Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ccc Of West Green Bay during CMS and state inspections, most recent first.
A facility failed to thoroughly investigate an incident where a resident kicked another resident in the hallway. Despite the facility's policy requiring a comprehensive investigation, the involved resident was not interviewed, and no other staff interviews were conducted. The care plan of the aggressive resident, who had severe cognitive impairment, was not updated to include interventions for monitoring behaviors related to resident-to-resident altercations.
The facility failed to provide written transfer or discharge notices to two residents. One resident was discharged to a community-based residential facility, and another was transferred to the hospital with sepsis, both without receiving the required notices. The Nursing Home Administrator confirmed the lack of documentation, and the facility did not have a policy for transfer/discharge notices.
The facility failed to provide written bed hold notices to two residents upon their transfer to a hospital, as required by policy. One resident was transferred with sepsis, and another due to critical lab results, but neither received the necessary documentation. The Nursing Home Administrator confirmed the lack of documentation for these notifications.
The facility did not maintain an effective infection prevention and control program during a COVID-19 outbreak. Three housekeeping staff members were not provided with appropriate education and PPE prior to and during the outbreak. Two housekeepers were not fit-tested for N95 masks until 11 days after the outbreak began, and they worked multiple shifts in COVID-19 positive areas without the necessary PPE. Interviews confirmed the absence of documented infection control training for these employees prior to the outbreak.
The facility failed to provide proper catheter care and documentation for two residents, leading to deficiencies in measuring output and preventing UTIs. One resident's catheter tubing was not held at the meatus during care, and output was not documented per policy, with records showing improper maintenance. The second resident's catheter output was not emptied or documented as required, with staff confirming that catheter bags should be emptied every shift but were not consistently done.
A resident with a history of dysphagia and impaired cognition was not provided with a recommended and ordered video swallow study to assess swallowing difficulties. Despite a physician's order and the facility's policy requiring confirmation and completion of such orders, the study was not scheduled or completed. The resident was later hospitalized with acute hypoxic respiratory failure, potentially linked to recurrent aspiration pneumonia. Facility staff confirmed the order was in the medical record but could not explain the oversight.
The facility failed to provide scheduled showers and baths for three residents, as required by their policy. One resident reported not receiving a shower since before Christmas, leading to skin issues. Another resident did not receive weekly showers during their stay, and a third resident had to request washcloths to clean themselves. Staff cited staffing shortages as a reason for not completing showers, and documentation was often missing or falsified.
A resident with moderate cognitive impairment and multiple diagnoses sustained several skin injuries without proper assessment or notification to their physician or POAHC. The facility's policy required weekly skin assessments and documentation, which were not completed, leading to unreported skin tears on the resident's elbow and knees. The DON confirmed the oversight, and the POAHC expressed concern over the lack of communication.
A resident with moderate cognitive impairment experienced three unwitnessed falls at the facility. Despite the facility's policy requiring neurological assessments after falls, staff did not complete the required neurochecks for two of the falls. The facility's policy mandates specific intervals for neurochecks, but these were not adhered to, as confirmed by interviews with the RN and DON. The resident's medical history included conditions necessitating careful monitoring, highlighting a deficiency in care standards.
A resident in the facility experienced discrepancies in the administration and documentation of lorazepam, a psychotropic medication. The facility's records showed inconsistencies between the Controlled Drug Record/Disposition Form and the Medication Administration Record (MAR), with doses not aligning with physician orders. Staff interviews confirmed these discrepancies, highlighting a failure to adhere to medication administration policies.
A resident's guardian was not informed of a significant change in the resident's clonazepam dosage, leading to increased anxiety and a request to revert to the original dosage. The facility's staff failed to communicate the change, despite policy requirements, resulting in the guardian's dissatisfaction.
A resident's medical record lacked documentation of a visitation restriction after a family member threatened harm to staff and residents. The facility did not record the incident or actions taken, such as police contact, in the resident's care plan or medical record, leading to a deficiency.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents. Staff did not perform proper hand hygiene, lacked hair restraints, and failed to label or date food items. The dishwasher was malfunctioning, and staff did not consistently monitor sanitizing solution levels. These deficiencies indicate non-compliance with FDA Food Code and facility policies.
