East Troy Manor

Inspectors wroteBased on record review, interview, document review and policy review, the facility failed to ensure that fall risks were assessed and that adequate fall interventions were developed, implemented and revised for one of three residents (Resident (R)2) reviewed for falls. R2 was admitted to the facility following a fall at home where R2 sustained a subdural hematoma. The subdural hematoma was still present and in need of monitoring post admission to the facility. Upon admission, R2 was assessed to be at risk for falls with initial safety interventions including a low bed and frequent rounding (frequency not specified). On 4/20/25 the facility placed a sensor alarm to prevent falls. Progress notes indicate R2 frequently setting off the alarms related to impulsivity and frequent self-transfers. On 4/24/25 R2's Nurse Practitioner noted, in their neuro psych initial evaluation of R2: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 6 of 6 direct care staff, chosen at random, received required training on effective communication. Licensed Practical Nurse (LPN)-2, and Certified Nursing Assistants (CNA) CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive effective communication training. This deficient practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents: Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on resident rights and responsibilities. Dietary Aide (DA)1 and Certified Nursing Assistants (CNAs), CNA1, CNA8, and CNA9 did not receive required training on resident rights and responsibilities. This practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received training on abuse prevention, activities that constitute abuse, procedures for reporting abuse and dementia management and resident abuse prevention. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 did not receive this required training. This deficient practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 facility staff, chosen at random, received required training on Quality Assurance Performance Improvement (QAPI) training. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required QAPI training. This practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 facility staff chosen at random, received required training on infection prevention and control. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9 and Dietary Aide (DA)1 did not receive required training on infection prevention and control. This practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers.3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 5 facility staff, chosen at random, received required training on compliance and ethics which includes training on standards, policies, and procedures of the facility's compliance and ethics program. Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA10 and CNA11 and Dietary Aide (DA)1 did not receive the required compliance and ethics training. This practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 5 Certified Nursing Assistants (CNAs) reviewed completed the required 12 hours of educational inservice hours. CNA1, CNA8, CNA9, CNA10 and CNA11 did not receive 12 hours of annual inservice education training. This had the potential to affect all 39 Residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure 8 of 8 facility staff, chosen at random, received required training on behavioral health. Licensed Practical Nurse (LPN)2, Certified Nursing Assistants (CNAs), CNA1, CNA8, CNA9, CNA10, CNA11, Housekeeper (HK)1, and Dietary Aide (DA)1 did not receive the required behavioral health training. This deficient practice had the potential to affect all 39 Residents in the facility. Findings Include:The facility's In-Service Training, All Staff policy and procedure revised August 2022 documents:Policy StatementAll staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation1. All staff are required to participate in regular in-service education.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the daily nurse staff posting included all required information accurately. This deficient practice has the potential to affect a pattern of all 39 residents residing in the facility. The facility's nurse staff posting did not accurately reflect the correct number of staff members on each daily nurse staff posting. Findings Include:The facility's Posting Direct Care Daily Staffing Numbers policy and procedure revised August 2022 documents:. Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to Residents. Policy Interpretation and Implementation.1. [...]

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to establish an effective Quality Assurance and Performance Improvement (QAPI) program that obtained program feedback, utilized data, took action to conduct structured, systematic investigations, and analyzed underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life, and resident safety. Specifically, the facility QAPI program failed to track and trend falls.

Inspectors wroteBased on facility document review and interview, the facility failed to establish a training program to include an effective system of communication with contracted agency staff related to the level of care a resident requires.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure staff used the appropriate method of transferring residents, which affected 1 (Resident #3) of 4 residents reviewed for falls. Specifically, staff transferred the resident using only one staff person on two separate occasions, and used an improper lift during one of those occasions, which resulted in the resident falling on both occasions.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 1 resident (R291) reviewed with a significant change in condition had a comprehensive assessment performed consistent with professional standards of nurse practice (N6, Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choices. *On [DATE], R291 was having increased difficulty with transfers and eating. The difficulty continued to worsen and on [DATE] at approximately 12:41 a.m., R291 required use of a mechanical lift and had difficulty speaking. The Registered Nurse (RN) on duty did not take vital signs (other than an undocumented pulse oximetry) and did not perform a comprehensive assessment into the change in condition. There was no physician notification of the change in condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 (R24) of 2 residents reviewed was provided adequate supervision and assistance devices to prevent accidents. R24 was identified by the facility as a wander/elopement risk due to altered mental status/dementia in June 2023. The facility did place a Wanderguard bracelet, however, at one point they placed it on the resident's wheelchair even when it was known resident was physically capable of standing up from her wheelchair and ambulating without assistance. Resident was able to elope from the facility and was found outside of the facility on two separate occasions, once when it was raining, and once at 1 am. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 4 of 4 facility infectious outbreaks were thoroughly investigated. The facility had a Covid 19 outbreak in August 2023 and November 2023, a norovirus outbreak in December 2023 and an influenza outbreak in January 2024. All of the infectious outbreaks were not thoroughly investigated.

