Elroy Health Services

In the surveyor’s words

From the most serious findings on record at Elroy Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 20, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF686Mar 3, 2025

  Based 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. […]

• Actual harm, isolatedF684Jul 1, 2025

  Based 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. […]

• Actual harm, isolatedF689Jul 1, 2025

  Based 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. […]

• Actual harm, isolatedF684Feb 9, 2022

  Based on interview and record review, the facility did not ensure all residents receive treatment and care in accordance with professional standards of practice for 1 of 10 sampled residents (R1). R1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not weigh R1 as frequently as indicated in facility policy and did not measure abdominal girth when staff identified [CONDITION(S)]. When R1 experienced a change of condition, including a 9 pound weight gain, the facility did not reweigh the resident or update the provider despite R1's diagnoses. R1 was noted to have an increase in [CONDITION(S)] and complained of shortness of breath. Despite these findings the facility did not complete further weights or update the physician. […]