Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Troy Manor during CMS and state inspections, most recent first.
A CNA verbally abused a resident with dementia and schizophrenia by using loud, harsh, and profane language during personal care, despite the resident's care plan calling for a calm approach. The incident was witnessed by two other CNAs, who reported that the abusive language continued even after the resident was on the floor and visibly distressed. Staff interviews confirmed the behavior as verbal abuse, and it was noted that the CNA had a history of complaints regarding their demeanor.
A resident with dementia and schizophrenia was subjected to verbal abuse by a CNA, who was witnessed by two other CNAs using demeaning and profane language during care. The witnesses documented the incident in writing but did not immediately report it to the charge nurse or administration, resulting in a significant delay before the event was discovered and reported to the State Agency, contrary to facility policy and regulatory requirements.
A facility failed to promptly and thoroughly investigate an incident where a CNA was reported by two CNAs to have used demeaning and abusive language toward a resident with dementia and schizophrenia. The administrator did not discover the written reports until two days later, during which time the accused CNA continued to work with the resident and others. Required interviews with involved staff, the resident, and other residents were not conducted, and the investigation did not follow facility policy.
The facility was found deficient in providing food items at a safe and appetizing temperature, as determined through observation, interview, and record review. With a census of 87 residents, the facility did not meet the required standards for food safety and quality.
A resident with impaired cognition and behavioral disturbances caused harm to three other residents, resulting in injuries, including a shoulder fracture. Despite known behavioral issues, the facility's interventions were insufficient, leading to repeated incidents of abuse. Staff interviews confirmed the resident's aggressive behavior and the facility's failure to prevent harm.
The facility failed to provide hot water in resident rooms on the 200 hall, affecting at least two residents who required incontinence care. Staff reported the issue had persisted for two to three months, with water temperatures below the expected range. The maintenance director noted that the 100 and 200 halls shared a water heater, complicating temperature adjustments. The administrator and DON were unaware of the problem's extent until the survey.
The facility failed to serve food at safe and appetizing temperatures, as multiple residents reported receiving cold meals. Observations and temperature logs confirmed that food temperatures were below the required levels, with some items as low as 86 degrees Fahrenheit. The Dietary Manager was unaware of complaints and acknowledged issues with maintaining food temperatures, partly due to cold items being plated with hot items.
The facility failed to ensure proper infection control procedures during resident care, as staff did not wash hands or change gloves when soiled while assisting two residents with incontinence care. This led to handling clean items and areas with contaminated gloves, compromising infection control standards.
The facility failed to treat residents with dignity and respect, as evidenced by two incidents. A resident with legal blindness and dementia reported being handled roughly by an unknown staff member, causing pain and fear. Another resident with severely impaired cognition was frightened when a CNA yelled at them during care. These incidents were reported to the ADON and DON, who emphasized the importance of treating residents with dignity.
A resident with legal blindness and dementia alleged that a staff member yanked them out of their chair, causing pain and fear. This incident was witnessed by another resident and reported to the ADON and CMT, who informed the DON. However, the allegation was not reported to the administrator or state agency within the required timeframe, violating the facility's abuse reporting policy.
A resident with legal blindness and dementia reported being roughly handled by an unknown staff member, causing pain and fear. The incident was corroborated by the resident's roommate, who described the staff member's appearance. Despite these reports, the facility did not conduct a thorough investigation as required by their policy, failing to interview all relevant staff and provide a completed investigation form.
A resident with Alzheimer's and arm pain was improperly repositioned by staff using their arms under the resident's armpits, contrary to facility policy. This caused the resident discomfort and was due to a lack of proper training, as confirmed by interviews with the CNA, NA, and facility administrators.
The facility failed to follow proper infection control techniques for five residents, including improper sanitization of a glucometer used for blood glucose monitoring and inadequate hand hygiene and glove use during incontinence care. These actions increased the risk of cross-contamination and infection spread among residents.
The facility failed to respect and facilitate resident self-determination and choice regarding wake-up times. Staff were observed waking and dressing residents early in the morning based on a predetermined get-up list, without considering the residents' preferences. This practice affected several residents, including those with cognitive impairments, and was acknowledged by the DON as inappropriate.
The facility failed to provide necessary assistance with ADLs and oral hygiene for five residents, resulting in poor hygiene and unmet care needs. Observations revealed residents with unkempt hair, urine-soaked bedding, and poor oral hygiene, despite care plans indicating the need for substantial assistance.
The facility failed to provide an ongoing program of meaningful activities to meet the interests and well-being of residents. Several residents, including those with severe cognitive impairments and physical disabilities, were observed without engagement in scheduled activities. Staffing issues were cited as the primary reason for the lack of activities.
The facility failed to ensure the safety of six residents by not following care plan interventions for fall prevention, proper footwear, and the use of fall mats. Staff also failed to ensure residents were transported safely in their wheelchairs by not placing foot pedals on the wheelchairs prior to transport. Additionally, the facility did not prevent an elopement incident involving a resident who left the facility without approval and was found approximately one mile away. The facility also failed to protect two residents from another resident with a history of verbal and physical aggression.
