Elroy Health Services

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision and safety to prevent accidents and hazards for 1 of 1 Residents reviewed for smoking (R51). On 4/5/26, R51 was observed by staff to be smoking an illegal substance in his room. R51 had a history of illicit drug use, however, this was not addressed upon R51's admission. No monitoring was put in place for R51 regarding the use of illegal substances. R51 has a roommate, and residents in rooms near R51 use oxygen. The facility's failure to provide adequate supervision and protect residents from smoking in the facility and illegal substance use created a finding of immediate jeopardy (IJ) that began on 4/5/26. Surveyor notified NHA A (Nursing Home Administrator) and VPS E (Vice President of Success) of the immediate jeopardy on 5/7/26 at 1:50 PM. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 2 of 5 Residents (R68 & R6) reviewed for notification of change in condition. On 10/26/25, R68 had a BP (Blood Pressure) of 68/52, was feeling dizzy and lightheaded. Throughout the night R68 had BPs readings of 80/40, 89/56, and 94/58. The next morning on 10/27/25 at 9:15 AM, R68 had a fall. The facility did not notify physician of change in condition throughout the night. On 3/5/26, the facility sent an e-Interact communication to the provider of R6's change of condition. The facility did not follow up with the provider regarding the change of condition to get any new orders or monitoring recommendations for R6 for several hours, after the change of condition was noted. This is evidenced by: [...]

Inspectors wroteBased on record review and interview the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC); thus, did not provide the notice of Medicare services ending and the accurate potential financial liability to residents whose Medicare coverage was ending for 1 of 3 residents reviewed (R48). R48 was receiving Medicare A benefits. R48 was not provided with the NOMNC and SNFABN form thus not being provided with the accurate financial liability. Evidenced by:The facility's policy titled Advance Beneficiary Notice dated 5/12/25 states in part .5. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 16 sampled Residents (R7). R7 reported that facility staff do not assist with shaving, despite R7 having their own shaver. R7 noted to have approximately 1/4 facial hair on their chin. Evidenced by:The facility's policy titled Activities of Daily Living (ADLS) dated 7/26/22 states in part .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. [...]

Inspectors wroteBased on interview and record review, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (R43) reviewed for transportation for medical appointments. R43 had a medical appointment scheduled for 5/4/26 and the facility failed to arrange transportation. Evidenced by: The facility does not have a transportation policy. R43 was admitted to the facility on [DATE] with diagnoses that include cognitive communication deficit (a condition where cognitive impairments disrupt a person's ability to communicate effectively, despite intact language or speech abilities), cirrhosis of liver (a complication of long-term inflammation of the liver. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 39 opportunities that affected 2 out of 5 residents (R54 & R46) included in the medication pass task, which resulted in an error rate of 5.13%.R54's orders include levothyroxine daily at 5:30 AM. Staff administered R54's levothyroxine at 8:09 AM. Staff administered R54's levothyroxine and calcium at the same. Staff administered R54's levothyroxine at the wrong time and against manufacturer's directions not to administer with Calcium. Staff administered R46's levothyroxine at 7:46 AM. The order is to administer levothyroxine at 6:00 AM. Staff administered this medication late. Evidenced by:The facility policy entitled Medication Administration, dated 1/26, states, in part: . POLICY: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (R2). R2 had a fall on 5/29/25. PA D (Physician Assistant) ordered x-rays STAT (right away) due to complaints of pain to right wrist and right hip. X-rays did not get completed as ordered. R2 was shaking due to severe pain the next morning and was sent to the hospital. R2 was diagnosed with a fracture to the right hip and pelvis as well as avulsion (a small piece of bone pulled off the wrist bone, causing a small fracture) to right wrist. The facility's failure to get the x-rays completed STAT as ordered resulted in a delay in treatment for R2. Evidenced by: The facility policy entitled Change in Condition, dated 9/20/22, states, in part: . A facility should immediately inform the resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents (R3) reviewed for falls. R3's family provided information related to R3's familiar routine and preferences. The facility failed to get this information on R3's baseline care plan, on R3's comprehensive care plan, or get it to the front line staff to use for fall prevention. R3's alarm did not sound when she self transferred. R3 fell and sustained a hip fracture. The facility's management staff reported to Surveyor that R3 has behaviors of deactivating her alarm system. R3's medical record does not contain goals, monitoring, or interventions related to this behavior in regard to fall prevention. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 3 residents (R3) reviewed for receiving a psychotropic medication were free from unnecessary drugs. R3 receives Olanzapine, an antipsychotic medication, for Alzheimer's disease with late onset. This is evidenced by: The facility policy titled, Use of Psychotropic Medications, reviewed 4/27/25, includes: it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contradicted. Additionally these medications should only be used to treat residents medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services to promote healing and prevent new injuries from developing for 2 of 5 residents (R35 and R44) reviewed for pressure injuries. R35 was at risk for PI development. R35 developed two stage 3 facility acquired PIs that deteriorated. Observations were made of multiple layers between R35 and the air mattress. The facility failed to provide education and/or risks vs benefits when R35 declined repositioning. Staff did not ensure consistent documentation of repositioning or incontinence care, which were noted contributors to R35's PIs. Staff did not protect R35's periwound when applying the prescribed treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 68 residents residing at the facility. Surveyors entered on the weekend due to the facility triggering for low weekend staffing. NHA A (Nursing Home Administrator) indicated the schedule is based on the census and hours per patient day (HPPD), which does not take into consideration the acuity of the facility's resident population. Residents in Resident Council voiced concerns that staff take too long to answer call lights and meal trays on the halls are not passed timely due to staff not being available. R56 voiced concerns about long wait times when wanting to get up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 68 residents who reside at the facility. Surveyor observed dietary aide without a beard restraint in the kitchen. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed spilled food or drink in the walk-in fridge. Evidenced by: The facility policy, Employee Sanitary Practices- Food and Nutrition Services, dated, 7/27/22, states, in part; .All food and nutrition services employees will practice good personal hygiene and safe food handling procedures .1. Wear hair restraints (hairnet, beard restraint) to prevent hair from contacting exposed food . On 2/16/25 at 9:45 AM, Dietary Manager K (DM) and Surveyor toured the kitchen. [...]