The facility failed to properly label and date medications for four residents, with issues found in two of three medication carts. Medications such as inhalers, eye drops, and nebulizer solutions lacked open or expiration dates and resident names. Additionally, expired Glucerna bottles were found in a medication storage area, which were not removed as required by policy.
The facility failed to follow prescribed dietary requirements and meal plans for several residents, resulting in unmet nutritional needs. Observations revealed that staff did not adhere to menu and meal tickets, leading to residents not receiving appropriate serving sizes or dietary accommodations. Interviews with staff indicated systemic issues such as budget constraints and miscommunication regarding meal preparation.
A resident with a history of falls and moderately impaired cognition experienced multiple unwitnessed falls, and staff failed to complete the required neurological checks according to the facility's policy. The Director of Nursing confirmed the missed checks, highlighting a deficiency in the facility's fall prevention and response procedures.
A resident with moderately impaired cognition and multiple diagnoses, including pleurodynia and PTSD, was placed on 2 liters of oxygen after their oxygen level dropped to 82%. The facility failed to obtain physician orders for continued oxygen use, did not replace oxygen supplies as required, and did not initiate a care plan for oxygen therapy, as confirmed by the ADON.
A facility failed to dispose of a medication properly according to its policy. An RN was observed disposing of a risperidone tablet in a sharps container instead of using the designated chemical compound for drug destruction. The DON confirmed that medications needing to be wasted should be placed in the drug buster. The resident involved had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia.
A resident prescribed gabapentin for pain was not monitored for potential adverse reactions or side effects, despite having a care plan that should have included such monitoring. Interviews with the ADON and DON confirmed the oversight, acknowledging that staff should have been observing the resident for side effects of the medication.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, R4 and R5. On November 20, 2024, R5 was observed kicking R4 in the hallway. Despite this incident, the facility did not conduct a comprehensive investigation. The facility's Abuse Prevention Policy requires that any alleged abuse be thoroughly investigated, including interviews with anyone likely to have direct knowledge of the incident. However, the investigation did not include an interview with R5, who, despite severe cognitive impairment, was able to express wants and needs. Additionally, no other staff members besides RN-D were interviewed, and there was no documentation indicating that R5's care plan was revised to include interventions for monitoring behaviors related to resident-to-resident altercations. R4 had severe cognitive impairment with a BIMS score of 3 out of 15 and was discharged to another facility on January 20, 2025. R5, who also had severe cognitive impairment with a BIMS score of 4 out of 15, was discharged home on November 23, 2024. R5's care plan, dated October 30, 2024, noted significant mood distress related to sundowning but did not address resident-to-resident altercations. The Nursing Home Administrator confirmed that R5 was not interviewed and that no other staff interviews were completed to determine if staff had knowledge of R5's aggression. The care plan was not updated after the incident because R5 was scheduled for discharge shortly after the altercation.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents, R3 and R8, as required. R3 was discharged to a community-based residential facility on January 16, 2025, without receiving a written discharge notice, despite being informed of the facility's impending closure a month earlier. Similarly, R8 was transferred to the hospital on January 22, 2025, with a diagnosis of sepsis, but neither R8 nor their legal representative received a written transfer notice. Interviews with the Nursing Home Administrator confirmed that staff did not document the provision of these notices, and the facility did not have a policy related to transfer/discharge notices.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R8 and R10, upon their transfer to a hospital, as required by the facility's policy. R8 was transferred to the hospital on January 22, 2025, with a diagnosis of sepsis, but neither R8 nor R8's legal representative received a bed hold notice. This was confirmed by an interview with R8's guardian, who stated they did not receive the notice when R8 was discharged to the hospital. Similarly, R10 was transferred to the hospital on January 5, 2025, due to critical lab results, but there was no documentation in R10's medical record indicating that a bed hold notice was provided to R10 or their legal representative. A progress note indicated that R10 was discharged from the hospital to another skilled nursing facility on January 10, 2025. The Nursing Home Administrator confirmed that the facility did not have documentation of a bed hold notification being completed and provided to either R8 or R10 and their legal representatives.
