Troy Manor

In the surveyor’s words

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

• Immediate jeopardy, patternF880Apr 9, 2024

  Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for five residents (Resident #27, #29, #59, #501, #502 and #503) in a sample of 23 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #27 and #29 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #29 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). […]

• Immediate jeopardy, isolatedF760Apr 26, 2023

  Based on interview and record review, the facility failed to ensure two residents (Residents #1 and #12), in a sample of 16 residents, were free from significant medication errors. Staff failed to correctly transcribe an admission order for metoprolol tartrate (a medication used to treat high blood pressure), writing instead the order as haloperidol (an antipsychotic medication used to treat mental health disorders) for Resident #1. Staff administered the incorrect medication, haloperidol, to the resident for 97 days, with no doses of metoprolol tartrate administered. […]

• Immediate jeopardy, isolatedF689Dec 21, 2022

  Based on interview and record review, the facility failed to provide one resident (Resident #1), who had diagnosis of schizophrenia (mental illness) and a history of elopement and exit seeking behaviors from the facility, with sufficient supervision and monitoring to ensure the resident did not leave the facility grounds without staff knowledge. Staff said they last saw the resident on 12/2/22 at approximately 9:45 P.M. in the resident smoking area outside the facility. Housekeeper A, who was responsible to supervise the residents' smoke break, did not ensure the resident returned inside the facility on 12/2/22 after the 9:30 P.M. scheduled smoke time. The resident said he/she walked away from the facility on 12/2/22 during the 9:30 P.M. smoke break. […]

• Immediate jeopardy, isolatedF689Oct 27, 2022

  Based on interview and record review, the facility failed to provide one resident (Resident #1) who had a diagnosis of schizophrenia and a history of elopement and exit seeking behaviors with sufficient supervision and monitoring to ensure the resident did not exit the facility without staff knowledge. Staff left the resident's secured unit unattended for approximately 10 minutes, during which time the resident exited the facility through a delayed egress door just before midnight. The resident was not located until he/she called his/her family member over seven hours after leaving the facility. A sample of four residents was selected for review. The facility census was 84. On 10/19/22 at 4:00 P.M. […]

• Actual harm, isolatedF600Oct 3, 2024

  Based on interview and record review, the facility failed to ensure three residents (Residents #3, #5 and Resident #11), in a review of seven sampled residents, were free from abuse when Resident #1 caused physical harm to Resident #5 when he/she pulled him/her out of his/her wheelchair, resulting in a left shoulder fracture, and when he/she hit an additional resident, Resident #11, in the face and grabbed Resident #3's arm, causing the resident pain. The census was 85. Review of the facility policy, Abuse Prohibition, dated 11/2016, showed the following: -The purpose of the facility policy is to prohibit mistreatment, neglect or abuse of any resident; -Abuse is the willful infliction of injury with resulting physical harm, pain or mental anguish. […]