Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at East Troy Manor during CMS and state inspections, most recent first.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment contained risks that were not properly addressed, and oversight was insufficient to ensure resident safety.
Six direct care staff, including an LPN and several CNAs, did not receive required training on effective communication, as confirmed by missing documentation and staff interviews. This deficiency was identified during a review of staff records and acknowledged by facility leadership, potentially impacting all residents due to lack of staff competency in communication.
Four staff members, including a dietary aide and three CNAs, did not receive required training on resident rights and responsibilities as mandated by facility policy. Review of employee records revealed missing documentation of this training, and the NHA confirmed that no further evidence of completed training was available.
Four CNAs did not receive required training on abuse prevention, reporting procedures, and dementia management, as confirmed by a review of employee records and staff interviews. The facility's policy mandates this training for all staff, but documentation was lacking, and the NHA acknowledged the deficiency. This lapse had the potential to impact all residents in the facility.
Four staff members, including CNAs and a Dietary Aide, did not receive mandatory QAPI training as required by facility policy. Review of employee records revealed missing documentation of completed training, and the NHA confirmed no further records were available. This deficiency had the potential to impact all residents in the facility.
Four staff members, including CNAs and a Dietary Aide, did not receive mandatory infection prevention and control training as required by facility policy. The facility could not provide documentation of completed training for these staff, and the NHA confirmed the lack of records. This deficiency had the potential to impact all residents.
Five staff members, including CNAs and a Dietary Aide, did not receive required compliance and ethics training as mandated by facility policy. The facility was unable to provide documentation of completed training for these staff, and the NHA confirmed the absence of records. This deficiency had the potential to impact all residents in the facility.
Five CNAs did not complete the required 12 hours of annual inservice education, as shown by a lack of documentation in their employee records. The facility's policy mandates regular inservice training on key topics such as abuse prevention, dementia care, and infection control, but the staff development coordinator did not document completion for these CNAs. The NHA confirmed the absence of records, and the deficiency had the potential to impact all residents.
The facility did not ensure that all staff, including nursing, housekeeping, and dietary personnel, received required behavioral health training as mandated by facility policy. Documentation verifying completion of this training was not available for eight randomly selected staff members, and the NHA confirmed the absence of records. This deficiency had the potential to impact all residents in the facility.
The facility did not consistently document and post the actual daily nursing staff hours for each category as required, with several days missing this information. Staff interviews confirmed that postings were not updated in real time to reflect actual hours worked, and the required information was often completed after the fact or left blank.
The facility did not maintain an effective QAPI program, failing to systematically track and trend falls as required by policy. Despite documentation showing 37 falls over six months, the DON did not consistently analyze or report this data, and the Administrator confirmed that falls were not being properly tracked or discussed in QAPI meetings.
The facility did not ensure that agency CNAs received adequate training or communication regarding resident care requirements, as evidenced by incomplete documentation of training, agency staff unfamiliarity with care cards, and inconsistent adherence to care protocols for resident transfers. Facility staff acknowledged that the current system was ineffective, and some resident falls were linked to staff not following care cards.
Staff did not follow established transfer protocols for a resident with significant mobility and medical needs, using improper equipment and insufficient staff assistance during transfers. This led to two separate falls, as the resident was transferred with only one staff member and, in one instance, with the wrong type of lift, despite clear care plan instructions and facility policy requiring two-person assistance with a Sara Steady.
A resident with multiple health conditions experienced a significant change in condition, including difficulty with transfers and eating, but the RN on duty failed to perform a comprehensive assessment or notify the physician. The resident later became unresponsive and was diagnosed with severe sepsis at the hospital, where they subsequently expired. The facility's failure to follow protocol resulted in a finding of immediate jeopardy.
A resident identified as a wander/elopement risk due to dementia was not provided adequate supervision and assistance devices, leading to two elopement incidents. The facility placed the resident's Wanderguard on the wheelchair instead of the resident, despite the resident's ability to ambulate independently. This failure to adhere to policies and procedures resulted in the resident being found outside the facility on two occasions, creating a reasonable likelihood for serious harm.
The facility did not thoroughly investigate four infectious outbreaks, including COVID-19, norovirus, and influenza, between August 2023 and January 2024. Documentation was limited to line lists and training records, with no investigation into the outbreaks' sources. The IP-C was unaware of the need for documented investigations.
