Geneva Lake Manor
Geneva Lake Manor in Lake Geneva, WI — inspection on March 17, 2025.
Found 22 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
in the room.
communicating to R13 about the room change. DON-B stated that to my understanding social services
asked about the length of time the room change will be for and was told the Facility will repeat labs continuously to determine if can move back.
Surveyor asked about the set up of the room and was told we can set it up. To DON-B's knowledge R13 asked someone about it, R13 can set it up per wishes.
Surveyor notes no documentation was found indicating R13 had been aware of the room change, given a preference as to which room R13 would like, and there was no documented follow-up on how R13 was adjusting to the new room.
On 03/04/25, at 10:12 AM, Surveyor let DON-B know this is a concern, R13 was transferred to another room and there is no documentation R13 received prior written notice of the reason for the transfer or documentation on how R13 was adjusting to new room.
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teeth brushing among other things, R13 is working on getting that accomplished.
time R13 got up. CNA-K replied it was before they got here so must be before 6:30 AM. CNA-K stated
On 03/04/25, at 10:10 AM, Surveyor interviewed Director of Nursing (DON)-B about R13's desire to get up by 6:30 AM. DON-B stated that there is a sign on the door and R13's desired time is on the get up list CNA get.
Per DON-B R13 refuses sometimes if staff ask and it should be documented but it's not.
Surveyor let DON-B know this is a concern as a resident has the right to get up at the time desired.
No additional information was provided.
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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 R13 get ready that morning and asked about 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 R13 is not wearing the binder due to rash, stated will have to talk to 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.
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was sent together in an email dated February 20th, 2025.
Per NHA-A the Social Worker was out sick a
during the survey.
On 03/03/25, at 09:45 AM, Surveyor interviewed Social Worker (SW)-S and asked why December and January discharge information was not sent to the Ombudsman until 2/20/2025. SW-S knows it should be done the 1st of a new month it was their error, it was a busy time.
No further information was provided regarding discharge information being sent to the ombudsman in a timely manner monthly.
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notices for 10/30/2024, 12/24/2024, 1/9/2025, and 1/19/2025.
DON-B stated there were not any bed hold notices scanned into R47's medical record and they were
3.) R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. 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.
R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression.
No behavior concerns are documented. R13 is coded as making self understood and understands others.
Surveyor reviewed R13's electronic medical record which indicated R13 was transferred to the hospital emergency room for leaking nephrostomy tubes and urine with foul odor on 2/14/2025.
Surveyor requested evidence from the Facility that a bed hold notice was provided to R13 and to R13's responsible party when R13 went to the hospital.
Surveyor was given a form Bed Hold Consent Form/Policy dated 11/19/24 that R13 had signed and checked the box indicating Accept Bed Hold.
On 02/27/25, at 02:47 PM, Surveyor interviewed Director of Nursing (DON)-B and was told that November 19th was the last admission for R13 and the form given was is all they have.
On 03/03/25, at 09:45 AM, Surveyor interviewed Social Worker (SW)-S and was told bed hold notices are done by nursing staff.
On 03/04/25, at 07:56 AM, DON-B told Surveyor that they do not have any paperwork provided at the time of transfer.
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Review (PASARR) assessment for 1 (R37) of 1 residents reviewed.
R37 was admitted to the facility on [DATE], and did not have a PASARR Level I completed at time of admission.
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.
R37 was admitted to the facility on [DATE] with a diagnosis that includes Bipolar disorder, Depression, Anxiety, and Post Traumatic Stress Disorder (PTSD).
R37's hospital documentation dated 12/20/24, documents 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 R37 and MPM- C states she completed the Level I PASARR today on 2/27/25.
Surveyor notes R37 was admitted on [DATE].
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 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 R37 not having a Level I PASARR completed on admission. NHA- A, ANHA- D, and DON- B acknowledge concerns.
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the time of a planned discharge.
discharge received a thorough discharge summary in order to communicate necessary information to
*R50 discharged from the facility on 1/13/25.
The facility did not complete a discharge summary or a recapitulation of their stay that was available to R50.
Findings include: R50 was admitted to the facility for rehabilitation on 1/7/25 with dehydration, weakness and congestive heart failure. On 1/13/25, R50 had a planned discharge from the facility into the community.
Surveyor reviewed R50's physician orders and noted no discharge order documented by a physician.
Surveyor reviewed R50's electronic medical record. R50 was discharged from the facility on 1/13/25.
Surveyor could not identify a completed recapitulation of R50's stay at the facility or a completed discharge summary.