Inadequate Infection Control Training and PPE Provision During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, which began on September 14, 2024. Three housekeeping staff members were not provided with appropriate education and personal protective equipment (PPE) prior to and during the outbreak. Specifically, two housekeepers, HK-D and HK-E, were not fit-tested for N95 masks until September 25, 2024, 11 days after the outbreak began. Additionally, HK-E and another housekeeper, HK-C, did not receive education on the facility's COVID-19 procedures until after the outbreak had started. This lack of preparedness had the potential to affect all 45 residents in the facility. The facility's policy required employees to consult with management if they had not been fit-tested for N95 masks before entering the room of a COVID-positive resident. However, HK-D and HK-E worked multiple shifts during the outbreak without fit-tested N95 masks. HK-D worked three shifts and HK-E worked seven shifts in COVID-19 positive areas without the necessary PPE. Interviews with the housekeeping staff and human resources confirmed the absence of documented infection control training for these employees prior to the outbreak. The housekeeping supervisor also confirmed that HK-D and HK-E cleaned COVID-19 positive rooms without the appropriate PPE during the outbreak.
Deficient Catheter Care and Documentation for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care and documentation for two residents with indwelling catheters, leading to deficiencies in measuring output and preventing urinary tract infections (UTIs). For one resident, the staff did not hold the catheter tubing at the meatus during catheter care, and the catheter output was not emptied or documented according to the care plan and facility policy. This resident had a history of type 2 diabetes with diabetic chronic kidney disease, retention of urine, obstructive and reflux uropathy, and a UTI. The resident's medical records showed that the catheter bag was not emptied and documented properly on 21 out of 25 days, and there was a previous incident where a large volume of urine was drained in the emergency department, indicating improper catheter maintenance. For the second resident, the staff also failed to empty and document the catheter output per the care plan and facility policy. This resident had diagnoses including neuromuscular dysfunction of the bladder, cystostomy, flaccid neuropathic bladder, type 2 diabetes mellitus, and toxic megacolon. The resident reported that the catheter bag was typically emptied only once a day, usually during the night shift. The documentation confirmed that the catheter output was not properly documented on 15 out of 24 days. Interviews with staff confirmed that catheter bags should be emptied and documented every shift, but this was not consistently done.
Failure to Complete Ordered Video Swallow Study
Penalty
Summary
The facility failed to ensure a resident received a recommended and ordered video swallow study for swallowing difficulties. The resident, who had a history of dysphagia and other medical conditions, was assessed by speech therapy on 6/14/24 and referred for a video swallow study. A physician ordered the study on 7/3/24, but the facility did not complete it. The facility's policy required licensed nurses to confirm and complete physician orders, but this was not adhered to in this case. The resident was admitted for wound care and therapy following a right leg amputation and had severely impaired cognition. Despite the speech therapy evaluation indicating the need for a video swallow study to assess the resident's swallowing safety, the study was not scheduled or completed. The resident was later hospitalized with acute hypoxic respiratory failure, potentially linked to recurrent aspiration pneumonia. Interviews with facility staff, including the Rehab Director and Nursing Home Administrator, confirmed the order was in the resident's medical record, but no explanation was provided for the failure to schedule or complete the study.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for three residents, specifically in relation to scheduled showers or baths. The facility's policy required that showers or bed/sponge baths be offered weekly, with residents having the right to refuse or choose the timing. However, the facility did not adhere to this policy, as evidenced by the experiences of three residents who did not receive regular showers or baths. One resident, who had intact cognition, reported not receiving a shower since before Christmas, despite having skin issues that were potentially exacerbated by lack of hygiene. The resident's medical records showed significant gaps in shower documentation, with only a few showers and bed/sponge baths recorded over several months. Staff interviews revealed that showers were often not completed due to staffing shortages, and there were instances where staff were asked to falsify shower records. Another resident, who had moderate cognitive impairment, also did not receive weekly showers during their stay, with documentation missing for two weeks. A third resident, with intact cognition, reported not receiving weekly showers as scheduled and had to request washcloths and towels to clean themselves. The resident's care plan did not reflect their bathing needs or preferences, nor did it include the facility's practice of pairing staff for care. The Director of Nursing acknowledged the documentation issues and the lack of adherence to the care plan.
