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 |