Inspectors wroteBased on observations, interview, and record review the facility did not 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 has the potential to affect all 68 residents (R) residing in the facility. The facility's outbreak that started in October 2024 was resolved too early. Facility staff were unaware of their current outbreak and were not following proper source control during the outbreak. Staff surveillance was not complete for staff illnesses and staff returned to work too early from illnesses. This is evidenced by: The facility's policy titled Infection Prevention and Control Program, dated 7/23/24, states in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment for 1 of 20 sampled residents (R316) and 6 of 12 supplemental residents ((R15, R11, R30, R18, R26, R42). R316, R42, R15, R11, R30, R18, and R26 indicated that the dining room was very cold, and they were wearing jackets or wrapped in blankets to stay warm. Resident Council meeting minutes dated 1/23/25, indicated the facility was aware that residents had concerns of it being too cold in the dining room. Evidenced by: Facility policy, entitled Safe and Homelike Environment Policy, dated 6/16/22, includes in part . Definitions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 2 (R38 and R58) of 20 total sampled Residents and 2 (R33 and R25) of 12 supplemental residents who reside on D Hallway. Surveyor observed R38, R58, R33 and R25 from 2/16/25-2/18/25. The facility did not provide residents with meaningful activities. Evidenced by: The facility policy, Activities, dated 7/11/22, states, in part; .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote or enhance emotional health. e. [...]

Inspectors wroteBased on observation and interview and record review, the facility did not ensure that residents were ensured a dignified existence and self-determination for 1 of 20 sampled residents (R316). R316 voiced concerns that he had no clothes to wear and was forced to wear a hospital gown all the time, including to the dining room for meals. As evidenced by: The Facility policy titled, Resident Rights, dated 9/2017, states, in part: Purpose: To ensure that resident rights are respected, protected, and promoted . Procedure: Residents will be treated with respect and dignity and care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality . 38. All facility staff are to encourage residents to exercise their rights by providing choices . [...]

Inspectors wroteBased on observation, interview, and record review the facility did not promote and facilitate resident self-determination through support of resident choices and preferences for 1 (R44) of 20 sampled residents and 1 (R15) of 12 supplemental residents reviewed. R44 and R15 voiced concerns with receiving eggs almost every day for breakfast. R44 and R15 indicated they shared this concern, and it has not been corrected. Evidenced by: The facility policy, Resident Rights, dated 7/22, states, in part; .17. The resident has the right and this facility promotes and support the right to make choices about aspects of his/her life in the facility that are significant to the resident . Example 1 R44 was admitted to the facility on [DATE]. R44's most recent MDS dated [DATE] states that R44 has a BIMS of 15 out of 15, indicating that R44 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all incidents involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the incident, if the events involve abuse to the appropriate agencies for 2 of 2 resident-to-resident abuse allegations (R50 and R53). R50 has a history of being verbally aggressive towards others. R50 was verbally aggressive towards R53 and made him cry on 2/10/25. The UC J (Unit clerk), NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RN I (Registered Nurse), were aware of this incident, but it was not reported to the state agency. Evidenced by: Facility policy, titled Abuse, Neglect and Exploitation dated 2/2018 with a revision date of 7/15/22, states, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 2 of 2 Residents (R50 and R53) reviewed for abuse. On 2/10/25, the facility became aware of an allegation of resident-to-resident abuse between R50 and R53 and did not conduct a thorough investigation. Evidenced by: Facility policy, titled Abuse, Neglect and Exploitation dated 2/2018 with a revision date of 7/15/22, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Definitions: [...]

