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Deficiency Records for East Troy Manor

A list of the most recent deficiencies for East Troy Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for East Troy Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-07-12 2023-09-22 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-07-12 2023-08-09 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-12 2023-08-09 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2023-07-12 2023-08-09 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-07-12 2023-08-09 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2023-07-12 2023-08-09 N
Ensure medication error rates are not 5 percent or greater. Health 2023-07-12 2023-08-09 N
Provide and implement an infection prevention and control program. Health 2023-07-12 2023-08-09 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2023-07-12 2023-08-09 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-07-12 2023-08-09 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-07-12 2023-08-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-07-12 2023-08-09 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-07-12 2023-08-09 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2023-07-12 2023-08-09 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2023-07-12 2023-08-09 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-07-12 2023-08-09 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-18 2023-03-01 Y
Provide and implement an infection prevention and control program. Health 2023-01-18 2023-02-22 Y
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2023-01-18 2023-02-22 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-03-29 2022-05-03 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-03-29 2022-04-29 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-03-29 2022-04-26 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-03-31 2022-04-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-03-31 2022-04-25 N
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2022-03-29 2022-04-25 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-03-29 2022-04-25 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2022-03-29 2022-04-25 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-03-29 2022-04-25 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-03-29 2022-04-25 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-01-06 2022-01-28 Y
Respond appropriately to all alleged violations. Health 2020-03-09 2020-05-15 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2020-03-09 2020-05-15 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2020-03-09 2020-05-15 N
Ensure medication error rates are not 5 percent or greater. Health 2020-03-09 2020-05-15 N
Provide and implement an infection prevention and control program. Health 2020-03-09 2020-05-15 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2020-03-09 2020-04-02 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2020-03-11 2020-04-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-03-11 2020-04-01 N

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