The facility failed to assess the need for bed rail use and obtain informed consent for three residents before installing and using bed rails. Observations and interviews revealed that bed rail assessments and consents were not documented as required, despite the residents' medical conditions and care plans indicating the need for such assessments.
The facility failed to ensure adequate staffing on the SCU, leading to residents being left unattended and incidents such as a verbal altercation and a near fall. Staff expressed concerns about insufficient monitoring, and the facility lacked a clear staffing policy, resulting in significant deficiencies.
The facility failed to ensure that three nurse aides completed their CNA training within four months of employment. Despite not being certified, these aides continued to work, with delays attributed to testing issues and lack of policy guidance.
The facility failed to ensure proper food storage and cleanliness, with scoops stored inside bulk containers, unsealed food items, a buildup of debris in the exhaust vent, and damaged microwaves. Staff interviews revealed a lack of adherence to cleaning and maintenance protocols.
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails for three residents, leading to potential entrapment risks. Despite the residents' varying levels of cognitive impairment and dependence on assistive devices, there was no evidence of recent inspections in their medical records. The Administrator confirmed that these assessments were supposed to be done quarterly by the DON or management team.
The facility failed to ensure call lights were within reach for two residents, one of whom had contracted hands and could not use a traditional call light. Despite being cognitively intact and dependent on staff for mobility, the residents were observed multiple times with call lights on the floor out of reach, leading to long waits for assistance.
A facility failed to develop a comprehensive care plan for a resident with dementia and depression. The resident's frequent tearfulness, rejection of care, and use of antidepressants were not documented in the care plan, despite severe cognitive impairment and ongoing distress. Staff were unaware of the resident's behaviors and medication needs.
The facility failed to obtain orders for oxygen use and maintain equipment according to policy for two residents. One resident with heart failure had no physician orders for oxygen therapy, and staff did not consistently monitor or maintain oxygen levels. Another resident required weekly changes of oxygen tubing, but observations showed outdated tubing in use. The Director of Nursing confirmed the facility's policies were not followed.
A resident with severe cognitive impairment and insomnia received an incorrect dose of trazodone for ten days due to a transcription error. The new order to increase the dosage was not properly updated in the system, and the old medication card was not removed from the cart, leading to the continued administration of the incorrect dose.
The facility failed to ensure that residents on a pureed diet received food in the proper form as per their physician's orders. Observations showed that pureed corn and potatoes were served with visible chunks and no gravy, contrary to the facility's policy and diet spreadsheet menu. The Dietary Manager confirmed that pureed food should be smooth and pudding thick.
The facility failed to notify three residents or their representatives in writing of their transfer to the hospital, including the reasons for the transfer. Additionally, the facility did not send a copy of the transfer notice to a representative of the Office of State Long-Term Care Ombudsman. Interviews revealed a lack of awareness and adherence to the facility's policy on Discharge/Transfer of Resident.
The facility failed to provide written bed hold notices to residents and/or their representatives during hospital transfers. Three residents were transferred without receiving the required bed hold policy documentation. Interviews revealed that the Social Services Director was unaware of the follow-up requirement, and the administrator confirmed the lack of documentation.
Verbal Abuse of Resident by CNA on Dementia Unit
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) used derogatory and abusive language toward a resident on the dementia care unit. The resident, who had diagnoses including schizophrenia and unspecified dementia, was dependent on staff for personal hygiene and required substantial to maximal assistance for mobility. The resident's care plan indicated behavioral symptoms and recommended a calm, slow, and understandable approach, but did not document any history of aggressive behaviors toward staff, aside from occasional refusal of medications. On the day of the incident, the CNA attempted to change the resident's incontinence brief. The resident yelled and refused care, at which point the CNA responded with loud, harsh, and profane language directed at the resident, including calling the resident a "fucking bitch" and a "fucking witch." These actions were witnessed by two other CNAs, who reported that the CNA continued to use abusive language even after the resident was on the floor by the bed. The resident did not appear hurt, but was visibly distressed and accused the CNA of being a "monster" and causing harm. Interviews with staff confirmed that the CNA's behavior was considered verbal abuse and that the resident did not typically display aggression toward staff. The CNA involved had previously been counseled for speaking gruffly to others, and both staff and residents had made complaints about the CNA's demeanor in the past. The incident was reported to the administrator, who initiated an investigation after receiving written statements from the witnesses.
Failure to Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
A staff-to-resident verbal abuse incident occurred involving a resident with schizophrenia and unspecified dementia, who was dependent on staff for personal hygiene and required substantial to maximal assistance for mobility. During care, a CNA was witnessed by two other CNAs yelling and using demeaning, derogatory, and profane language directed at the resident. The incident was observed by the two CNAs, who documented the event in written statements but did not immediately report the abuse to the charge nurse on duty. The written statements were left under the doors of the administrator and DON, but were not discovered until approximately two days after the incident. During this period, the alleged perpetrator continued to work and had further contact with the resident. The charge nurse on duty did not receive a direct report of the abuse, and other staff members who were aware of the written statements did not inquire further or escalate the report to administration as required by facility policy. Facility policy and federal and state regulations require that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in bodily injury. In this case, the delay in reporting resulted in the State Agency not being notified until at least 40 hours after the occurrence of the alleged abuse. The failure to follow established reporting protocols led to a deficiency finding during the survey.