The facility failed to provide required transfer or discharge notices to four residents, as identified during a survey. The Nursing Home Administrator admitted that no transfer notices were issued, and the facility's policy was not followed. This deficiency was confirmed through interviews and record reviews.
A resident with cognitive intactness was found with bruising on her thigh and knee, but the LTC facility failed to report this injury of unknown origin to the state survey agency within the required timeframe. The NHA and DON were unaware of the incident due to a lapse in communication, and the investigation was initiated late. The facility did not submit the investigation findings within the mandated period, violating their policy.
A resident with cognitive intactness but physical dependency was found with unexplained bruising on her inner thigh and knee, areas not prone to trauma. The facility did not investigate or report the injury as required by their policy. The NHA only began investigating after being informed by surveyors, citing a lack of communication as the reason for the delay.
The facility failed to provide written bed hold notices to residents during hospital transfers, as required by policy. Three residents did not receive documentation about the bed hold policy, reserve bed payment, and their right to return. The Nursing Home Administrator admitted that no one was responsible for issuing these notices, leading to non-compliance with the facility's policy.
A facility failed to develop a comprehensive care plan for a resident with an indwelling catheter, despite the resident's diagnosis of neurogenic bladder and history of failed voiding trials. The resident's electronic medical record lacked documentation of a care plan addressing the catheter's long-term use and the resident's occasional refusals of care. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that a care plan should have been completed and updated.
A resident received medications that were not properly labeled or dated during a medication pass. The LPN confirmed that the vitamins were purchased by the resident and lacked necessary labeling and expiration information. The facility's policy requires medications brought in by residents to be reported and dated, but this was not followed. The DON acknowledged the issue but could not explain why the medications were administered without proper labeling.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight to mitigate these risks. The report specifically notes the lack of preventive measures and supervision in the area, which directly contributed to the potential for accidents among residents. No further details about individual residents or their medical conditions are provided in the report.
Failure to Provide Required Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that six randomly selected direct care staff members, including an LPN and five CNAs, received the required training on effective communication as outlined in the facility's in-service training policy. The policy mandates that all staff, including new and existing personnel, must participate in initial orientation and annual in-service training, with effective communication being a required topic for direct care staff. During the survey, the facility was unable to provide documentation verifying that these staff members had completed the necessary training on effective communication. Interviews with the Nursing Home Administrator (NHA) confirmed the absence of documentation for the required training and acknowledged the ongoing issue with staff education. The NHA indicated that there was no further documentation available for the selected staff and recognized the need for a designated training coordinator. This lack of documented training had the potential to affect all 39 residents in the facility, as staff competency in effective communication is essential for quality resident care.
Failure to Provide Required Resident Rights Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including a dietary aide and three certified nursing assistants, received the required training on resident rights and responsibilities. According to the facility's own policy, all staff must participate in initial orientation and annual in-service training, including specific topics such as resident rights and responsibilities. Documentation of completed training, including date, topic, method, and competency assessment, is required to be maintained by the staff development coordinator or designee. During the survey, the surveyor reviewed employee records for the selected staff and found no documentation verifying that they had received the required training. When questioned, the Nursing Home Administrator acknowledged the lack of documentation and stated that there was no further evidence of completed training for these staff members. The deficiency was confirmed during interviews with the administrator and the Director of Nursing, who both recognized the issue with staff education and training documentation.
Failure to Provide Required Staff Training on Abuse Prevention and Dementia Care
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs), selected at random, received the required training on abuse prevention, activities that constitute abuse, procedures for reporting abuse, and dementia management. Review of employee records for these CNAs revealed that there was no documentation verifying completion of the mandated training. The facility's policy requires all staff, including new and existing personnel, contract workers, and volunteers, to participate in initial orientation and annual in-service training on these topics, with documentation maintained by the staff development coordinator or designee. During the survey, the Nursing Home Administrator (NHA) acknowledged the lack of documentation for the required trainings and indicated that there was no further evidence available to demonstrate compliance. The NHA also stated that education is a problem within the facility and mentioned considering the designation of a training coordinator. This deficiency had the potential to affect all 39 residents in the facility, as staff may not have been adequately prepared to prevent, identify, or report abuse, neglect, or exploitation, or to manage residents with dementia.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including three Certified Nursing Assistants and one Dietary Aide, received the required training on the Quality Assurance and Performance Improvement (QAPI) program. According to the facility's policy, all staff must participate in initial orientation and annual in-service training, which includes QAPI as a required topic. The policy also mandates that training be completed prior to staff providing services to residents, and that documentation of completed training be maintained by the staff development coordinator or designee. During the survey, the surveyor reviewed employee records for the selected staff and found no documentation verifying completion of the required QAPI training. The Nursing Home Administrator confirmed that there was no further documentation available for these staff members and acknowledged ongoing issues with staff education. The lack of required QAPI training had the potential to affect all 39 residents in the facility.
