Lake Geneva, WI

Geneva Lake Manor

1-star overall rating with 1-star inspections with $201,107 in total fines with 29 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

211 S Curtis St, Lake Geneva, WI

(262) 248-3145

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Wisconsin Illinois Senior Housing, Inc.

Operator or chain grouping

Approved since

1995-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 2 overall / 2 health / 4 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing · state 0.97 · national 0.68

LPN hours / resident day

1.17

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

3.23

Nurse aide staffing · state 2.59 · national 2.35

Total nurse hours

4.95

All reported nurse hours · state 4.20 · national 3.89

Licensed hours

1.72

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

4.30

Weekend nurse staffing · state 3.72 · national 3.43

Weekend RN hours

0.29

Weekend registered nurse coverage · state 0.66 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

5.22

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

79%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

74%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,356

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.90

Composite VBP score used to determine payment impact.

Payment multiplier

0.9833

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.35% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

6.63

Baseline 5.93% · Performance 5.85% · Measure score 6.63 · Achievement 6.63 · Improvement 0.34

Total nurse turnover

Baseline 44.23% · Performance 74.03% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.93

Baseline 3.76 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 0.24

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.41%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 177 · Observed rate 14.69% · Lower 95% interval 9.34%
Discharge to community	64.77%	50.57% 14.2 pts better	Better than the National Rate · Eligible stays 132 · Observed rate 62.88% · Lower 95% interval 56.57%
Medicare spending per beneficiary	0.69	1.02 0.3 pts better
Drug regimen review with follow-up	97.73%	95.27% 2.5 pts better	Numerator 86 · Denominator 88
Falls with major injury	1.14%	0.77% 0.4 pts worse	Numerator 1 · Denominator 88
Discharge self-care score	50.75%	53.69% 2.9 pts worse	Numerator 34 · Denominator 67
Discharge mobility score	41.79%	50.94% 9.1 pts worse	Numerator 28 · Denominator 67
Pressure ulcers or injuries, new or worsened	4.55%	2.29% 2.3 pts worse	Numerator 4 · Denominator 88 · Adjusted rate 4.61%
Healthcare-associated infections requiring hospitalization	5.85%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 90 · Observed rate 3.33% · Lower 95% interval 3.34%
Staff COVID-19 vaccination coverage	19.15%	8.2% 10.9 pts better	Numerator 18 · Denominator 94
Staff flu vaccination coverage	26.8%	42% 15.2 pts worse	Numerator 41 · Denominator 153
Discharge function score	46.27%	56.45% 10.2 pts worse	Numerator 31 · Denominator 67
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 28 · Denominator 28
Transfer of health information to patient	94.74%	96.28% 1.5 pts worse	Numerator 36 · Denominator 38
Resident COVID-19 vaccinations up to date	31.91%	25.2% 6.7 pts better	Numerator 15 · Denominator 47

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	1.6 0.3 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	2.2 0.7 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.7%	95.7% 1 pts worse	93.4% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 94.9% · Q3 91.9% · Q4 97.3% · 4Q avg 94.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	86.4%	95.0% 8.6 pts worse	95.5% 9.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4%
Percentage of long-stay residents experiencing one or more falls with major injury	3.3%	3.2% 0.1 pts worse	3.3% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 5.4% · Q4 5.4% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.8%	5.0% 0.2 pts better	11.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.2% · Q4 7.7% · 4Q avg 4.8%
Percentage of long-stay residents who lose too much weight	11.1%	4.9% 6.2 pts worse	5.4% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 11.8% · Q3 3.2% · Q4 6.9% · 4Q avg 11.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.2%	16.6% 3.6 pts worse	19.6% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.1% · Q3 21.9% · Q4 16.7% · 4Q avg 20.2%
Percentage of long-stay residents who received an antipsychotic medication	13.6%	16.7% 3.1 pts better	16.7% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.7% · Q3 20.8% · Q4 12.5% · 4Q avg 13.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	15.2%	21.1% 5.9 pts better	16.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.4%	17.3% 9.9 pts better	14.9% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 3.0% · Q3 0.0% · Q4 6.9% · 4Q avg 7.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	2.3% 0.8 pts better	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.7%	3.0% 1.7 pts worse	1.7% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	7.3%	25.5% 18.2 pts better	19.8% 12.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 10.2% · Q3 9.3% · Q4 2.9% · 4Q avg 7.3%
Percentage of long-stay residents with pressure ulcers	6.6%	5.5% 1.1 pts worse	5.1% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.5% · Q3 5.1% · Q4 7.0% · 4Q avg 6.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.0%	86.8% 9.8 pts worse	81.7% 4.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 72.3% · Q3 71.2% · Q4 82.4% · 4Q avg 77.0%
Percentage of short-stay residents who had an outpatient emergency department visit	24.2%	15.0% 9.2 pts worse	12.0% 12.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.4% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	58.1%	82.2% 24.1 pts worse	79.7% 21.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 58.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.6%	22.7% 4.9 pts worse	23.9% 3.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 26.0% · Expected 22.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-17 · Fire 2025-03-17

29 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

9 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2024-01-16 · Fire 2024-01-16

27 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-09-12 · Fire 2022-09-12

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-03-17

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2025-04-09

F · Potential for more than minimal harm 2025-03-17

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-04-10

F · Potential for more than minimal harm 2025-03-17

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-04-17

F · Potential for more than minimal harm 2025-03-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-15

F · Potential for more than minimal harm 2025-03-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-16

E · Potential for more than minimal harm 2025-03-17

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-04-07

E · Potential for more than minimal harm 2025-03-17

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-03-17

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-03-17

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2025-04-14

F · Potential for more than minimal harm 2024-01-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-02-14

F · Potential for more than minimal harm 2024-01-16

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-02-14

F · Potential for more than minimal harm 2024-01-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-14

F · Potential for more than minimal harm 2024-01-16

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-02-14

C · Minimal harm 2024-01-16

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-02-14

C · Minimal harm 2024-01-16

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-02-14

F · Potential for more than minimal harm 2022-09-12

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-09-28

E · Potential for more than minimal harm 2022-09-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-09-28

E · Potential for more than minimal harm 2022-09-12

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-09-28

E · Potential for more than minimal harm 2022-09-12

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2022-09-28

E · Potential for more than minimal harm 2022-09-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-09-28

E · Potential for more than minimal harm 2022-09-12

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2022-09-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-10

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-12-10

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-12-10

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-12-10

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-12-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-12-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-10

J · Immediate jeopardy 2025-11-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-01

E · Potential for more than minimal harm 2025-11-06

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2025-12-01

E · Potential for more than minimal harm 2025-11-06

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-12-01

H · Actual harm 2025-03-17

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-11

G · Actual harm 2025-03-17

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2025-04-11

F · Potential for more than minimal harm 2025-03-17

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-04-11

F · Potential for more than minimal harm 2025-03-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-11

F · Potential for more than minimal harm 2025-03-17

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-03-17

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-03-17

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-03-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F698 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-03-17

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-11

C · Minimal harm 2025-03-17

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-04-11

J · Immediate jeopardy 2024-11-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-12-06

E · Potential for more than minimal harm 2024-11-12

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F551 · Resident Rights Deficiencies

Health

Give the resident's representative the ability to exercise the resident's rights.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-06

D · Potential for more than minimal harm 2024-11-12

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-06

G · Actual harm 2024-01-16

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-02-14

F · Potential for more than minimal harm 2024-01-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-02-14

E · Potential for more than minimal harm 2024-01-16

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-02-14