Failure to Monitor and Report Skin Injuries
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of skin concerns for a resident, identified as R1, who sustained multiple skin injuries during their stay. R1, who had diagnoses including renal disease, anxiety, and stroke with a traumatic brain injury, was admitted with moderate cognitive impairment. Despite the facility's policy requiring weekly skin assessments and documentation, R1's medical record lacked assessments for the week of admission and discharge, and there were no documented notifications to R1's physician or Power of Attorney for Healthcare (POAHC) regarding the skin injuries. R1 sustained skin tears on three separate occasions, with no documented assessments or notifications to the POAHC or medical doctor. The injuries included a 5 mm x 5 mm skin tear on the right elbow, a 2.5 cm skin tear on the left knee, and two additional tears on the right knee. The facility's Director of Nursing confirmed that weekly skin checks and notifications to the resident's MD and representative were required but not performed. The POAHC expressed concern over the lack of communication and the unknown origins of the injuries.
Failure to Conduct Required Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment. The resident experienced three unwitnessed falls during their stay at the facility. Despite the facility's policy requiring neurological assessments after falls, the staff did not complete the required neurochecks for two of the three falls. The resident's medical record indicated falls on three separate occasions, with incomplete neurological assessments documented for the falls on two of those dates. The facility's policy, revised on 9/25/23, mandates specific intervals for neurochecks following a fall, but these were not adhered to in the resident's case. Interviews with the RN and DON confirmed that neurochecks should be completed for unwitnessed falls, yet the documentation was incomplete. The resident's medical history included traumatic subdural hemorrhage, dysphagia, narcolepsy, chronic kidney disease, bipolar disorder, anxiety, and mild cognitive impairment, which necessitated careful monitoring. The failure to conduct thorough neurological assessments as per policy represents a deficiency in the facility's care standards.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident, identified as R1. The deficiency was identified through staff interviews and record reviews, which revealed discrepancies in the administration and documentation of lorazepam, a psychotropic medication prescribed to R1. The facility's policy required medications to be administered according to the prescriber's written orders and documented immediately after administration. However, the records for R1 showed inconsistencies between the Controlled Drug Record/Disposition Form and the Medication Administration Record (MAR). R1 was admitted with multiple diagnoses, including traumatic subdural hemorrhage, dysphagia, narcolepsy, chronic kidney disease, depression, bipolar disorder, anxiety, and mild cognitive impairment. The resident's MARs for July and August 2024 indicated that lorazepam was prescribed with varying administration frequencies, but the documentation did not consistently reflect these orders. For instance, doses were recorded on the MAR without corresponding entries on the Controlled Drug Form, and vice versa. Additionally, some doses were administered at intervals that did not align with the physician's orders. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the discrepancies. The staff acknowledged that the Controlled Drug Receipt Record/Disposition Form and the MAR should match, and any errors should be reported and addressed. Despite this acknowledgment, the surveyor found missing documentation for several dates, indicating a failure to adhere to the facility's medication administration and documentation policies.
Failure to Notify Guardian of Medication Change
Penalty
Summary
The facility failed to notify a resident's guardian of a significant change in treatment, specifically a reduction in the dosage of clonazepam, an anti-anxiety medication. The Nurse Practitioner (NP) ordered a decrease in the dosage from 1 mg twice daily to 0.5 mg twice daily based on a pharmacy recommendation for a gradual dose reduction. However, the resident's guardian was not informed of this change until over a week later, which led to the guardian noticing increased anxiety in the resident and subsequently requesting the original dosage be reinstated. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for notifying the guardian. The Licensed Practical Nurses (LPNs) involved in processing the order did not ensure the guardian was informed, and there was confusion about who was responsible for this task. The Director of Nursing and the Regional Director acknowledged the guardian's dissatisfaction due to the delay in notification, and the NP confirmed the guardian's upset reaction. The facility's policy required notification of significant treatment changes, which was not adhered to in this instance.