Inspectors wroteBased on record review and staff interviews, the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 20 total sampled residents (R23). R23's medical record indicates he has schizoaffective disorder and behaviors. R23's comprehensive care plan does not include a care plan with goals or interventions that included monitoring and supervision, related to inappropriate behaviors. This is evidenced by: The facility's policy titled Comprehensive Care Plan, dated 9/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents (R50) reviewed for dementia care out of a total sample of 20 residents. R50 has a diagnosis of dementia. R50 has a history of exhibiting verbally aggressive and socially inappropriate/disruptive behavior towards staff and other residents. The facility staff did not provide person-centered services to maintain R50's highest practicable physical, mental, and psychosocial well-being. Evidenced by: The facility policy titled Dementia Care, dated 4/23/24, states, in part: Policy: [...]

Inspectors wroteBased on interviews, record review, and facility policy reviews, the facility failed to ensure that privacy was maintained for one resident (R1) of 14 residents reviewed. Specifically, R1's positive COVID status was announced in front of residents and a hospice staff member. Additionally, the Social Services Director (SSD) discussed R1 not following the facility's smoking protocol in the common area making R1 feel scared and uncomfortable.

Inspectors wroteBased on interviews, record review, and facility policy reviews, the facility failed to ensure that activities of daily living (ADL) assistance was provided for 1 resident (R1) of 15 residents reviewed for ADLs. Specifically, R1 was not provided assistance with showering/bathing for 21 days while on COVID quarantine.

Inspectors wroteBased on record reviews, interviews, and facility policy reviews, the facility failed to ensure that quality of care/treatment were provided to one resident (R6) of 12 sampled residents. Specifically, the facility failed to provide a timely assessment for R6 after she sustained a fall.

Inspectors wroteBased on record reviews, interviews, and facility policy reviews the facility failed to ensure that qualify of care/treatment were provided to 1 residents (R3) of 12 sampled residents. Specifically, the facility failed to follow physician orders related to wound care for R3.

Inspectors wroteBased on observation and interview, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment for 6 of 9 sampled residents (R2, R1, R5, R3, R8, and R7). R8 and R7 indicated they have not had a working sink in their bathroom for over a week and have to go down the hallway in order to complete their personal hygiene. R2, R1, R5, and R3 voiced concerns regarding not having any hot water for about 3 weeks. Grievance Form, dated 7/12/24, indicates the facility has had concerns of no hot water since 7/12/24. Evidenced by: Facility policy, entitled Safe and Homelike Environment, dated 6/16/22, includes in accordance with residents' rights the facility will provide a safe, clean, comfortable, and home-like environment allowing the residents to use his or her personal belongings to the extent possible . [...]

Inspectors wroteBased on interview and record review, the facility did not provide showers to 4 of 4 residents reviewed for Activities of Daily Living (ADL) assistance (R1, R2, R5, R3). R1, R2, R3, and R5 indicated they have missed showers due to the facility not having hot water. Evidenced by: Facility policy, entitled Activities of Daily Living (ADLS), dated 7/26/22, includes: The facility will . ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following ADLs: bathing, dressing, grooming, oral care, transfer, ambulation, toileting, eating, using speech . A resident who is unable to carry out ADLs will receive the necessary services to maintain good . grooming and personal and oral hygiene . Example 1 R1 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 of 1 resident (R2) reviewed for self-administration of medications out of a total sample of 9 residents. Surveyor observed R2 holding a med cup of pills in her room without staff present. The facility did not complete a self-administration of medication assessment on R2 and R2 did not have a physician order for administering her own medications. Evidenced by: The facility's policy, entitled Self-Administration by Resident, dated 2007, includes: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing center interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration . [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, to the appropriate agencies in accordance with State law through established procedures for 1 of 1 sampled residents (R7). R7 voiced an allegation of abuse to Surveyor and to the facility using the grievance process. The facility failed to report the allegation of abuse to the state agency immediately within 2 hours. Evidenced by: Facility policy, entitled Abuse, Neglect, and Exploitation, dated 7/15/2022, includes: . Verbal abuse- means the use of oral, written, or gestured communication or sounds . [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 1 residents reviewed (R7). R7 voiced an allegation of abuse to Surveyor and to facility using the grievance process. The facility failed to protect R7 and failed to conduct a thorough investigation of the incident. Evidenced by: Facility policy, entitled Abuse, Neglect, Exploitation, dated 7/15/22, includes: .Verbal abuse- means the use of oral, written, or gestured communication or sounds . includes disparaging language and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Identification of abuse, neglect, or exploitation: . Verbal abuse of a resident overheard or inappropriate verbal conduct overheard . [...]

