Golden Years of Lake Geneva

In the surveyor’s words

From the most serious findings on record at Golden Years of Lake Geneva, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 28, 2021

  Based on observation, interview and record review, the facility did not ensure residents with pressure injuries were comprehensively assessed to determine appropriate treatment and interventions. This was observed with 2 (R7 and R24) of 3 residents reviewed with pressure injuries. - R7 developed multiple pressure injures that were not comprehensively assessed to determine changes in treatment and interventions. R7's care plan interventions were not revised and R7's physician was not notified when there was a deterioration to the right posterior heel pressure injury. R7 was observed on 9/22/21 and 9/27/21 sitting up in her recliner. […]

• No harm, potential for more than minimal, patternF689Sep 28, 2021

  Based on interview and record review, the facility did not ensure that 4 of 5 residents reviewed for falls (R4, R22, R24, and R9) received adequate supervision and assistance devices to prevent accidents. R4 had a fall on 8/1/21. The facility did not implement recommended changes following the fall. On 9/2/21 R4 had a fall and was sent to the hospital for evaluation. R4 returned to the facility with a with a large hematoma above her right eye that was bleeding and R4 was unable to see out of her right eye. The facility did not identify interventions, implement interventions, and update the care plan to prevent further falls for R4. R22 had a fall. […]

• No harm, potential for more than minimal, isolatedF755Jan 9, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF609Feb 8, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF610Feb 8, 2024

  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. […]