Failure to Timely and Thoroughly Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into a reported incident of verbal abuse involving a resident with schizophrenia and unspecified dementia. Two CNAs witnessed another CNA using demeaning and derogatory language, including cursing, while providing personal care to the resident. The CNAs documented the incident and submitted written statements by placing them under the administrator and DON's door. However, the administrator did not discover these statements until two days later, resulting in a delay in initiating the investigation. During this period, the accused CNA continued to work on the dementia unit and had ongoing contact with the resident and others. Upon review, it was found that the administrator did not follow the facility's abuse investigation policy, which required immediate initiation of an investigation, interviews with all involved staff, attempts to interview the resident, and interviews with other residents who had received care from the accused staff member. The administrator did not interview the involved CNAs after reading their statements, did not attempt to interview the resident or other residents on the unit, and did not interview other staff who may have had relevant information. The DON was unaware of the incident until returning from vacation, and some staff were not immediately in-serviced on abuse and neglect following the event. The resident involved was dependent on staff for personal hygiene and mobility, had moderate hearing difficulty, and was rarely understood, according to the most recent MDS. The incident was witnessed by two CNAs, who reported that the accused CNA used harsh and abusive language multiple times. Despite these reports, the facility's response was delayed and incomplete, failing to meet its own policies for abuse investigation and resident protection.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature. This deficiency was identified through observation, interview, and record review. The facility had a census of 87 residents at the time of the survey. The report does not provide specific details about the residents affected or the exact nature of the temperature issues, but it highlights a general failure in maintaining food safety and quality standards.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with severely impaired cognition and behavioral disturbances. This resident physically harmed three other residents, resulting in significant injuries. The incidents included pulling a resident out of a wheelchair, causing a left shoulder fracture, hitting another resident in the face, and grabbing a third resident's arm, causing pain. These actions were documented in the resident's progress notes and were observed by staff members. The resident involved in these incidents had a history of behavioral issues, including agitation and aggression, as noted in their care plan. Despite this, the facility's interventions were insufficient to prevent harm to other residents. The care plan included behavior monitoring and interventions to prevent harm, but these measures were not effectively implemented, leading to repeated incidents of abuse. Interviews with staff members revealed that the resident's aggressive behavior was known, and there were attempts to manage it through medication and monitoring. However, the staff's inability to consistently supervise and intervene allowed the resident to continue causing harm. The Director of Nursing and the Administrator acknowledged that the incidents constituted resident-to-resident abuse, highlighting a failure in the facility's responsibility to ensure a safe environment for all residents.
Failure to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to ensure that residents on the 200 hall had access to hot water in their rooms, affecting at least two residents. Resident #9's care plan indicated the need for routine and as-needed perineal care due to incontinence. However, during an observation, a CNA informed the resident that there was no hot water, and the water used for care was cold. The CNA mentioned that the 200 hall had been without hot water for two to three months, and they had to obtain warm water from another hall. The water temperature in Resident #9's room was measured at 90.1 degrees Fahrenheit, below the expected range of 105-120 degrees Fahrenheit. Similarly, Resident #13, who required incontinence care after each episode, experienced cold water during care, which was bothersome. The water temperature in their room was recorded at 97.1 degrees Fahrenheit. The maintenance director acknowledged the issue, stating that the 100 and 200 halls shared a water heater, and adjusting it for the 200 hall would make the 100 hall's water too hot. Despite complaints from staff, the administrator and DON were unaware of the extent of the issue, with the administrator only learning about it on the day of the interview.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. The facility's policy requires hot food to be at least 120 degrees Fahrenheit when served to residents. However, multiple residents who ate in their rooms reported that their food was consistently cold. Temperature logs and observations confirmed that food temperatures were below the required levels, with recorded temperatures as low as 86 degrees Fahrenheit for soup and 90 degrees Fahrenheit for a hot dog. The Dietary Manager was unaware of resident complaints and acknowledged that the temperature of food decreases once plated and sent to residents' rooms. The Dietary Manager also noted that the cold salad plated with hot items likely contributed to the reduced temperature of the hot food. Despite the facility's policy, the Dietary Manager admitted that the plate warmer was not maintaining the desired temperature, as kitchen staff found the plates too hot to handle. The administrator was also unaware of any resident complaints regarding cold food, although the expectation was that food should be served at an appropriate and appetizing temperature.