Failure to Provide Required Infection Prevention and Control Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including three Certified Nursing Assistants (CNAs) and one Dietary Aide, received the required training on infection prevention and control as mandated by the facility's own policies. The policy specifies that all staff must participate in initial orientation and annual in-service training, including infection prevention and control standards, prior to providing services to residents and annually thereafter. During a review of employee records, the surveyor was unable to find documentation verifying that these staff members had completed the required training. When questioned, the Nursing Home Administrator (NHA) acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The NHA also indicated that education was a problem within the facility and mentioned considering the designation of a training coordinator. The absence of documented infection prevention and control training for these staff members had the potential to affect all 39 residents in the facility.
Failure to Provide Required Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to ensure that five randomly selected staff members, including four Certified Nursing Assistants (CNAs) and one Dietary Aide, received the required training on compliance and ethics. According to the facility's own policy, all staff are mandated to participate in initial orientation and annual in-service training, which must include compliance and ethics program standards, policies, and procedures. The surveyor's review of employee records revealed that there was no documentation verifying that these staff members had completed the required compliance and ethics training. During interviews, the Nursing Home Administrator (NHA) acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The NHA also indicated that education is a problem within the facility and mentioned considering the designation of a training coordinator. The deficiency was identified as having the potential to affect all 39 residents in the facility, as staff training is essential for ensuring quality of care and compliance with facility policies.
Failure to Ensure Required Annual Inservice Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required 12 hours of annual inservice education training, as mandated by facility policy and federal regulations. During a survey, a review of employee records for five randomly selected CNAs revealed that none had documentation verifying completion of the required inservice hours for their respective annual periods based on their hire dates. The facility's policy specifies that all staff must participate in regular inservice education, including training on topics such as effective communication, resident rights, abuse prevention, dementia care, infection control, and behavioral health. However, the staff development coordinator or designee did not document the completion of these trainings for the selected CNAs. The facility assessment did not include details regarding the requirement for CNAs to receive a minimum of 12 hours of training per year. When interviewed, the Nursing Home Administrator acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The deficiency had the potential to affect all 39 residents residing in the facility, as the CNAs may not have been adequately trained in essential care and safety topics.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received the required behavioral health training as outlined in its own policy and procedure. During a review of employee records for eight randomly selected staff members, including nursing, housekeeping, and dietary personnel, the facility was unable to provide documentation verifying completion of behavioral health training for any of these individuals. The policy requires all staff, including new hires and existing personnel, to participate in initial orientation and annual in-service training on behavioral health, with documentation maintained by the staff development coordinator or designee. Interviews with the Nursing Home Administrator (NHA) confirmed that there was no further documentation available to verify that the required training had been completed for the selected staff. The NHA acknowledged the lack of documentation and indicated that education was a problem within the facility. This deficiency had the potential to affect all 39 residents in the facility, as staff may not have been adequately prepared to address behavioral health needs as required by facility policy and federal regulations.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings included all required and accurate information, specifically the total nursing staff hours for each category. According to the facility's policy, the number of licensed and unlicensed nursing personnel, their actual hours worked, and other staffing details must be posted within two hours of each shift's start. However, a review of daily postings over a two-week period revealed that several dates were missing the required documentation of total nursing staff hours. On the day of survey, the posting also lacked this information. Interviews with the scheduler and the nursing home administrator confirmed that the postings were not consistently updated to reflect actual hours worked, especially when changes occurred during the day. The scheduler stated that hours were often completed the next morning and not adjusted in real time, and acknowledged that missing information indicated the task was not done. The administrator confirmed the expectation that actual working hours should be documented daily and adjusted as needed, but observed that this was not occurring. No further information was provided by the facility regarding the missing documentation.
