East Troy Manor

In the surveyor’s words

From the most serious findings on record at East Troy Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 18, 2023

  Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 13 of 13 residents reviewed for the use of lifts and 2 of 4 residents reviewed for falls out of total sample of 16 (R1, R2, R3, R6, R8, R9, R10, R11, R12, R13, R14, R15, and R16). R1 was transferred via a Hoyer lift with assist of 2. R1 fell out of the Hoyer lift and struck her head on the floor. The fall caused several facial fractures, a subdural hematoma, neck fractures, and a large laceration to the right side of the head. R1 expired the following day as a result of her injuries. Facility staff had not been educated on the type of sling/harness or size of sling/harness to be used for R1. […]

• Immediate jeopardy, isolatedF689Jul 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Aug 15, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Aug 15, 2024

  Based 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. […]

• Actual harm, isolatedF686Jul 12, 2023

  Based on observation, interview, and record review, the facility did not ensure residents with a pressure injury or those at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R31, R35, & R20) of 3 residents reviewed for pressure injuries. * R31 was admitted with a pressure injury which the facility identified as a Stage 3. The weekly assessments were not comprehensive and not accurate as assessments dated 5/16/23, 5/23/23, 5/30/23, & 6/6/23 document 100% epithelial tissue for R31's stage 3 pressure injury which would indicate the pressure injury was healed. On 7/5/23, R31's pressure injury was assessed as a Stage 4. […]