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during resident care, specifically in handwashing and glove use. For Resident #9, the care plan indicated bladder incontinence and required toileting assistance. During an observation, CNA C and NA D performed incontinent care without washing hands before or after the procedure. They also failed to change gloves after they became soiled with urine and feces, and continued to handle clean items and assist the resident with soiled gloves. Similarly, for Resident #10, who also required assistance due to bladder and bowel incontinence, NA J and CNA K did not adhere to proper infection control protocols. They performed perineal care without changing gloves or washing hands between tasks. They touched the resident's clean areas and items with soiled gloves, further compromising infection control standards. Interviews with the involved staff and the Director of Nursing confirmed the lapses in infection control practices. Staff acknowledged the need for handwashing before and after care, and the necessity of changing gloves when soiled. The Director of Nursing reiterated the expectation for staff to follow these protocols, highlighting the importance of changing gloves and washing hands after perineal care and before touching clean areas or items.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect, as evidenced by incidents involving two residents. Resident #4, who has legal blindness and dementia, reported that an unknown staff member entered their room without speaking, pulled back the covers, and yanked on their arm, causing pain and fear. This incident was corroborated by Resident #4's roommate, who reported the rough treatment to a Certified Medication Technician (CMT) B. The CMT reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). In another incident, Resident #8, who has severely impaired cognition, was subjected to verbal aggression by a Certified Nurse Assistant (CNA) F. The CNA yelled the resident's name angrily during a care routine, which frightened the resident. A Nurse Assistant (NA) G witnessed the incident and intervened by asking CNA F to leave the room. The resident later confirmed that CNA F's behavior was frightening. The ADON was unaware of this incident, but the DON acknowledged that staff should not yell at residents and emphasized the importance of treating residents with dignity and respect.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a staff-to-resident allegation of abuse to the state agency as required by their policy. On the morning of September 30, 2024, Resident #4, who has legal blindness and unspecified dementia, alleged that an unknown staff member yanked them out of their chair and rushed them around, causing pain and fear. This incident was witnessed and reported by Resident #12, who described the staff member as a short, blonde-haired individual with a ponytail. Both residents reported the incident to the Assistant Director of Nursing (ADON) and Certified Medication Technician (CMT) B, who then informed the Director of Nursing (DON). However, neither the ADON nor the DON reported the allegation to the administrator or the state agency within the required timeframe. The facility's policy mandates that all alleged violations involving abuse or mistreatment be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in bodily injury. Despite this, the DON did not report the incident, as she believed the resident's statement only indicated that they had been rushed, not that they had been yanked. The DON had not spoken with either Resident #4 or Resident #12 and did not inform the administrator of the incident. The administrator was unaware of the situation and expected that staff would have reported any issues to her. The failure to report the allegation of abuse within the required timeframe constitutes a deficiency in the facility's adherence to its abuse reporting guidelines. The administrator acknowledged that an allegation of yanking on a resident's arm would be considered abuse and should have been reported to the state agency within two hours. This oversight highlights a breakdown in communication and adherence to established protocols for reporting suspected abuse within the facility.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with legal blindness and unspecified dementia. The resident reported that an unknown staff member entered their room early in the morning, pulled back the covers, and yanked on their arm, causing pain and fear. The resident could not identify the staff member due to their impaired vision. The incident was documented in a statement initialed by the resident, and the resident's care plan noted the report of a Certified Nurse Assistant (CNA) being disrespectful and rough. Another resident, who was the roommate of the affected resident, corroborated the incident. This resident reported that a short, blonde-haired staff member entered the room, stated they were running late, and then roughly pulled the affected resident out of bed. This account was documented in a statement signed by the roommate. The roommate reported the incident to the Assistant Director of Nursing (ADON), who then informed the Director of Nursing (DON). Despite these reports, the facility did not conduct a thorough investigation as required by their policy. The facility failed to provide a completed investigation form with the necessary elements, such as interviews with all relevant staff and documentation of findings. The DON and Administrator, who were responsible for investigating abuse allegations, did not suspend any staff pending investigation and did not interview all potential witnesses, including night aides and the night nurse. The facility did not provide the state agency with an investigation within five working days of the incident.
Improper Repositioning Technique Causes Resident Discomfort
Penalty
Summary
The facility failed to ensure proper repositioning of a resident, identified as Resident #9, which led to discomfort and potential harm. Resident #9, who has diagnoses including pain in the right arm and Alzheimer's disease, was observed being repositioned in bed by a CNA and a NA. The staff members stood on opposite sides of the bed and pulled the resident up by placing their arms under the resident's armpits, contrary to the facility's policy which requires the use of a draw sheet and two staff members to lift the resident. This improper technique was confirmed by the resident, who reported shoulder pain and discomfort from being pulled up by the arms. Interviews with the staff involved revealed a lack of proper training and understanding of the correct repositioning techniques. CNA C admitted to using the method of locking arms with the resident to pull them up, while NA D was unsure of what a draw sheet was and had been taught to reposition residents by placing arms under the resident's arms. The Director of Therapy and the Director of Nursing both stated that the correct method involves using a pad or draw sheet, and not lifting under the arms due to the risk of causing pain. The Administrator also confirmed that the expected practice is to use a draw sheet for repositioning.
