Elroy Health Services
ELROY HEALTH SERVICES in ELROY, WI — inspection on March 3, 2025.
Found 16 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
stated that it felt good to be wearing regular clothes, even if they were not his own.
Surveyor asked
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
substitutions.
Surveyor asked BOM H if she had offered R15 a substitution when she stated that she
that the dietary manager meets with the residents when they first move in to the community and then
On 2/18/25 and again on 2/19/25, Surveyor reviewed R15's meal ticket in the dining room. R15's meal ticket stated both times: Regular cut meat into bite size, large portions, built up fork, built up knife, built up spoon. No amendment was made to indicated that R15 did not like scrambled eggs.
On 2/19/25 at 10:57 AM, [NAME] OO indicated the kitchen will add resident preferences to their meal tickets at admission and as needed. [NAME] OO indicated she will let DM (Dietary Manager) know about the need to update R44 and R15's meal tickets.
On 2/19/25 at 1:20 PM Nursing Home Administrator A (NHA) indicated understanding regarding the need to update R44 and R15's meal tickets to include preferences.
The facility did not promote and facilitate resident self-determination through support of resident choices and preferences.
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Elroy Health Services 307 Royall Ave Elroy, WI 53929
64.4 degrees Fahrenheit.
dining room had been an issue. NHA A indicated that there is only a concern when the temperature
the heat in.
Surveyor pointed out that many of the blinds in the dining room were up on this day and throughout the survey period. NHA A stated that they also will provide the residents with blankets and sweaters if they ask.
Surveyor shared with NHA A that this was a concern that was brought up at resident council in January and asked why it had not been corrected. NHA A indicated that the facility is in need of two brand new boilers, and they needed an opportunity for the weather to get warmer in order to install them. NHA A stated that they had contracted with a company to come out and repack the ceiling with more insulation to maintain the heat.
This was originally scheduled for 2/14/25 but was canceled and rescheduled for 2/21/25. NHA A stated that they had shut the dining room in January when it was very cold, but that they like to respect the resident's choice to eat in the dining room.
Surveyor pointed out to NHA A that 56.8 degrees Fahrenheit was well below the acceptable air temperature range for the facility, and asked if he would consider that to be a homelike environment.
NHA A stated that he believes they do everything they can to maintain a homelike environment in the facility, but they respect the resident's choice above all else.
On 2/18/25 at 1:45 PM, Surveyor interviewed Maintenance G.
Surveyor asked if he monitors the ambient temperature in the dining room.
Maintenance G stated that he did not.
Surveyor asked Maintenance G if 56.8 degrees Fahrenheit was an acceptable dining room temperature.
Maintenance G stated no it was not.
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
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: F-F609 & F-F744
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
other residents specifically regarding to this incident.
Surveyor asked NHA A if he had followed-up
R53 to see if he had any concerns about this situation, but that he already talks to him everyday and
The facility did not follow their policy to complete a thorough investigation, as no other residents were interviewed to identify any further abuse by R50. No statements were taken from R50 or R53/ No staff witness statements were obtained for this incident.
Cross Reference: F-F609 & F-F744
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
month where R23 had behavioral symptoms of yelling/screaming, repeated movements, abusive
R23's CNA documentation for February 2025 indicates 10 shifts where R23 had behavioral symptoms
On 2/18/25 at 9:25 AM, Surveyor interviewed MT M (Med Tech, a CNA that can administer medications) regarding R23's behaviors. MT M indicates R23 will get upset, swear, and lash out verbally. MT M indicated when he becomes behavioral, MT M will try to calm him down by talking to him. MT M did not indicate other interventions that may help when R23 becomes behavioral.
On 2/18/25 at 9:27 AM, Surveyor interviewed CNA U regarding R23's behaviors. CNA U indicated R23 will get upset and say nasty things, but then he will apologize later. CNA U indicated when R23 become behavioral, CNA U will try to redirect him or get another staff member to come help. CNA U did not indicate other interventions that may help when R23 becomes behavioral.
On 2/18/25 at 9:58 AM, Surveyor interviewed RN V (Registered Nurse) regarding R23's behaviors. RN V indicated R23 will become manic, will start calling people on the phone and demand phone numbers, will yell at people, and becomes fixated on a topic. RN V indicated calling R23's sister to speak with him will help. RN V indicated if a resident had behaviors, the care plan would show what the behaviors are and what interventions to use.