Incomplete Documentation of Visitation Restriction
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information regarding a visitation restriction. The resident, who had intact cognition and was admitted with diagnoses including depression, anxiety, seizure disorder, diabetes, and hypertension, had a baseline care plan that allowed a family member to visit during specified hours. However, a progress note indicated a change in visitation was discussed with the Nursing Home Administrator due to safety concerns, but this change was not documented in the resident's medical record, care plan, or care conference notes. The incident involved a family member who threatened harm to staff and potentially to residents, leading to a suspension of visitation. Despite the severity of the threat, the facility did not document the incident or the actions taken, such as police contact or changes in visitation, in the resident's medical record. The Social Worker confirmed that documentation was not completed following the care conference where the threat was made, and the administration was not alerted immediately. The lack of documentation and timely communication contributed to the deficiency identified by the surveyor.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 53 residents. During an initial tour of the kitchen, it was observed that there was no soap or paper towels available at the handwashing sink, and staff were not performing appropriate hand hygiene. Additionally, staff members were observed handling food without wearing required hair restraints, such as hair nets and beard nets, which are necessary to prevent contamination. The facility also did not properly label or date food items in storage, which is a violation of the 2022 FDA Food Code. During the kitchen tour, multiple undated and unlabeled food items were found in the cooler and dry storage areas, including pitchers of liquids, containers of wafers, sugar, and other food products. The walk-in freezer lacked an internal thermometer, and the Dietary Manager confirmed that all food and beverages should be labeled and dated, and that all coolers and freezers should have thermometers. Furthermore, the facility did not adequately monitor and document dishwasher and surface temperatures. The dishwasher was observed to be malfunctioning, and staff were using a three-compartment sink to wash and sanitize dishes without consistently testing the parts per million (PPM) of the sanitizing solution. The facility's Dish Machine Log-High Temp did not contain internal temperature documentation, and dishwashing temperatures were not recorded for several meals. The lack of proper monitoring and documentation of sanitizing procedures indicates a failure to adhere to the facility's policies and guidelines.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications for four residents were properly labeled and dated, as observed in two of the three medication carts. Specifically, medications such as inhalers, eye drops, and nebulizer solutions lacked open or expiration dates and resident names. This included a Fluticasone prop nasal spray and a Combivent inhaler for one resident, an Albuterol nebulizer solution package and a Ventolin inhaler for another, an Anoro Ellipta inhaler for a third resident, and an Ipratropium/Albuterol inhaler and a bottle of Artificial Tears for a fourth resident. The Director of Nursing confirmed that these medications should have been labeled with the resident's name and open or expiration dates according to the facility's policy. Additionally, the facility did not remove expired supplements from one of the two medication storage areas. During an observation, three bottles of Glucerna with expired dates were found stored on a shelf. A Registered Nurse confirmed the Glucerna was outdated and should have been removed, and subsequently contacted the Assistant Director of Nursing to address the issue. These findings indicate a failure to adhere to the facility's policies regarding medication labeling and storage, as well as the removal of expired products.