Infection Control Deficiencies in Blood Glucose Monitoring and Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed for five residents in a sample of 23. Specifically, the staff did not appropriately sanitize the glucometer machine after use, which was used for blood glucose monitoring. This failure was observed with Resident #27 and #29, where the glucometer was cleaned with an alcohol wipe instead of the required bleach wipes. Resident #29 had Hepatitis C, and the same improperly disinfected glucometer was used on Resident #59, posing a risk of cross-contamination. The facility identified that this multi-resident use glucometer was utilized for five residents on the 300 hall, including Resident #29, #59, #501, #502, and #503. The staff's improper cleaning practices were based on outdated training and incorrect instructions provided by the facility, despite the availability of proper disinfectant wipes. Additionally, the facility's policy and CDC guidelines were not followed, which required the use of EPA-registered disinfectants and adherence to manufacturer guidelines for cleaning and disinfecting glucometers between uses. The staff's actions were contrary to these guidelines, leading to potential exposure to bloodborne pathogens for multiple residents. The facility also failed to use appropriate infection control procedures for hand hygiene and changing gloves during incontinence care for two residents, Resident #12 and #27. Observations showed that staff did not perform hand hygiene or change gloves when moving from dirty to clean tasks, such as cleaning the resident's perineal area and then handling clean linens and clothing. This lack of proper hand hygiene and glove use increased the risk of spreading bacteria and other infection-causing contaminants. The staff's actions were inconsistent with the facility's policy on standard and transmission-based precautions, which required handwashing and changing gloves to prevent cross-contamination. Interviews with staff, including the LPN and DON, revealed a lack of awareness and adherence to proper infection control practices. The LPN admitted to using alcohol wipes based on outdated training, and the DON acknowledged that bleach wipes were the appropriate disinfectant but were not being used. The facility's failure to ensure proper training and adherence to infection control policies contributed to the deficiencies observed. The administrator and DON were unaware of the specific residents with bloodborne viruses and the need for individualized glucometers, further highlighting the gaps in infection control practices and oversight within the facility.
Failure to Respect Resident Wake-Up Preferences
Penalty
Summary
The facility failed to respect and facilitate resident self-determination and choice, particularly regarding wake-up times, for several residents. Staff were observed waking and dressing residents early in the morning based on a predetermined get-up list, without considering the residents' preferences. This practice was noted for four residents (Residents #6, #34, #58, and #70) who were cognitively impaired and dependent on staff for assistance with activities of daily living, as well as one additional resident (Resident #89) who was also cognitively impaired. The facility's policy for resident rights emphasized the importance of respecting residents' dignity and individuality, yet this was not reflected in the observed practices. For instance, Resident #34, who had Alzheimer's disease and other cognitive impairments, was woken up at 5:15 A.M. by a nurse aide who turned on the light and dressed the resident while they remained mostly unresponsive. Similarly, Resident #89, who had severe cognitive impairment, was told it was time to get up at 5:30 A.M. despite expressing a preference for not waking up so early. Resident #70, who was cognitively intact but dependent on staff for mobility and dressing, reported being woken up at 5:00 A.M. daily, despite preferring to sleep until closer to 8:00 A.M. Resident #58, who had moderate cognitive impairment, was also observed being dressed and moved to the dining room early in the morning against their preference. The Director of Nursing acknowledged that residents' rights regarding wake-up times should be honored and that 4:30 A.M. was too early for staff to start waking residents for breakfast. Despite this acknowledgment, the facility's practices did not align with the stated policies and residents' preferences, leading to a failure in creating an environment respectful of the residents' rights to make choices about significant aspects of their lives.
Failure to Provide Adequate ADL Assistance and Oral Hygiene
Penalty
Summary
The facility failed to ensure that five residents who required assistance with activities of daily living (ADL) received the necessary support. Resident #28, who had diagnoses including urinary tract infection, overactive bladder, and panic disorder, was found to have received inadequate assistance with showering and toileting. The resident's shower records showed significant gaps, with no documentation of showers for extended periods. Observations revealed the resident lying in urine-soaked bedding and with greasy, unkempt hair. The resident reported not having had a shower for two weeks and that staff did not assist with sponge baths, leading to distress and discomfort. Resident #4, diagnosed with schizophrenia and dementia, required supervision for oral hygiene but was observed with poor oral hygiene, including missing and broken teeth. Staff failed to provide oral care before meals, and the resident's care plan did not address dental status or assistance needed for dental care. Similar issues were observed with Resident #34, who had Alzheimer's disease and dementia, and Resident #27, who had dementia. Both residents required assistance with oral hygiene but were not provided with the necessary care, resulting in poor oral hygiene and unaddressed dental needs. Resident #1, with severe intellectual disabilities, dysphagia, and quadriplegia, was dependent on staff for oral hygiene. Observations showed the resident with dry, cracked lips, plaque-covered teeth, and uncombed hair. Despite the care plan indicating the need for frequent oral care, staff did not provide the required assistance. Interviews with staff, including the Director of Nursing, confirmed that the expected care routines were not followed, leading to the deficiencies observed in the residents' care.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of several residents. Specifically, the facility did not adhere to its own activity schedule, and there were significant lapses in the provision of activities for residents in both the general population and the special care unit (SCU). For instance, Resident #1, who had severe intellectual disabilities and quadriplegia, was observed in bed without any of the sensory stimulating activities outlined in their care plan. Similarly, Resident #58, who had moderate cognitive impairment and preferred one-on-one activities, reported that staff did not provide such activities, and observations confirmed that the resident was often left staring at the wall without engagement from staff. In the SCU, the activity schedule was not followed, and residents were often left without any structured activities. For example, Resident #82, who had severe cognitive impairment and enjoyed group activities, was observed walking up and down the hall without any engagement in the scheduled activities. The same was true for Resident #34, who also had severe cognitive impairment and enjoyed group activities but was observed self-propelling in their wheelchair without any engagement from staff. Additionally, Resident #4, who had schizophrenia and dementia, was observed in bed without any one-on-one activities as required by their care plan. Interviews with staff, including the Activity Director and nursing aides, revealed that the lack of activities was due to staffing issues. The Activity Director admitted that there was no activity aide on the SCU on the days in question, and the scheduled activities were not conducted. Nursing aides also confirmed that they were too busy with other tasks to conduct activities. The Director of Nursing and the Administrator both acknowledged that activity staff should always be present in the SCU and that one-on-one visits should be completed as indicated in the residents' care plans.
