostomy tube being pulled out, Resident R13 got a bacterial infection in the kidneys.

On 03/03/25, at 01:11 PM, Surveyor interviewed Resident R13 again regarding the number of times sent out to hospital due to nephrostomy tube issues. Per Resident R13 staff don't take the time to do the job correctly. Some are just not conscientious, Resident R13 will give them instructions if needed to prevent issues with nephrostomy tubes but some just are not willing to learn.

On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding Resident R13's nephrostomy tubes and asked about training given to staff. Per ADON-F there is a nurse and CNA meeting every other week, and training on how to transfer Resident R13 with a Hoyer has been discussed. Surveyor asked about interventions to keep nephrostomy tubes in place and was told the Facility had started using an abdominal binder to hold tubes in place. Also, discussed with NP today if there are other ideas on how to keep tubes in so not pulled out. (Cross-reference