Failure to Track and Trend Falls in QAPI Program
Penalty
Summary
The facility failed to establish and maintain an effective Quality Assurance and Performance Improvement (QAPI) program as required by its own policy and regulatory standards. Specifically, the QAPI program did not adequately track and trend falls, which is a key indicator of resident safety and quality of care. Although the facility's policy outlined a systematic approach to identifying, analyzing, and correcting quality deficiencies, including tracking and measuring performance, the actual practice did not align with these requirements. The Director of Nursing (DON) admitted to not consistently tracking or trending falls, stating she did not perceive a pattern, and did not always prepare or distribute fall reports for QAPI meetings as expected. The Administrator confirmed that the DON was not fulfilling the responsibility to track and trend falls, which should have been a significant focus of the QAPI meetings. Facility documentation showed that there were 37 falls over a six-month period, but this data was not systematically analyzed or used to identify trends or underlying causes. The DON's review of falls was limited to certain factors, such as time of day and associated illnesses, and did not include other potential contributing factors like days of the week. The lack of structured, data-driven investigation and analysis meant that the facility did not fully utilize available information to improve resident safety and quality of care, as required by its QAPI policy.
Deficient Training and Communication for Agency Staff on Resident Care Requirements
Penalty
Summary
The facility failed to establish an effective training and communication system for contracted agency staff regarding the level of care required by residents. Agency CNAs were expected to review resident care information in a binder and use care cards located in residents' closets to determine transfer needs. However, documentation showed that not all agency CNAs had signed off on having reviewed this information. Interviews with agency CNAs revealed that some did not recall signing any forms or receiving adequate training upon starting at the facility, and one CNA stated that it was difficult to know how to care for residents due to insufficient information provided by the facility. Further interviews with facility staff, including an LPN and the DON, confirmed that staff were expected to follow care cards for resident transfers, but this was not consistently done. The DON acknowledged that staff did not always adhere to the care cards, as evidenced by some resident falls. The Administrator also recognized that the current system for educating agency staff was ineffective, noting that more agency staff were present than had signed the education sheet and that some agency staff were unaware of the care cards.
Failure to Follow Transfer Protocols Results in Resident Falls
Penalty
Summary
Staff failed to use the appropriate method of transferring a resident, resulting in two separate falls. The facility's policies required that at least two nursing assistants assist with mechanical lifts, and that specific devices such as the Sara Steady be used according to the care plan. Despite these clear directives, staff transferred a resident using only one staff member on two occasions, and used an improper lift during one of those occasions. On one occasion, the resident was transferred with an EZ stand instead of the required Sara Steady, and on another, the transfer was attempted by a single staff member, leading to the resident's knees coming out of the knee holders and the resident sliding to the floor. The resident involved had a complex medical history, including muscle wasting, severe obesity, vascular dementia, and arthritis, and was dependent on staff for transfers. The care plan and care card for the resident specified that transfers should always be performed with two staff members using a Sara Steady, with additional instructions to ensure the resident's knees remained together and stable during the transfer. Occupational therapy assessments and progress notes also confirmed the need for two-person assistance and the use of the Sara Steady for safe transfers. Despite these documented requirements, staff did not consistently follow the care plan or facility policy. Incident and event reports, as well as interviews with staff and therapy personnel, confirmed that on both occasions, the resident was transferred incorrectly, either with the wrong equipment or with insufficient staff assistance. These failures directly resulted in the resident experiencing falls during transfers, although no injuries were reported.
Failure to Assess and Notify Physician Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a comprehensive assessment was performed for a resident, identified as R291, who experienced a significant change in condition. R291, who had a history of Transient Ischemic Attack, Vascular Dementia, Chronic Kidney Disease stage 3, Chronic Obstructive Pulmonary Disease, and Diabetes type 2, began having increased difficulty with transfers and eating. Despite these changes, the Registered Nurse (RN) on duty did not take a full set of vital signs or perform a comprehensive assessment, nor was the physician notified of the change in condition. On a subsequent day, R291 became unresponsive and was transferred to the hospital with a diagnosis of severe sepsis, where the resident later expired. The facility's policy required that any change in condition should prompt a notification to the attending physician, especially during non-office hours, and a full set of vital signs should be taken. However, this protocol was not followed, as evidenced by the lack of documented vital signs and the absence of physician notification. Interviews with staff and the resident's healthcare power of attorney revealed that the RN did not perceive the severity of R291's condition, leading to a delay in appropriate medical intervention. The failure to conduct a thorough assessment and notify the physician resulted in a finding of immediate jeopardy, indicating a reasonable likelihood for serious harm to the resident.