Failure to Ensure Resident Safety and Follow Care Plans
Penalty
Summary
The facility failed to ensure the safety of six residents by not following care plan interventions for fall prevention, proper footwear, and the use of fall mats. Staff also failed to ensure residents were transported safely in their wheelchairs by not placing foot pedals on the wheelchairs prior to transport. Additionally, the facility did not prevent an elopement incident involving a resident who left the facility without approval and was found approximately one mile away. The resident's elopement risk assessment was scored incorrectly, and staff did not provide the required protective oversight. The facility also failed to protect two residents from another resident with a history of verbal and physical aggression. The aggressive resident had altercations with other residents, including hitting and punching incidents. Despite these behaviors, the facility did not implement any interventions other than instructing the residents to stay away from each other. The aggressive resident had not been evaluated by psychiatry, and there was no policy regarding behavioral and resident safety. Furthermore, the facility did not follow its policy for wheelchair use, which required footrests to be in place during transport. Observations showed that residents were transported without foot pedals on their wheelchairs, and some residents were not wearing proper footwear. One resident, who was at high risk for falls, was observed multiple times without proper footwear and without foot pedals on the wheelchair. Another resident, who required a fall mat as per the care plan, was observed without a fall mat in place. Staff interviews confirmed that they were unaware of the care plan requirements or did not follow them.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rail use and obtain informed consent for three residents before installing and using bed rails. Resident #25 had Alzheimer's disease, falls, and weakness, and was observed using U-bars on both sides of the bed without documented assessment or consent. Despite the resident's physical decline and increased need for assistance, there was no documentation of a bed rail assessment or consent in the resident's electronic medical record. Resident #62 had generalized weakness, ataxic gait, history of falls, and dementia, and was observed with a U-bar on the left side of the bed. The last documented bed rail assessment was dated 8/5/22, with no subsequent assessments recorded. The resident's care plan indicated the need for quarterly assessments, but these were not completed as required. Resident #58 had diagnoses including cerebral infarction, contracture, muscle weakness, reduced mobility, and seizures, and was observed with U-bars on both sides of the bed. The resident's responsible party confirmed that no consent was obtained for the use of bed rails. The facility's Director of Nursing and Administrator confirmed that bed rail assessments were to be completed quarterly, but this was not done for the residents in question.
Inadequate Staffing on Special Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing on the Special Care Unit (SCU), which housed residents with impaired cognition and at risk for falls and behaviors, including resident-to-resident altercations. Observations revealed that the SCU was often staffed with only two nurse aides (NAs) and occasionally an activity aide, without the presence of a certified nurse assistant (CNA). On multiple occasions, residents were left unattended, leading to incidents such as a verbal altercation between two residents and a resident almost falling out of their wheelchair while unsupervised. Interviews with staff indicated that the facility's staffing policy was unclear, and there was confusion about the appropriate staffing levels for the SCU. Staff members, including NAs and LPNs, expressed concerns about the inability to monitor all residents adequately, especially when providing care behind closed doors. The staffing coordinator and Director of Nursing (DON) acknowledged that the SCU should ideally have a CNA working with NAs and that having only one staff member on the night shift was insufficient for proper resident oversight. The administrator confirmed that NAs should not be working alone and that the facility should adjust staffing times to ensure residents are not left unattended during morning care. Despite these acknowledgments, the facility continued to operate with inadequate staffing, leading to potential risks for resident safety and well-being. The lack of a clear staffing policy and the failure to provide sufficient certified staff on the SCU were significant deficiencies identified during the survey.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed a certified nurse aide (CNA) training program within four months of their employment. NA E was hired on 7/5/21 and had not completed the CNA training program within the required timeframe. NA E was scheduled to take the knowledge portion of the certification test on 3/29/24 but had not yet scheduled the skills test. NA N, hired on 1/16/23, and NA O, hired on 2/13/23, also did not complete the CNA training program within four months of their hire dates. Both NA N and NA O had failed their previous tests and were waiting for retest dates. Despite these deficiencies, all three NAs continued to be scheduled and work as NAs in March 2024. During interviews, the staffing coordinator and the nurse educator/CNA instructor confirmed that the NAs should have been certified within four months and should not have been working without certification. The nurse educator mentioned delays in testing due to scheduling issues from the testing site and noted that NA E was scared to test. The Administrator acknowledged that NAs should be certified within four months and should not be working if they had not tested and/or passed the certification test. The facility did not have a policy on Nursing Assistant and Certified Nursing Assistant training programs, as confirmed by the Administrator.
