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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? |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-15 | 2024-09-13 | N |
Respond appropriately to all alleged violations. | Health | 2024-08-15 | 2024-09-13 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-15 | 2024-09-13 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-15 | 2024-09-13 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-15 | 2024-09-13 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-15 | 2024-09-13 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-15 | 2024-09-13 | N |
Provide and implement an infection prevention and control program. | Health | 2024-08-15 | 2024-09-13 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-15 | 2024-09-13 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-12 | 2024-09-13 | 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 | 2024-08-12 | 2024-09-13 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-12 | 2024-09-13 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-08-12 | 2024-09-05 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-12 | 2024-09-05 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-12 | 2024-09-04 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-12 | 2024-08-29 | N |
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 |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-08-12 | Not Fixed | N |
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