Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brown Cty Comm Treatment Ctr-bayshore Village during CMS and state inspections, most recent first.
A resident with schizophrenia, dementia, and moderate cognitive impairment had a PASRR Level I Screen from years earlier that was never updated despite later use of antipsychotic meds and documented hallucinations. The record did not include an updated PASRR Level I or Level II reevaluation reflecting the resident’s current mental health status, and the CSW confirmed the PASRR should have been updated.
A resident with dementia, wandering, and exit-seeking behavior was identified as at risk for elopement and placed on 15-minute checks, but multiple check sheets were incomplete and staff interviews confirmed the checks were not consistently documented. Progress notes showed repeated wandering and attempts to exit the unit, and an observation found the resident in another resident’s room without timely staff monitoring. CNAs were responsible for the checks, and the DON verified several sheets were missing entries.
The facility failed to store and prepare food in a sanitary manner, as observed during a kitchen tour. Pre-cooked leftover food items in the freezer were not documented on cooling logs, and interviews revealed that the facility did not use an approved cooling method. This practice had the potential to affect all 61 residents.
PASRR screening not updated for resident with schizophrenia and hallucinations
Penalty
Summary
The facility did not ensure a PASRR Level I Screen was updated and submitted for a PASRR Level II reevaluation for one resident with schizophrenia, dementia, insomnia, and anxiety disorder. The resident’s MDS assessment showed moderate cognitive impairment, and the resident had a guardian responsible for healthcare decisions. The resident’s PASRR Level I Screen from 2002 indicated a major mental illness, use of a major tranquilizer and/or antipsychotic medication, and cognitive deficits due to dementia, and a PASRR Level II Screen was completed at that time. The resident’s record later showed prescriptions for haloperidol and risperidone for schizophrenia, and psychiatry notes documented hallucinations. However, the record did not contain an updated PASRR Level I or PASRR Level II Screen reflecting the antipsychotic medications or the symptoms of mental illness. During interview, the CSW stated the facility had not completed any PASRR screenings since 2002 because there had been no change in payor source, need for specialized services, or new mental health diagnosis, and then verified that the PASRR Level I Screen should have been updated and submitted for PASRR Level II reevaluation.
Incomplete 15-Minute Checks for Resident at Risk for Elopement
Penalty
Summary
The facility did not ensure 15-minute checks were consistently completed for a resident who was at risk for elopement. The resident had diagnoses including dementia with psychotic disturbance, delusional disorder, wandering, and anxiety, and had a BIMS score of 8 out of 15 indicating moderately impaired cognition. The resident’s care plan identified risk for elopement and wandering, noted a WanderGuard due to impaired cognition and exit-seeking behavior, and also identified moderate fall risk. The resident’s elopement risk assessment indicated the resident was at risk for elopement and referenced 15-minute checks or a WanderGuard as possible prevention measures. The resident’s progress notes documented repeated wandering and exit-seeking behavior, including wandering to another unit, attempting to exit the unit, and being redirected by staff. Survey review of the resident’s 15-minute check sheets showed multiple periods where checks were not documented, including 23 missed checks on one date, 11 missed checks and 3 missed checks on another date, 15 missed checks on another date, and 14 missed checks on another date. Staff interviews confirmed that CNAs were responsible for completing and documenting the checks, and one RN stated that agency staff get busy, forget, and do not document. The DON also verified that several sheets were not completed and was not aware the resident’s safety checks were not consistently documented. During observation, the resident was seen with a documented 15-minute check at 9:14 AM, but at 9:32 AM staff had not checked on the resident, who was in another resident’s room and had to be removed by the Life Enrichment Supervisor. Staff interviews also showed differing views about the resident’s unit placement and supervision, with one CNA stating the resident could exit through automatic push doors independently and go to the town square on the way to the main exit. The facility’s elopement/AWOL policy stated staff must immediately report any consumer whose whereabouts cannot be determined or who is knowingly attempting elopement, and the facility later stated it did not have a policy related to wandering, supervision, or monitoring.
Improper Food Storage and Cooling Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as observed during a kitchen tour. The surveyor noted that the freezer contained pre-cooked leftover food items labeled with use-by dates, but there were no cooling logs for October and November 2024. The food observed in the freezer was not listed on the cooling logs provided, indicating a lack of documentation and adherence to proper cooling methods as outlined in the 2022 Federal Food and Drug Administration (FDA) Food Code. Interviews with the Dietary Manager (DM-C) and Cook (CK-D) revealed that the facility did not use an approved cooling method for pre-cooked leftover food. CK-D admitted that the food in the freezer was not cooled using the facility's blast chiller and was not documented on the logs with an appropriate cooling method. The blast chiller was only used for specific items like roasts and pork loins, and the food was left to cool before being labeled and stored in the freezer for future use. This practice had the potential to affect all 61 residents residing in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Green Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of Green Bay | 0.7 mi | ★★★★★ | 5 | 0 |
| Odd Fellow Home | 5.1 mi | ★★★★★ | 5 | 0 |
| Serenity Spring Senior Living At Green Bay | 6.6 mi | ★★★★★ | 6 | 0 |
| Green Bay Health Services | 6.9 mi | ★★★★★ | 0 | 0 |
| Ccc Of West Green Bay | 7.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.