Golden Years of Lake Geneva

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one of five residents (Resident (R) 1) reviewed received his pain medications as ordered creating the potential for increased discomfort. Findings include: Review of the facility's 2024 policy titled, Pain Assessment and management revealed The care team will respect and support every patient's right to optimal pain relief through education, initial and ongoing assessment, and effective and appropriate pain management. Review of the Face Sheet located under the Demographics tab in the electronic medical record (EMR) revealed R1 was admitted on [DATE] with diagnoses including unilateral primary osteoarthritis, left knee; open wound of lower back and pelvis without penetration into retroperitoneum; non-pressure chronic ulcer of other part of right foot limited to breakdown of skin. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/06/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out…

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 interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150 B of the Act for 1 (R11) of 1 residents reviewed for an allegation of a crime. R11 alleged facility staff forced her to take a shower and slammed her into the wall. R11's allegation of abuse was not reported timely to local law enforcement. Findings include: R11 was admitted to the facility on [DATE] with diagnosis that included Anxiety disorder. R11's quarterly MDS (minimum data set) dated 1/15/24 indicates R11 was assessed as having a Brief Interview for Mental Status score of 13 which indicates R11 is cognitively intact. On 2/7/24, at 9:37 AM, R11 was interviewed by this Surveyor and reported a few days ago she was forced to take a shower against her will and was slammed into the wall. R11 indicated she would like the allegation reported right away and taken care of. On 2/7/24, at 9:45 AM, this Surveyor…

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 interview & record review, the Facility did not ensure that 1 (R11) of 1 resident alleged incidents of physical abuse was thoroughly investigated, and the results of the investigation reported to the State Agency. R11 alleged staff forced her to take a shower and slammed her into the wall. The allegation was not thoroughly investigated as all staff involved were not interviewed, a physical assessment was not completed for injuries and other residents were not interviewed to see if they had similar concerns. Findings include: R11 was admitted to the facility on [DATE] with diagnosis that included Anxiety disorder. R11's quarterly MDS (minimum data set) dated 1/15/24 indicate R11 was assessed as having a Brief Interview for Mental Status score of 13 which indicates R11 is cognitively intact. On 2/7/24, at 9:37 AM, Surveyor interviewed R11 who indicated a few days ago she was forced to take a shower against her will and was slammed into the wall. R11 indicated she would like the allegation reported right…

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, interview, and record review the Facility did not ensure that 1 (R134) of 1 Residents observed during medication pass with a gastronomy tube (G-tube) receives the appropriate treatment and services. R134's G-tube placement was not checked prior to administering medication via the G-tube. Findings include: R134 was admitted to the facility on [DATE] with diagnosis that included Dysphasia. On 2/7/24, at 7:45 AM, Registered Nurse (RN)-C was observed administering medication to R134. RN-C prepared the medication then flushed R134's gastronomy tube with water. RN-C-then administered R134's medication one at a time flushing the tube with water between each medication and after the administration was complete. Immediately after the observation RN-C was interviewed and indicated it is the facility's policy not to check gastronomy tube placement by any means before administration of medication or feeding formula. On 2/7/24, Surveyor reviewed the Facility's policy and procedure titled: Tube Feeding…

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 interview, observation and record review, the facility did not ensure that a resident with a deep tissue injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new deep tissue injuries from developing for 1 (R6) of 4 residents reviewed for pressure injuries. R6 developed a deep tissue injury and the facility did not implement an intervention put in place to promote healing. Findings include: The facility policy, entitled Pressure Ulcer Treatment, dated 2020, states: A. To promote tissue healing. B. To prevent further tissue breakdown by relieving pressure, reducing friction and shear, correcting or containing incontinence, improving nutritional status, and educating resident and/or significant other. C. Follow established treatment program focused on assessment of resident and pressure ulcer. Section B: Plan: 1. Reduce or eliminate causative factors: pressure, shear, friction, moisture, circulatory…

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, interview, and record review the Facility did not ensure that 1 (R19) of 1 Residents observed during medication pass with a gastrostomy tube (G-tube) receives the appropriate treatment and services. R19's G-tube placement was not checked prior to administering medication via the G-tube. Findings include: R19 was admitted to the facility on [DATE] with diagnosis that included Cancer of the tonsils and thyroid gland as well as Dysphasia On 11/10/22 the facilities policy and procedure titled Tube Feeding dated 2018 was reviewed and read: Assess tube placement by aspirating stomach contents. The policy does not say how often placement should be checked. On 11/9/22 at 11:37 AM the surveyor observed Registered Nurse (RN)-G administer medication to R19's G-tube. RN-G flushed R19's G-Tube to which no tube feeding was running prior and then administered 50 milligrams of liquid Vancomycin via R19's G-tube. RN-G then flushed R19's G-Tube with more water and hooked her up to her feeding pump. RN-G did…

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 interview, the facility did not ensure residents received their medications. This was discovered with 2 (R3 and R16) of 4 residents that did not receive their medication as ordered. R3 and R4 had medications that were not administered to them as ordered. Findings include: The facility's policy and procedure for Medications, dated 1/2018, was reviewed by Surveyor. The procedure includes: Identify resident by name before administration and observe that all medications are taken. 1.) R3's medical record was reviewed. The Progress Note on 11/01/2022 at 5:40 AM indicates the Writer found a cup of medications in resident medication cabinet containing the following: - one acetaminophen 325 mg(milligram) tablet - two Seroquel 25 mg tabs - one 2 mg loperamide tab - one 5-325 mg Norco The DON-B (Director of Nurses) was notified. R3 takes these medications twice a day and therefore hard to determine which shift the error occurred on. R3 was admitted on Hospice care on 5/8/22…

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 interview, the facility did not ensure psychotropic PRN (as needed) medication had indications for long term use. This was discovered with 2 (R3 and R2) of 4 residents reviewed for medication. R3 and R2 have received PRN Ativan beyond 14 days without indications for use to continue. Findings include: The facility's policy and procedure for Use of Psychotropic Medications/Psychotropic Medication Reviews, dated 1/2018, was reviewed by Surveyor. The policy indicates: The goal of the facility is to make every effort to practice according to current medical guidelines and best practices related to the use of psychopharmacological medications in the long term care facility, to include regular reviews, continued need, appropriate dosage, side effects and risks and benefits. 1.) R3's medical record was reviewed by Surveyor. R3 was admitted on Hospice care on 5/8/22 for Dementia. R3 has an activated POA (Power of Attorney). R3 had a Quarterly MDS (minimum data set) assessment on 9/2/22…

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, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R18) of 5 residents observed. Two medication errors were observed out of thirty-one opportunities, for a total error rate of 6.45%. * R18 was administered Potassium Chloride Extended Release 10 Millequivalents (MEQ) extended release and Sublingual (under the tongue) Vitamin B12 1,000 milligrams (MG) crushed when they should not have been. Findings include: On 11/10/22 the website Drugs.com was reviewed for instructions on how to take Potassium Chloride extended release and read: Do not crush, chew, break, or suck on an extended-release tablet or capsule. Swallow the pill whole. Breaking or crushing the pill may cause too much of the drug to be released at one time. On 11/10/22 the website Drugs.com was reviewed for instructions on how to take sublingual vitamin B12 and read: Place under tongue and let dissolve all…

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.