Wilora Lake Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to protect a resident from misappropriation of personal funds when the former Business Office Manager used a resident's debit card to pay the former Business Office Manager's personal bills. This deficient practice affected 1 of 3 residents reviewed for prevent misappropriation of resident property (Resident #14). The findings included:Resident #14 was admitted to the facility on [DATE]. Resident #14 was her own Responsible Party.A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #14 was cognitively intact.A review of the Initial Allegation Report dated 3/6/2026 indicated the facility became aware of the misappropriation of Resident #14's funds by the former Business Office Manager on 3/6/2026 when the Travel Business Office Manager assumed the former Business Office Manager's duties of assisting Resident #14 with an ongoing Medicaid application. The former Business Office Manager had resigned her position as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to provide toileting hygiene after a bowel movement and prior to placing a new and clean pull up on a resident dependent on staff for assistance with activities of daily living (ADL) for 1 of 4 residents (Resident #24).The findings included:Resident #24 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, neurogenic bladder with suprapubic urinary catheter, muscles weakness and lymphedema.Resident #24's care plan dated 02/26/26 revealed a focus area for impaired physical mobility with goal for resident to be able to perform activity within physical limits. The interventions included:Consult physical therapy per order.Determine level of assistance needed based on activities of daily living (ADL) evaluation.Encourage resident to increase activity as indicated.Evaluate resident's ability to perform ADL.Monitor for environment barriers to mobility.Observe resident's posture and gait.Observe range…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility failed to follow their Infection Control policies and procedures for Hand Hygiene when Nurse Aide (NA) #1 failed to sanitize his hands in between changing his gloves while providing suprapubic urinary catheter care to Resident #24. The facility also failed to follow their Enhanced Barrier Precautions (EPB) policy and procedure when NA #1 failed to wear a gown while providing incontinence care and while transferring Resident #24 and then NA #1 and NA #2 adjusted the same resident up in the bed after placing a turn sheet under her without wearing a gown. The deficient practice occurred for 2 of 8 staff observed for infection control practices (NA #1 and NA #2).The findings included:1. a. Review of the facility's Hand Hygiene policy and procedure which is part of the Infection Control policies and procedures last revised on 11/13/25 revealed the following:Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, Resident Representative, and Department of Social Services (DSS) Guardian interviews, the facility failed to ensure residents were given the right to participate in the revision of their person-centered care plans for 2 of 2 residents reviewed for care planning (Resident #12 and Resident #14). The findings included: 1. Resident #12 was admitted on [DATE] with diagnoses that included rheumatoid arthritis, frequent falls, depression, degenerative joint disease, and chronic joint pain. The quarterly Minimum Data Set (MDS) assessments dated 10/31/2024 and 01/24/2025 specified Resident #12 was cognitively intact. Review of Resident #12's electronic medical record revealed no evidence that she was invited to attend care plan meetings to discuss and provide input regarding her plan of care. An interview with Resident #12 on 02/10/2025 at 2:42 PM revealed that she did not recall being invited to a care plan conference or having her goals/progress discussed with her. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interview, the facility failed to provide personal privacy during incontinent care when the Nurse Aide exited the room during care and left the door to Resident #48's room open while the resident was unclothed and uncovered resulting in the resident being visible from the hallway while he was exposed. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident 48). The findings included: Resident # 48 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #48 was cognitively intact, frequently incontinent, and dependent on assistance for activities of daily living (ADL). An observation of incontinent care provided by Nurse Aide (NA) #1 for Resident #48 was conducted on 2/12/25 at 6:22 AM. NA #1 placed gloves on her hands outside the room. She was observed to have washcloths and linen supplies in the room with running water in the bathroom sink. She wiped Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident, and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #20 hit Resident #7 on the back of his head and neck with a metal cane after Resident #7 entered back into their shared room to retrieve a personal item. Resident #7 had a raised red area on the back of his neck. This affected 1 of 3 residents reviewed for abuse (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and essential primary hypertension. A review of Resident #7's care plan updated on 12/23/24 read he had a psychosocial wellbeing problem potentially related to disease process. The goal read Resident #7 will demonstrate adjustment to nursing home placement through review date. The interventions included allowing time to answer questions and verbalize feelings perceptions, and fears and initiate referrals as needed. Review of the annual Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and physician interviews, the facility failed to maintain documented evidence of a thorough investigation of an allegation of misappropriation of medication for 2 of 4 residents (Residents #278 & #279) reviewed for misappropriation of property. Findings included: a. Resident #278 was admitted to the facility on [DATE] with diagnoses that included hypertension and non-Alzheimer's dementia. b. Resident #279 was admitted to the facility on [DATE] and discharged home on 7/31/24. Her