On 2/19/25 at 12:58 PM, Surveyor interviewed DON B (Director of Nursing) regarding R23's behaviors.
DON B indicated if a resident has behaviors, there would be an order in the physician orders for behavior monitoring every shift. DON B indicated if a resident has behaviors, the residents care plan should be updated to include that information.
Surveyor informed DON B that R23 does not have a care plan that includes triggers, goals, or interventions for his behaviors. DON B indicated it would be difficult for staff to know what R23's behaviors are and what de-escalation interventions are effective for R23 without a care plan. DON B indicated R23 should have a care plan for his behaviors that includes interventions but does not.
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
The facility failed to provide an on going program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident who resides at the facility.
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
transfers, bathing, and dressing her lower body.
jeopardy to resident health or R44's care plan initiated on 12/17/24 states: .Focus: The resident has a stage 2 pressure ulcer to safety coccyx or potential for pressure ulcer development r/t Hx (history) of ulcers, decreased mobility.
Goal: The resident's pressure ulcer will show signs of healing and remain free from infection
lose [sic] dressing to treatment nurse. *Monitor nutritional status.
Serve diet as ordered, monitor intake and record. *Monitor/ document/ report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size .* The resident requires air flotation pressure redistribution device. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate .
R44's documentation on facility's Pressure Injury (PI) Weekly Tracker is as follows: 12/16/24: .Location: Coccyx Type: Pressure.
Length 0.9cm Width 0.8cm Depth 0.3cm stage 2. 5.
Tissue type: 5c.
Granulation 50% 5d.
Slough 50%. 6.
Drainage b.
Serous 7.
Amount of drainage b.
Light .B.
Plan/ Treatment .6.
Turn and reposition every 2 hours .
R44 was admitted with a PI that was 50% slough, which would indicate it's at least a stage 3. 12/18/24: .
Length 1.1cm Width 0.8cm Depth 0.3cm stage 3. 5.
Tissue type: 5c.
Granulation 20% 5d.
Slough 80%. 6.
Drainage b.
Serous 7.
Amount of drainage c. moderate .B.
Plan/ Treatment .6.
Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], apply medihoney to wound bed, cover with bordered foam dressing.
Skin prep to periwound daily x 30 days.
Surgical excisional debridement performed to remove necrotic tissue and establish viable tissue .
It is important to note that there were no wound measurements from 12/18/24-1/8/25, during which time R44's PI increased in size. 1/8/25: .Length 4.1cm Width 0.5cm Depth 0.1cm stage 3. 5.
Tissue type: 5a.
Skin 50% 5c.
Granulation 10% 5d.
Slough 40%. 6.
Drainage b.
Serous 7.
Amount of drainage c. moderate .B.
Plan/Treatment .6.
Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], app[TRUNCATED]
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
to toileting or repositioning the residents frequently enough.
Cross Reference: F-F686
525452 03/03/2025
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: F-F609 & F-F610.
The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.
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Elroy Health Services 307 Royall Ave Elroy, WI 53929
listed. 1/21/25 HO JJ (Housekeeper) called in with symptoms of fever, headache, sore throat, rhinorrhea (runny nose), and itching.
Testing results listed Influenza.
Comments section states return to work 1/25/25 if fever free without medication and symptoms improve. Of note, there is no date symptoms resolved. 1/28/25 CNA KK call in with symptom of sore throat.
Return to work date 1/7/25 [sic]. Of note, there is no date symptoms resolved. 1/28/25 CNA LL called in with symptoms of nausea, emesis, and diarrhea. Of note, there is no date symptoms resolved.
On 2/18/25 at 12:30 PM, Surveyor interviewed IP S (Infection Preventionist) regarding staff surveillance. DON B was also present for the interview. IP S indicated staff should remain out of the facility if they have GI symptoms for 48 hours after symptoms have resolved. IP S indicated without completing the section of when symptoms resolved it is hard to determine if staff returned to work too early. IP S indicated HA FF and CNA GG returned to work too early. IP S indicated COVID testing should be completed if staff have symptoms of COVID and it should be documented on the line listing.
IP S indicated RN I and UC J should have had testing completed. IP S indicated MN II should have had documented symptoms when he called in. IP S indicated the staff line listing should be filled out completely and was not.
525452 03/03/2025
Elroy Health Services 307 Royall Ave Elroy, WI 53929
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.