Improper Food Storage and Cleanliness Issues
Penalty
Summary
The facility failed to ensure proper food storage and cleanliness in the kitchen and other areas. Observations revealed that scoops were stored inside bulk containers with food items such as sugar, oats, and breadcrumbs, which were not labeled or sealed properly. Additionally, containers of ground white pepper and lemon and pepper seasoning salt were found with open and unsealed lids. The exhaust vent over the dish machine had a heavy buildup of dark fuzzy debris, and two microwaves were found with significant food debris and damage, making them difficult to clean. One microwave had a buildup of melted, burnt, and peeling black coating, while the other had heavy food debris on the door and glass plate. The light bulb in the walk-in freezer was also found to be unshielded and unprotected from breakage. Interviews with staff revealed a lack of awareness and adherence to cleaning and maintenance protocols. The Dietary Manager confirmed that food scoops should not be stored inside food containers and that lids on spices should be sealed after use. The Maintenance Supervisor was unaware of the missing light bulb shield in the freezer and the damage to the microwave in the kitchen. The Dietary Manager also mentioned that the damage to the microwave had been present for three years, and the microwave needed to be replaced. The facility's policies on receiving and storing food, cleaning workspaces, and maintaining equipment were not followed, leading to these deficiencies.
Failure to Inspect Bed Frames, Mattresses, and Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment for three residents. Resident #25, who had moderately impaired cognition and required assistance with bed mobility and transfers, was observed with assist bars on both sides of the bed. There was no evidence in the resident's medical record that staff conducted an inspection of the bed frame, mattress, or assist bars for potential entrapment risks. Resident #62, who had severely impaired cognition and required a U-bar side rail for assistance with positioning and transfers, had not had bed rail assessments, including entrapment zone measurements, completed since 8/5/22. Despite the resident's need for the U-bar due to chronic pain and other medical symptoms, there was no documentation of recent inspections in the resident's electronic medical record. Resident #58, who had moderately impaired cognition and was dependent on staff for bed mobility and transfers, was observed with assist rails in the upright position on both sides of the bed. Similar to the other residents, there was no evidence in the medical record that staff conducted inspections of the bed frame, mattress, or assist bars to identify areas of possible entrapment. The Administrator confirmed that the Director of Nursing and/or the management team were responsible for completing these assessments at least quarterly, but this had not been done.
Failure to Ensure Call Lights Were Accessible for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of individual needs by ensuring call lights were within reach at all times for two residents. Resident #31, who was cognitively intact but had functional limited range of motion in both upper extremities and was dependent on staff for bed mobility and transfers, was observed multiple times with the call light on the floor out of reach. Despite the resident's inability to use a traditional call light due to contracted hands, no alternative means to contact staff was provided, forcing the resident to holler for assistance, which was ineffective and led to long waits for help. Interviews with the resident and staff confirmed the resident's inability to use the call light and the lack of an alternative solution. Similarly, Resident #70, who was cognitively intact and required assistance for bed mobility and transfers, was observed multiple times with the call light on the floor and out of reach. The resident confirmed that he/she could use the call light if it was within reach, but staff frequently left it on the floor. Interviews with staff, including an LPN and the Director of Nursing, acknowledged that call lights should be within reach at all times and that Resident #31 should have a soft touch call light due to hand contractures. The facility's failure to ensure call lights were accessible and to provide an alternative for Resident #31 led to deficiencies in accommodating the residents' needs and preferences.
Failure to Develop Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident diagnosed with dementia and depression. The resident's care plan did not address their depression, rejection of care, or the use of an antidepressant, despite the resident exhibiting severe cognitive impairment and frequent tearfulness. Observations and interviews revealed that the resident cried frequently, felt that nobody cared about them, and resisted care, yet these behaviors were not documented in the care plan. The resident's admission and quarterly Minimum Data Set (MDS) assessments indicated severe cognitive impairment and frequent feelings of depression. Despite these assessments and a physician's order for an antidepressant, the care plan was not updated to reflect the resident's needs. Staff observations and family interviews confirmed the resident's ongoing distress and resistance to care, but these issues were not addressed in the care plan. Interviews with facility staff, including the Care Plan Coordinator and the Director of Nursing, revealed a lack of awareness regarding the resident's behaviors and medication needs. The Care Plan Coordinator admitted that the resident's behaviors and use of antidepressants should have been documented in the care plan but were not. The Director of Nursing also acknowledged that the resident's tearfulness, rejection of care, and use of antidepressants should have been included in the care plan.