Removal Plan
- The Change of Condition policy has been reviewed by DON and modified with the following modifications: Examples of Change of Condition, Use of Interact tools - include the change of condition pathways and Stop and Watch, VS will be taken immediately or as soon as possible with any change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order.
- All changes in condition will be listed on the 24-hour report board.
- Nurse practitioner will provide education to all nurses related to recognition of physiological changes of condition as well as behavioral responses that may indicate a physiological change in condition. Education will include response including interventions, notifications, and documentation. This education will be taped and all nurses not present will be required to view the in-service prior to their next working shift.
- Nurse involved in incident was part of the NP's education and was also provided one on one education by the DON and ADON on physiological change of condition and behavioral responses that may indicate a change of condition and expectations for response and notification.
- Interact tools have been implemented and are available electronically within the electronic medical record as well as all Interact tool change of condition pathways have been printed and are located at each nursing station. All licensed staff have been educated on the use of Interact tools as well as their location.
- All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse.
- Post tests will be given following the education to ensure competency.
- Medical Director consulted during the development of this corrective action plan.
- The DON and ADON will review progress notes and 24-hour report board daily for any changes of condition to ensure audits will continue with ad hoc training provided as necessary for any missed opportunities. Audits will continue. All audits and results will be brought to the quality improvement committee for review.
Inadequate Supervision and Assistance Devices for Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident identified as a wander/elopement risk due to altered mental status and dementia. The resident, who was severely cognitively impaired, had a history of wandering behavior and required partial/moderate assistance with mobility. Despite being identified as a risk, the facility placed the resident's Wanderguard bracelet on the wheelchair, even though the resident was capable of standing and ambulating independently. This led to two separate elopement incidents where the resident was found outside the facility, once in the rain and once at 1 am. The facility's policy required that residents at risk for elopement have a Wanderguard placed on their person and be monitored for proper functioning and placement daily. However, the resident's Wanderguard was placed on the wheelchair, which did not prevent the resident from leaving the facility. The facility's staff were aware of the resident's elopement risk and had documented multiple instances of the resident attempting to leave the facility, yet the Wanderguard was not consistently placed on the resident's person. Additionally, there was no investigation conducted for the first elopement incident, and the facility's policy did not consider an elopement to have occurred unless the resident left the facility grounds. The facility's inaction and failure to adhere to its own policies and procedures regarding elopement prevention contributed to the resident's ability to elope on two occasions. The lack of adequate supervision and proper placement of the Wanderguard created a reasonable likelihood for serious harm to the resident. The facility's deficient practice was identified as immediate jeopardy, indicating a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.
Failure to Investigate Infectious Outbreaks
Penalty
Summary
The facility failed to thoroughly investigate four infectious disease outbreaks, including two COVID-19 outbreaks, a norovirus outbreak, and an influenza outbreak, occurring between August 2023 and January 2024. The documentation provided for each outbreak was limited to line lists for residents and staff, and records of PPE and handwashing training. There was no documentation of investigations into the source of the outbreaks or any findings related to the cause of the outbreaks. The Infection Preventionist (IP-C) was unaware of the requirement to complete and document investigations into the outbreaks. During an interview, the IP-C mentioned having email communications with the county public health department regarding the outbreaks, but these were not initially provided to the surveyor. After the survey team exited the facility, the facility submitted copies of these emails, which included line lists and documentation of interventions such as cleaning and isolation. However, no additional documentation was provided to explain the source of the outbreaks or why they were not thoroughly investigated.