Failure to Follow Prescribed Diets and Meal Plans
Penalty
Summary
The facility failed to adhere to prescribed dietary requirements and meal plans for six residents, leading to unmet nutritional needs. During multiple meal observations, staff did not follow the menu and meal tickets, resulting in residents not receiving the appropriate serving sizes or dietary accommodations. For instance, residents were not offered cereal as per the menu, and those requiring double portions or specific dietary restrictions did not receive them. This was evident during breakfast and lunch meals over several days, where residents expressed dissatisfaction with the quantity and type of food served. The report highlights specific cases where residents with medical conditions such as severe protein calorie malnutrition, chronic kidney disease, and end-stage renal disease did not receive meals according to their dietary needs. One resident, who required a low concentrated sweet and no added salt diet, received inappropriate food items like wheat bread and canned fruit, contrary to their dietary restrictions. Another resident, who had a grievance resolved to receive double portions, did not receive the agreed-upon meal adjustments. Interviews with staff, including the Food Service Director and kitchen staff, revealed systemic issues such as budget constraints and miscommunication regarding meal preparation and serving. The Food Service Director acknowledged the problem of insufficient portions and the failure to follow meal tickets, attributing it to budget limitations and errors in meal ticket production. Staff also reported that residents frequently complained about inadequate food portions, and some staff attempted to compensate by combining extra trays when available.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed according to policy for a resident who experienced multiple falls. The resident, who had a history of falls and moderately impaired cognition, was admitted with diagnoses including palliative care and anxiety. The facility's policy required neurological assessments after head injuries or changes in condition, with a specific schedule for neurochecks. However, staff did not consistently complete these checks following the resident's unwitnessed falls on several occasions. The resident's medical record indicated unwitnessed falls on four separate dates, with staff missing a total of 16 neurochecks across these incidents. The Director of Nursing confirmed the missed neurochecks and stated that nurses were expected to complete them as per the facility's neurological flow sheet. This failure to adhere to the established protocol for neurological assessments after falls represents a deficiency in the facility's fall prevention and response procedures.
Failure to Ensure Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide necessary respiratory care and treatment for a resident, identified as R32, who was placed on 2 liters of oxygen. The deficiency was identified through observation, staff interviews, and record reviews. The facility's Oxygen Administration policy requires obtaining a physician order if oxygen is continued beyond 24 hours, replacing oxygen tubing weekly, and observing skin integrity behind the ears daily. However, the staff did not obtain physician orders for the use of oxygen or the cleaning and replacement of supplies, nor did they initiate a care plan when R32 was placed on oxygen. R32, who was admitted to the facility with a history of tobacco use and diagnoses including pleurodynia, diabetes, hyperlipidemia, anxiety, and PTSD, had a BIMS score indicating moderately impaired cognition. On a specific date, R32's oxygen level dropped to 82%, prompting staff to administer oxygen. Despite this, R32's medical record lacked a care plan for oxygen use and did not specify when the oxygen equipment should be cleaned or replaced. The Medication Administration Record and Treatment Administration Record also did not contain orders for oxygen, which was confirmed by the Assistant Director of Nursing.
Improper Medication Disposal
Penalty
Summary
The facility failed to properly dispose of a medication in accordance with its Medication Destruction policy. During an observation, a Registered Nurse (RN) was seen disposing of a risperidone tablet in a sharps container after it fell on top of the medication cart. This action was not in line with the facility's policy, which requires non-controlled, non-hazardous medications to be destroyed using a chemical compound for drug destruction. The Director of Nursing confirmed that medications needing to be wasted should be placed in the drug buster, not a sharps container. The resident involved, identified as R27, was admitted to the facility with diagnoses including Alzheimer's disease, dementia, anxiety, and depression. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and rarely understood. This incident highlights a deviation from the facility's established procedures for medication disposal.
Failure to Monitor Adverse Reactions to Gabapentin
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for potential adverse reactions to gabapentin, an anticonvulsant medication. The resident, who was admitted with diagnoses including anxiety, depression, borderline personality disorder, bipolar disorder, and type 2 diabetes mellitus with diabetic neuropathy, had a BIMS score indicating intact cognition. Despite having an order for gabapentin to be administered twice daily, the resident's care plan lacked interventions for monitoring adverse reactions or side effects such as drowsiness, dizziness, blurred vision, and other symptoms associated with gabapentin. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that staff did not monitor the resident for side effects of gabapentin. The Assistant Director of Nursing acknowledged that the resident was prescribed gabapentin for pain and that staff should have been monitoring for side effects. The Director of Nursing also verified the lack of monitoring and indicated that staff should have been observing the resident for adverse reactions to the medication.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Green Bay Health Services | 0.3 mi | ★★★★★ | 0 | 0 |
| Grancare Nursing Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Woodside Lutheran Home | 3.3 mi | ★★★★★ | 13 | 0 |
| Odd Fellow Home | 3.5 mi | ★★★★★ | 5 | 0 |
| Anna John Resident Centered Care Community | 5.6 mi | ★★★★★ | 0 | 0 |
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