Wilora Lake Healthcare

In the surveyor’s words

From the most serious findings on record at Wilora Lake Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 23, 2021

  Based on record review, staff, Nurse Practitioner and physician interview, the facility failed to document blood glucose results for 1 of 3 residents reviewed for change of status (Resident #253). Resident #253 was admitted to the hospital 4/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Elevated blood glucose can contribute to dehydration, which resulted in Resident #253 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #253 was admitted to the facility 4/19/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF602Apr 24, 2026

  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… […]

• No harm, potential for more than minimal, patternF761Jun 23, 2022

  Based on observations, staff interviews and record review, the facility failed to discard expired medications for 2 of 3 medication carts (400 hall and 100 hall). Findings included: 1a. An observation on 6/21/22 at 9:12am of the medication cart on the 400 revealed three cards of [MEDICATION(S)] 500 mg(milligrams) (anticonvulsant) prescribed to Resident #33 with expiration dates of 9/30/21, 10/31/21, and 3/31/22. An interview with the Nurse #1 on 6/21/22 at 9:20am revealed that it was the nurse's responsibility to check the medication cart and discard expired medications. She further revealed she checked the medication cart before she started her medication pass, but somehow missed the expired medications. Nurse #1 revealed the medication was last given on 6/20/22. 1b. […]

• No harm, potential for more than minimal, patternF812Jun 23, 2022

  Based on observations, interviews and record review, the facility failed to maintain and serve a potentially hazardous cold food (milk) at least 41 degrees Fahrenheit (F) and remove expired yogurt from 1 of 3 nourishment refrigerators. Milk was placed on a meal cart for delivery to residents at 45.6 degrees F and yogurt for Resident #41 remained in refrigeration after its manufacturer expiration date. This failure had the potential to affect 9 of 62 residents. 1. A continuous observation of the lunch meal tray line occurred on [DATE] from 12:04 PM until 12:54 PM. A bin which contained 7, 8-ounce cartons of milk was stored on the bottom shelf of a cart, from 12:04 PM until 12:24 PM. At 12:24 PM, Dietary Aide (DA) #1 covered the milk with ice. […]

• No harm, potential for more than minimal, patternF563Jul 23, 2021

  Based on record review, family member interview, and staff interviews, the facility had imposed a schedule which determined not only limited visitation duration, but also limited the opportunity to visit to weekdays during a specified time period, and restricted visitation to supervised visits either outside of the facility in a courtyard or a supervised visit in a common area inside of the facility. This practice impacted a resident receiving hospice services for one of one resident reviewed for visitation (Resident #43). This deficiency was cited at a higher scope and severity, E, due to the potential to impact multiple residents beyond just the sampled resident, Resident #43. Findings included: Resident #43 was admitted to the facility on [DATE]. […]