diagnoses included Diabetes Mellitus. The Initial Allegation Report dated 2/20/24 revealed the facility became aware of an allegation of drug diversion of resident drugs on 2/20/24 at 8:30 AM. Resident #278 was noted to be the affected resident. The Facility Investigation Report dated 2/22/24 read in part on the summary of the investigation for alleged narcotics missing for Resident #278. The Director of Nursing (DON) was notified that the narcotic medication was unable to be located in the narcotic lock box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Regional Ombudsman interviews, the facility failed to provide a complete written notice of transfer/discharge that included the Nursing Home Hearing Request form to the Resident and Resident Representative for 1 of 3 residents (Resident #20) reviewed for facility-initiated discharge. The findings included: Resident #20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #20 was moderately cognitively impaired. A review of the record revealed Resident #20 had a Resident Representative (RR) listed as an emergency contact. A review of a nurse's progress note written by the Director of Nursing (DON) dated 2/2/25 revealed Resident #20 was sent to the emergency room for a psychological evaluation and treatment due to behaviors. The facility did not readmit Resident #20. An interview with the DON on 2/13/25 at 12:52 PM revealed she called Resident #20's RR on 2/3/25 and informed him that Resident #20 was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Hospital Case Manager and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for a medical evaluation using the residents' behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #20). The findings included: Resident #20 was admitted to the facility on [DATE]. Diagnosis included end stage renal disease, essential primary hypertension, and unspecified intellectual disabilities. A review of a nurse's progress notes dated 2/2/25 revealed Resident #20 struck another resident with a cane, attempted to hit staff with objects and barricaded himself in his room. Resident #20 was sent to the emergency room for a psychological evaluation. A review of a second nurse's progress note dated 2/2/25 revealed Resident #20 was sent to the emergency room for a psychological evaluation and treatment due to behaviors. An interview with the Director of Nursing on 2/13/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of prognosis for a resident receiving Hospice services and discharge location for 2 of 27 reviewed for accuracy of assessment (Resident #9 and Resident #73). The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and adult failure to thrive. A Hospice contract dated 01/14/2025 certified that Resident #9 was admitted under the care and services of Hospice for end of life. Further review of the Hospice admission documentation for Resident #9 indicated that a certification of Resident #9's prognosis of 6 months or less was received on 01/14/2025 at 9:24 AM. A significant change MDS assessment dated [DATE] had been completed. Resident #9 was cognitively intact and received Hospice services. Resident #9's prognosis of 6 months or less was coded no.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations,and family, staff, and Nurse Practitioner interviews, the facility failed to implement fall prevention interventions consistent with resident's care plan (Resident #5 and Resident #6) and failed to provide a safe transfer using a mechanical lift for Resident #36. This deficient practice occurred for 3 of 6 residents (Resident #5, Resident #6 and Resident #36) reviewed for accidents. The findings included: Resident # 6 was admitted to the facility on [DATE]. Diagnosis included cerebral infarction with right side weakness, muscle weakness, unspecified dementia, and unsteady on feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was severely cognitively impaired, required partial to moderate assistance for transfers, walking not attempted due to safety, no falls prior to admission and one fall since admission with no injury. The incident report dated 1/28/25 revealed that an aide and nurse observed resident sitting on buttocks on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Dialysis Nurse, staff and physician interviews, the facility failed to maintain ongoing communication with the dialysis center and failed to consistently document assessments of the dialysis access site post dialysis including monitoring for bleeding, pain, and condition of skin for 1 of 1 resident reviewed for dialysis (Resident #53). The findings included: Resident #53 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD) and dependent on dialysis. A physician's order written on 11/12/24 revealed Resident #53 to receive dialysis on Monday, Wednesday, and Friday; check dialysis access site each shift for bruit (sound) and thrill (pulsation); assess site (left lower forearm) for bruising/symptoms of infection. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired and received dialysis services. Resident #53's active care plan dated 11/29/24 revealed a plan of care for requiring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility failed to disinfect a resident's dedicated glucometer according to manufacturer's guidelines for cleaning and disinfecting glucometers for 1 of 2 residents observed for infection control practices (Resident #69). The findings included: Review of the glucometers manual revealed only wipes with environmental protection agency (EPA) registration number listed in the tables could be used to clean the glucometers. Resident glucometers should be cleaned with EPA regulatory wipe once for cleaning followed by one wipe for disinfecting. Then allow the glucometer to dry for 3 minutes. The facility's infection control policy on disinfecting glucometer (Not Dated) included: 1. Wear appropriate protective gear such as disposable gloves. 2. Open the cap of disinfectant container and pull out 1 towelette to clean the meter and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette. Carefully wipe around the test strip port. 4. Properly dispose of the used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.