Elroy Health Services
ELROY HEALTH SERVICES in ELROY, WI — inspection on March 3, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to recognize and report a resident-to-resident altercation, despite several staff members having knowledge of the incident.
The facility failed to recognize a resident's verbally aggressive behaviors and negative interactions with other residents as abuse and failed to report this incident to the state agency within the appropriate timeframes.
Cross Reference:
The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.
525452
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525452 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Elroy Health Services 307 Royall Ave Elroy, WI 53929
The facility failed to assess, develop, and implement an individualized care plan to ensure that R50's dementia care needs were met.
Cross Reference:
The facility failed to provide education and/or risks vs benefits when R35 declined repositioning.
Staff did not ensure consistent documentation of repositioning or incontinence care, which were noted contributors to R35's PIs.
Staff did not protect R35's periwound when applying the prescribed treatment.
The facility's failures to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs. benefits when a resident declined repositioning, and failure to correctly apply a prescribed treatment created a finding of immediate jeopardy that began on 1/15/25.
Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 2/28/25 at 10:05 AM.
The immediate jeopardy was removed on 2/28/25; however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as the facility continues to implement their action plan as evidenced by:
R44 was admitted with a pressure injury.
The facility failed to complete weekly pressure injury assessments per standards of practice.
Observations were made of multiple layers between R44 and the air mattress. R44's PI deteriorated as evidenced by undermining and tunneling.
Evidenced by:
The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device.
The ulcer may present as intact skin or as an open ulcer and may be painful.
The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications.
The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories:
Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.
525452
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525452 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Elroy Health Services 307 Royall Ave Elroy, WI 53929