Inspectors wrote3) On 8/2/24, R34 experienced a change in condition and was sent to the hospital for evaluation. R34 was admitted to the hospital for UTI and C-Diff (clostridium difficile)infection. R34 returned to the facility on 8/9/24. On 8/12/24 at 3:00 p.m. during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the transfer notice for R34 when he was sent to the hospital on 8/2/24. On 8/14/24 NHA-A spoke with Surveyor and stated they have no evidence a transfer notice was given to R34 on 8/2/24. 4.) R17 admitted to the facility on [DATE] with primary diagnosis of Alzheimer's disease. R17 was sent out of the facility with a discharge, return anticipated, on 11/27/2024 through 11/29/2024 and on 03/03/2024 through 03/06/2024 per R17's Minimum Data Set (MDS). On 08/13/2024, at 12:15 PM, Surveyor requested transfer notification documents for R17 from NHA-A. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that 1 (R13) out 1 injury of unknown origin investigations reviewed were reported to the state survey agency as required. R13 was observed to have bruising to her inner left thigh and knee and R13 could not state how the injuries occurred. This injury of unknown origin was not reported to the state survey agency as required.

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that they thoroughly investigated 1 (R13) out 1 injury of unknown origin investigations. * R13 was observed to have bruising to her inner left thigh and knee and R13 could not state how the injuries occurred. The facility was aware of the injuries but did not investigate as to how the injuries may have occurred. The bruising to the inner thigh is an area that is not vulnerable to trauma and R13 is depended on staff for activities of daily living .

Inspectors wrote3.) On 8/2/24 R34 experienced a change in condition and was sent to the hospital for evaluation. R34 was admitted to the hospital for UTI and C-Diff (clostridium difficile)infection. R34 returned to the facility on 8/9/24. On 8/12/24 at 3:00 p.m. during the daily exit meeting with DON-B and NHA-A, Surveyor asked for the bed hold notice for R34 when he was admitted to the hospital on [DATE]. On 8/14/24 NHA-A spoke with Surveyor and stated they have no evidence a bed hold notice was given to R34 on 8/2/24. No additional information was provided as to why the facility did not ensure that R2, R30, and R33 received written information of the duration of the bed hold policy, the reserve bed payment payment policy and the right to return to the facility upon being transferred to the hospital. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility did not always ensure that 1 (R33) out 1 residents reviewed for the use of an indwelling catheter, had a plan of care developed based on the findings of the comprehensive assessment. R33 was admitted to the facility on [DATE] with an indwelling catheter in place. The facility did not developed a plan of care that addressed the services would be provided to R33 and her continued long-term use of the indwelling catheter.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R26) of 3 residents observed during medication pass task had medications labeled and dated with an expiration date. * Surveyor observed R26 receive her morning medications. R26 received a multivitamin with minerals, Vitamin D 125 mg and Zinc 22.5 mg (milligrams) from a bottle that was not labeled with R26 name, not dated when the bottle was opened and no expiration date on the bottles.

Inspectors wrote3.) R4 was admitted to the facility on [DATE] and had diagnoses including periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's 2/12/23 quarterly Minimum Data Set (MDS) indicates R4 had rejection of care 1-3 days during the assessment. R4 has a stage 1 or greater pressure injury, is at risk for pressure injuries. The MDS indicates R4 has 1 stage 2 pressure injury. R4's care plan, with a start date of 2/16/23, documented, [name of resident ] has been diagnosed with an infection to wound on the left buttocks, and had interventions including, -Administer medications and treatments as ordered . [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect all 38 residents residing in the facility. The facility had no evidence of monitoring or tracking/trending of infections during the months of January to May 2023, including a time when the facility experienced a Covid outbreak. Appropriate PPE (Personal Protective Equipment) was not in place for staff sorting potentially contaminated linen.

Inspectors wroteBased on observation, interview and record review the facility did provide supervision to prevent accidents for 3 (R20, R28 and R35) of 6 residents reviewed for accidents. *R20 fell out of the wheelchair. The facility did not thoroughly investigate this fall to include whether R20's fall interventions were in place at the time of this fall. *R28 did not have Dycem in their wheelchair per care planned fall interventions. *R35 was lowered to the floor during a transfer with one staff member. Per R35's care plan, R35 should have been transferred with two staff members and not one staff member.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 2 (R29, R35) of 4 residents reviewed for incontinence care received services and assistance to maintain continence and a resident that enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible. *R29-admitted to the facility with an indwelling catheter. R29 had an order for a follow-up appointment with urology and a trial removal of the catheter. The facility did not arrange the follow up appointment with urology and did not attempt a voiding trial for potential removal of the catheter. *R35 had a decline in bowel status without a comprehensive assessment related to the decline. R35 did not have a care plan related to bowel incontinence.

Inspectors wroteBased on observation, interview and record review the Facility did not assess the risk of entrapment and review the risk & benefits for 1 (R28) of 4 Residents observed having bed rails. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars.

Inspectors wroteBased upon interview and record review, the facility did not ensure 2 (R28 & R30) of 2 residents reviewed for psychotropic medications had monitoring of behaviors.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 2 medication errors in 28 opportunities which resulted in a medication error rate of 7.14%. Medication errors were identified for R27 & R7. * R27 was not administered Flonase Allergy Relief (fluticasone propionate) nasal spray. * R7 received one drop of artificial tears in each eye instead of two drops.