Inspectors wroteBased on observation and interview, the facility did not ensure resident environments remained free of potential accidents/hazards for 3 of 9 residents (R6, R4, and R9) reviewed for hot water temperatures. R6, R4, and R9 voiced concerns of their water being too hot. Surveyor recorded unsafe temperatures on her thermometer of R6's, R4's, and R9's bathroom water. Evidenced by: Facility policy, entitled Safe Water Temperatures, dated 6/16/2022, includes, in part: It is the policy of the facility to maintain appropriate water temperatures in resident care areas. Direct staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms of burns and will respond appropriately. Staff will be educated on safe water temperatures upon employment and on a regular basis. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADL) for 2 of 17 residents (R21 & R24) reviewed for resident rights of a total sample of 20. R21 indicated to Surveyor a Certified Nursing Assistant (CNA) put an incontinence product on her instead of assisting R21 to the bathroom. R21 does not use incontinence products. The facility did not ensure that R24 was treated with dignity and respect when providing activities of daily living (ADL). Evidenced by: The facility Rights of Residents in Wisconsin Nursing Facilities, in the Facility's New admission Packet, undated, states, in part: . Resident Rights: Residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. [...]

Inspectors wroteThe facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 2 residents (R4 and R52) reviewed for Restorative Nursing Programming. R4 was discharged from therapy with a Restorative Nursing Program in place, Restorative Nursing Program was not being completed as directed by therapy. R52 was discharged from therapy with a Restorative Nursing Program in place, Restorative Nursing Program was not being completed as directed by therapy. This is evidenced by: Example 1 R4 was admitted to the facility on [DATE] with diagnoses that include dementia, weakness, anxiety disorder, chronic pain syndrome, history of stroke, and neuropathy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 resident (R32) of 7 reviewed out of a total sample of 20 residents receive adequate supervision and assistive devices to prevent accidents. R32 has PICA (put non-edible items in mouth.) The facility failed to ensure R32's Comprehensive Care Plan included details of the behavior, what items R32 will attempt to eat, what staff should do if they observe R32 put item in mouth, personalized interventions, and a system to track the incidents to ensure all staff provide adequate supervision and ensure the environment is as safe as possible. Evidenced by: The facility policy, titled, NSG (Nursing) Accidents and Supervision, Revised date, 7/14/22, states, in part; .Policy: The resident environment will remain as free of accident hazards as is possible. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident maintains acceptable parameters of nutritional status and weight. This affected 1 (R8) of 1 resident's reviewed for nutrition and hydration out of a total sample of 20 residents. The facility failed to follow the Registered Dietician's recommendation regarding weekly weights to be completed for R8 after R8 experienced weight loss. Evidenced by: The facility policy, titled, Weight Monitoring, revised date 12/21/22, states, in part; .Policy The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents 7. The Dietician will review the monthly weights to follow individual weight trends over time. Weight trends will be evaluated by the interdisciplinary team whether or not the criteria for significant weight change has been met . [...]

Inspectors wroteBased on interview and record review the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. This affected 1 of 2 resident's (R6) reviewed for antibiotic use. R6 was receiving an antibiotic to which she was resistant. This is evidenced by: R6 is a new admission to the facility. R6 has the following diagnoses: acute cystitis without hematuria, weakness, cognitive communication deficit, chronic kidney disease, and adult failure to thrive. R6's Discharge summary dated [DATE] contains the following antibiotic order: Trimethoprim 100 mg (milligrams) po (by mouth) at bedtime. R6's Clinical Laboratory Report dated 1/2/24 documents .Trimethoprim/Sulfamethoxazole >= 320 R . This means that R6 is resistant to Trimethoprim and it will not be effective for her. R6's care plan documents the following: [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention(CDC) guidance, and policy review, the facility failed to provide infection prevention procedures for 5 of 10 residents (R5, R6, R7, R4, and R3) during wound care, incontinence care, and when an infestation of maggots was found in R3's wound. In addition, the facility failed to ensure resident care equipment was clean and used exclusively for the resident intended. Specifically, bedpans and bath basins were unmarked, unbagged, and stored on the bathroom floors.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident bathrooms were clean and homelike. Specifically, two bathrooms (Rooms E5 and B8) on 2 of 4 resident care areas had toilet supports with rusted metal and stained pieces of wood. In addition, the floors in three bathrooms were stained and dirty (Rooms E5, B8, and D1).