On 3/3/25 at 9:45 AM, Surveyor conducted interview with Social Worker-S.
Social worker-S informed Surveyor that they were hired by the facility in July of 2023 in a Social Services role.
Surveyor asked Social Worker-S if a resident should be given a discharge summary and recapitulation of their stay at the facility upon discharge.
Social Worker-S responded Yes, that would be the expectation upon discharge.
On 3/3/25 at 3:15 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A related to R50 discharging from facility on 1/13/25 without evidence of a completed discharge summary or recapitulation of R50's stay at facility being provided to R50.
The facility did not provide any additional information at this time
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recommended Arginaid for wound healing. RD continued to suggest Arginaid to support wound healing.
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, 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 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 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 irregular, rolled back edges and denuded.
LEFT BUTTOCK On 2/3/2
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completed related to R44's swallowing abilities.
The facility did not do a thorough review to determine
assessment of her capabilities to eat safely.
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before voiding. R47 stated R47 knows when R47 has to go but the staff do not offer R47 anything to
R47 if the staff offered R47 a bed pan. R47 stated they tried to use a bed pan once, but it caused R47
On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R47 did not have a comprehensive bladder assessment completed after the urinary catheter was removed to determine a toileting program to meet R47's needs.
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serious concern related to R13's nephrostomy tubes and being sent to the ED six times for care
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Director of Nursing (DON)-B that R19 had sustained a documented 9.2 % weight loss from October
facility.
The facility did not provide any additional information at this time.
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with dialysis.
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nurse in charge on each shift.
provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of
* 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.
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minimal harm staffing data to include the date, resident census, and the total actual hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides, on a daily basis.
This has the potential
* 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.
.monitor lab work as ordered by MD .Observe for signs of active bleeding.
antidepressant medication) d/t depression.
The following interventions are documented:
Pharmacy consultant review.
Surveyor could not identify monitoring for R34's anticoagulant or antidepressant medications in R34's medical record.
On 2/27/25 at 2:47 PM, Surveyor requested 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 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 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.) R5 was admitted to the facility on [DATE]. R5's diagnoses include aphasia, diabetes mellitus and traumatic brain injury.
On 2/27/25 at 2:47 PM, Surveyor requested 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 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 R5 does not have any documented evidence of monthly pharmacy reviews. No additional information was given by the facility at this time.
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the improper medication or dose is given. R13 must be vigilant and watch each medication given.
missed doses of Amantadine HCl. ADON-F stated they will look into this.
Surveyor asked if the
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 R13 was free from this significant medication error.
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Geneva Lake Manor 211 S Curtis St Lake Geneva, WI 53147
hair net at all times while serving food and throughout the common dining room while serving food.
from using the restroom and was caught off guard which is why she didn't have a hair net on.
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.
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completed R17's wound treatments, RN-M pushed the cart out of R17's room and CNA-O followed.
drawers.
Surveyor asked CNA-O what would cause a resident to be in EBP. CNA-O stated if a resident
stated CNA-O did not know if 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 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 R17 and the concern RN-M brought the treatment cart into the room when providing wound care. 7.) R19 was admitted to the facility on [DATE] and was in EBP due to a heel wound.
On 2/27/2025 at 10:29 AM, Surveyor was with RN-M who was preparing to provide wound care to R19. A sign observed outside of R19's room door indicated R19 was in EBP. RN-M knocked on R19's door and entered the room pushing the treatment cart into R19's room. RN-M did not don a gown prior to providing wound care to R19's heel wound.
After RN-M completed the wound treatment RN-M pushed the cart back into the hallway, 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 R19's wound care.
Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care for R19 who is in EBP. No additional information was supplied by the facility at this time.
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without documentation of appropriate use of the antibiotic.
Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS © 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: -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. -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 R151's physician regarding the urine culture results and to stop Keflex immediately and start ciprofloxacin.
Surveyor noted R151 had not received Keflex, and no documentation was found of a McGeer criteria review being completed prior to the use of any antibiotic.
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 meets the McGeer criteria.
Antibiotic stewardship relies on the use of a standard of practice to prevent 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 the use of antibiotics.
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F-F604).
On 03/04/25, at 09:30 AM, Surveyor interviewed R13 regarding the abdominal binder, R13 stated they are not using it now because it is so tight that R13 got a rash. 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 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 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 R13 and both staff should watch the cords.
Surveyor asked about R13's abdominal binder and was told ya he wear it.
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Form Approved OMB
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
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.
525565
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.