A list of the most recent deficiencies for Geneva Lake Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-16 | 2024-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-16 | 2024-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-16 | 2024-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-16 | 2024-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-12 | 2022-10-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-12 | 2022-09-29 | N |
| 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. | Health | 2022-09-12 | 2022-09-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-12 | 2022-09-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-12 | 2022-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-12 | 2022-09-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-12 | 2022-09-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-12 | 2022-09-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-09-12 | 2022-09-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-12 | 2022-09-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-12 | 2022-09-29 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-12 | 2022-09-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-12 | 2022-09-29 | N |
| Keep all essential equipment working safely. | Health | 2022-09-12 | 2022-09-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-12 | 2022-09-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-09-08 | 2022-09-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-06-03 | 2021-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-03 | 2021-06-30 | N |
| 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. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-03 | 2021-06-30 | N |
| 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. | Health | 2021-06-03 | 2021-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-03 | 2021-06-30 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-01 | 2021-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-10 | 2021-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-07-11 | 2019-08-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-11 | 2019-08-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-11 | 2019-08-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-11 | 2019-08-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-11 | 2019-08-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-11 | 2019-08-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-11 | 2019-08-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-11 | 2019-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-11 | 2019-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-09 | 2019-08-11 | N |