Failure to Provide Transfer Notices
Penalty
Summary
The facility failed to provide timely transfer or discharge notices to residents, as required by regulations. Specifically, four residents (R2, R17, R30, and R34) did not receive written notices that included the date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was identified during a survey when the Nursing Home Administrator (NHA) admitted that no transfer notices were issued to these residents. The facility's policy, which mandates that notice of transfer be provided to the resident and representative as soon as practicable before the transfer, was not followed. The report details specific instances where residents were transferred to hospitals without receiving the required notices. For example, R34 was sent to the hospital on 8/2/24 due to a change in condition but did not receive a transfer notice. Similarly, R17 was discharged with an anticipated return on two occasions, yet no transfer consent documentation was available. The NHA acknowledged that no one in the facility was responsible for issuing transfer notices, which was identified as the main problem. This lack of documentation and adherence to policy was confirmed through interviews and record reviews conducted by the surveyor.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R13, to the state survey agency as required by their policy. R13, who has a cognitive status indicating intact mental faculties, was found with bruising on her inner left thigh and knee. Despite the resident's inability to recall how the bruises occurred, the facility did not report the incident within the mandated 24-hour period. The facility's policy requires immediate reporting of such incidents, but this was not adhered to in this case. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were not aware of the bruising until prompted by the surveyor, indicating a breakdown in communication and procedure. The DON was on vacation, and the nurse responsible for reporting skin issues did not inform the DON or NHA. The NHA admitted to starting the investigation late and had not reported the incident to the state survey agency. The facility also failed to submit the findings of their investigation within the required five working days, further compounding the deficiency.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as R13, who was observed with bruising on her inner left thigh and knee. R13, who is cognitively intact but dependent on staff for activities of daily living, could not explain how the injuries occurred. The facility's policy requires immediate investigation of such injuries to rule out abuse, especially when the injury is in an area not vulnerable to trauma. Despite this, the facility did not initiate an investigation when the bruising was first documented by staff during a bath, nor did they report the injury to the state survey agency. The Nursing Home Administrator (NHA) admitted to the surveyor that an investigation had only begun the day before the interview, as they were not made aware of the incident earlier. The Director of Nursing (DON) was on vacation and also unaware of the situation, indicating a breakdown in communication and protocol adherence. The facility's failure to investigate promptly and report the injury as required by their policy resulted in a deficiency noted by the surveyors.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified during a survey when it was found that three residents, identified as R2, R30, and R34, did not receive the necessary documentation regarding the duration of the bed hold policy, the reserve bed payment policy, and their right to return to the facility. Specifically, R34 was transferred to the hospital on 8/2/24 due to a UTI and C-Diff infection, but no bed hold notice was provided. Similarly, R2 and R30 were transferred to the hospital on 6/25/24 and 2/12/24, respectively, without receiving the required written information. The facility's policy, dated 10/22, mandates that residents or their representatives be given written information about bed hold policies at the time of transfer or within 24 hours in emergency situations. However, during interviews, the Nursing Home Administrator (NHA) admitted that no written bed hold information was provided to the residents in question and acknowledged that there was no designated person responsible for issuing these notices. This lack of accountability and adherence to policy resulted in the failure to inform residents of their rights and the facility's bed hold procedures during hospital transfers.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with an indwelling catheter. The resident, who had a diagnosis of neurogenic bladder and a history of failed voiding trials, was admitted to the facility with the catheter in place. Despite the resident's condition and the presence of the catheter since admission, the facility did not create a care plan addressing the services required for the resident's long-term catheter use. This omission was noted during a surveyor's review of the resident's electronic medical record, which lacked any documentation of a care plan for the catheter. The deficiency was further highlighted by the resident's occasional refusals to participate in voiding trials and care procedures, which were not addressed in a care plan. The surveyor observed the resident with the catheter in place and noted that the facility's staff had not developed a plan of care based on a comprehensive assessment. The Nursing Home Administrator confirmed that a care plan should have been completed upon admission and updated with any changes, but it was not done, leading to the deficiency noted in the report.
Improper Labeling and Dating of Resident's Medications
Penalty
Summary
The facility failed to ensure that medications used by a resident during a medication pass were properly labeled and dated with an expiration date. During an observation, a surveyor noted that a resident received a multivitamin with minerals, Vitamin D, and Zinc from bottles that were not labeled with the resident's name, did not have an expiration date, and were not marked with an open date. The Licensed Practical Nurse (LPN) administering the medications confirmed that the vitamins were purchased by the resident and lacked proper labeling and expiration information. The facility's policy requires that any medications brought in by residents or their families must be reported to the nursing staff and have an open date. However, the vitamins in question did not comply with this policy. The Director of Nursing (DON) was informed of the observations and acknowledged the lack of labeling and expiration dates on the bottles but could not provide additional information on why the medications were administered without proper labeling and dating.
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Illustrative
What surveyors actually found near you
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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
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Nursing homes near East Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lindengrove Mukwonago | 4.3 mi | ★★★★★ | 12 | 0 |
| Lakeland Health Care Ctr | 9.6 mi | ★★★★★ | 7 | 1 |
| Holton Manor | 9.8 mi | ★★★★★ | 19 | 0 |
| Burlington Health And Rehabilitation Center | 11.4 mi | ★★★★★ | 3 | 0 |
| Geneva Lake Manor | 14 mi | ★★★★★ | 9 | 1 |
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