Failure to Maintain Oxygen Therapy Orders and Equipment
Penalty
Summary
The facility failed to obtain an order for oxygen use and maintain equipment according to the facility policy for two residents. Resident #54, diagnosed with systolic congestive heart failure, returned from the hospital on continuous oxygen at 3 liters/minute via nasal cannula. However, there were no physician orders for oxygen frequency, liter flow, or changing tubing/cannulas. Multiple observations showed the resident with an oxygen cannula in place but with the oxygen tank either set to 0 liters/minute or empty. Staff members, including a nurse aide and a licensed practical nurse, were observed not addressing the empty oxygen tank promptly, and the resident's oxygen saturation levels were not consistently monitored or maintained as required by the facility's policy. Resident #28, with moderately impaired cognition, required continuous oxygen therapy. The resident's care plan indicated the use of an oxygen concentrator in the room and portable oxygen tanks when out of the room, with tubing to be changed weekly. However, observations showed the resident using oxygen tubing dated 2/28, despite the facility's policy requiring weekly changes. Interviews with staff revealed inconsistencies in following the schedule for changing oxygen supplies and labeling them appropriately. The Director of Nursing confirmed that oxygen tubing should be labeled, stored in a bag, and changed weekly or as needed. The facility's failure to adhere to its policies for oxygen administration and equipment maintenance resulted in deficiencies in providing safe and appropriate respiratory care for the residents involved.
Failure to Transcribe New Medication Order Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not transcribe a new order to increase the resident's trazodone dosage. The resident, who had severe cognitive impairment, depression, and insomnia, was supposed to have their trazodone increased from 25 mg to 50 mg at bedtime. However, due to a transcription error, the resident continued to receive the incorrect dose of 25 mg for ten days. This error was observed through the resident's Electronic Medication Administration Record (EMAR) and confirmed by staff interviews and medication cart inspections. The error occurred because the new order was not properly updated in the computer system, and the old medication card was not removed from the medication cart. The Director of Nursing (DON) admitted to missing the removal of the special instruction section on the computer, which led to the continued administration of the incorrect dose. The resident expressed ongoing difficulty sleeping, and the Nurse Practitioner expected the new dosage to begin within two days of the new order. The facility's policy on medication administration was not followed, leading to this significant medication error.
Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received food in the proper form as per their physician's orders. The facility's policy for a pureed diet specifies that food should be blended to a mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. However, during an observation, the Dietary Cook did not measure the amount of corn or hot water used and the resulting mixture was chunky and not smooth. Additionally, the pureed potatoes had visible red chunks, and no gravy was served with any of the pureed items, contrary to the diet spreadsheet menu for the lunch meal. During the lunch meal service, the Dietary Manager served pureed corn and potatoes that were not smooth and contained visible chunks. The Dietary Manager also failed to prepare or serve gravy with any of the pureed food items. An interview with the Dietary Manager confirmed that pureed food items should be pudding thick and smooth, and staff should follow the menu and diet spreadsheet to ensure all food items are prepared correctly. The facility census was 95, and two residents had a physician-ordered pureed diet during the period reviewed.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify three residents or their representatives in writing of their transfer to the hospital, including the reasons for the transfer. Additionally, the facility did not send a copy of the transfer notice to a representative of the Office of State Long-Term Care Ombudsman. This deficiency was identified during a review of 23 sampled residents, with a facility census of 95. The facility's policy on Discharge/Transfer of Resident was not followed, as it mandates explaining the transfer and providing a signed transfer or discharge notice to the resident and/or representative, even in emergency situations as soon as possible. Resident #48 was transferred to the hospital twice, once on 11/17/22 and again on 6/4/23, due to severe health issues including high blood sugar levels and low oxygen saturation. In both instances, there was no documentation that the resident or their representative received a written notice of transfer. Similarly, Resident #24 was transferred to the hospital on 7/1/23 for a stroke workup, and there was no documentation of a written notice of transfer being provided. Resident #4 experienced a sudden change in condition on 12/29/23 and was transferred to the hospital, but again, no written notice of transfer was documented. Interviews with the facility's administrator and Social Service Director (SSD) revealed a lack of awareness and adherence to the policy. The administrator admitted that transfer notices could not be located and that the charge nurses were responsible for providing them, with the SSD supposed to follow up. However, the SSD was unaware of her responsibility to follow up on transfer notices and notify the State Ombudsman of transfers/discharges. This lack of communication and adherence to policy led to the deficiency in notifying residents and their representatives of hospital transfers.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for three residents. Resident #48 was transferred to the emergency department on two occasions, and there was no documentation that the facility provided the bed hold policy to the resident or their representative during either transfer. Similarly, Resident #24 was transferred to the hospital for a stroke work-up, and there was no documentation that the bed hold policy was provided. Resident #4 experienced a sudden change in condition and was transferred to the emergency room, but again, there was no documentation that the bed hold policy was provided. During interviews, the Social Services Director (SSD) stated she was unaware that she needed to follow up to ensure bed hold notices were provided. The administrator confirmed that there was no documentation to show that bed hold notices were provided and stated that charge nurses were supposed to provide the bed hold policies, with the SSD following up to ensure completion. The facility's undated policy on Discharge/Transfer of Residents indicated that staff were to explain and give a copy of the bed hold form to the resident and/or representative, which was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln County Nursing & Rehab | 0.4 mi | — | 3 | 0 |
| Silex Community Care | 11.4 mi | — | 0 | 0 |
| Elsberry Missouri Health Care Center | 13.3 mi | ★★★★★ | 0 | 0 |
| Warrenton Manor | 13.9 mi | ★★★★★ | 7 | 0 |
| Cottages Of Lake St Louis | 17.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Troy Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.