Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Green Bay Health Services during CMS and state inspections, most recent first.
Two residents did not receive timely or consistently documented wound care for existing pressure injuries and wounds. One resident's wound dressings were not changed for several days after admission and wound care orders were delayed, with further missed dressing changes after orders were in place. Another resident's wound care was not documented as completed on a specific day, with the LPN later stating the care was done but not recorded. These actions did not align with facility policy for wound assessment and treatment.
A contracted hairstylist provided monthly services to residents and was paid by the facility without a required background check being completed prior to starting work, contrary to facility policy. The omission was identified when surveyors requested documentation, and the NHA confirmed the background check should have been done before the hairstylist began providing services.
Staff did not date or label open insulin pens and blood glucose test strips in two medication carts as required by facility policy. Three insulin pens for two residents and two containers of blood glucose test strips were found open and undated. Both an RN and an LPN confirmed the items should have been dated, and the DON acknowledged that the lack of dating would prevent staff from knowing expiration dates.
A facility licensed for 125 beds did not employ a qualified full-time social worker, as neither the Social Services Director nor the Social Services Coordinator met state licensing or experience requirements. Leadership confirmed that both staff members lacked the necessary credentials, potentially impacting multiple residents.
A resident's guardian reported suspected financial exploitation by a previous guardian who was also a staff member. Although the facility documented the allegation and updated the care plan to restrict the staff member's access, the required report to the State Agency was not made, despite ongoing investigations by police and APS.
A resident's guardian reported concerns of financial exploitation by a previous guardian who was also a staff member. Although the facility was aware of the allegation and placed restrictions on the staff member's access to the resident, no internal investigation was conducted and the incident was not reported to the State Agency as required by facility policy. Interviews and documentation confirmed staff awareness of the allegation, but the Nursing Home Administrator did not initiate an investigation.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed with an uncovered catheter drainage bag in direct contact with the floor, contrary to facility policy requiring catheter bags to be covered and not touch the floor. The DON confirmed that proper procedures were not followed.
A resident with complex medical needs, including renal dialysis and diabetes, was not weighed according to physician orders or facility policy, with an eight-day gap after admission. The facility also used an outdated weight from a previous admission for dietary assessment and dialysis communication, rather than current weights, as confirmed by the nursing home administrator.
A resident with moderate cognitive impairment was found with medication left at bedside hours after the scheduled administration, despite staff documentation that the medication had been given. The resident reported staff left the medication for self-administration, but there was no physician order or assessment authorizing this. Staff interviews revealed inconsistent practices, and facility policy prohibiting this action was not followed.
A resident with severe cognitive impairment was admitted under a temporary guardianship that expired, but the facility continued to allow the former temporary guardian to make healthcare decisions after the expiration. Despite being informed that the resident was their own decision maker, the facility did not obtain updated legal documentation and permitted the former guardian to act as the resident's representative.
A resident with severe cognitive impairment was allowed to execute a Power of Attorney for Health Care (POAHC) after their temporary guardianship expired, without a formal assessment of capacity. The POAHC was witnessed by staff who were not certified Social Workers as required by state law, and the facility did not ensure permanent guardianship was established before the temporary guardianship lapsed.
A facility failed to manage a resident's financial affairs properly, closing an Irrevocable Burial Trust (IBT) account and withdrawing $7,509 without notifying the resident's POA. The facility's policy requires written authorization for withdrawals and quarterly statements to be provided, which were not done. Additionally, the facility did not pay the resident's monthly care costs to the MCO, resulting in an overdue amount exceeding $10,000. The lack of communication and financial management led to the deficiency.
The facility did not follow its policy to prevent abuse and neglect by failing to conduct thorough background checks for two Business Office Managers. The checks, required by the facility's policy, were missing DOJ and IBIS letters for the staff members, as confirmed by the NHA.
The facility failed to complete neuro checks post-fall for three residents as per policy, leading to a deficiency. Residents with cognitive impairments and fall risks experienced unwitnessed falls, but neuro checks were often missing or delayed. Staff interviews revealed confusion about the timing and completion of neuro checks, particularly with agency staff.
The facility did not implement its abuse policy by failing to conduct out-of-state background checks for a CNA hired earlier in the year. Despite the policy requiring comprehensive checks, the CNA's file lacked these checks, even after an audit and process improvement plan were conducted.
The facility failed to complete PASRR Level II Screens for several residents with mental disorders or intellectual disabilities, despite indications from Level I Screens and the use of psychotropic medications. This oversight affected the assessment and care planning for these residents, as the necessary evaluations were not conducted after the initial 30-day county exemption period.
A resident reported feeling unusually chilled, but the facility did not complete an appropriate assessment or notify the physician timely. The resident was later diagnosed with sepsis. Additionally, the facility failed to consistently provide wound care as ordered, with multiple instances of missed treatments documented.
A resident with diabetes and severely impaired cognition did not receive routine nail care as per the facility's policy. Observations showed the resident's nails were overgrown and unclean, and staff interviews confirmed that nail care was neglected for several weeks.
A resident with cerebral palsy, epilepsy, and anxiety did not have pharmacy recommendations acted upon by a physician. The facility's policy required action within 30 days, but reviews on two occasions were not addressed. The Nursing Home Administrator confirmed the oversight and missing documentation.
The facility failed to monitor high-risk medications for two residents, leading to a deficiency in medication management. One resident on divalproex for epilepsy and another on insulin for diabetes had care plans lacking monitoring for adverse reactions or side effects, contrary to the facility's policy.
A CNA failed to perform hand hygiene after glove removal during incontinence care for a resident, violating the facility's infection control policy. The CNA handled soiled items and moved between tasks without washing hands, as confirmed by the ADON.
The facility failed to ensure adequate reconciliation of controlled medications across all four units, affecting 12 residents. The nurse-to-nurse controlled substance count verification forms were not consistently filled out, as required by the facility's policy. Missing signatures were observed on multiple dates and shifts, indicating that the required counts were not performed or documented properly.
The facility failed to thoroughly investigate an allegation of neglect involving an RN who was found sleeping during their shift and appeared to be under the influence. The RN did not sign out morning medications for residents, and the facility did not identify or rule out potential misappropriation of medication, resulting in an incomplete investigation.
The facility did not have a qualified Social Worker, affecting all 69 residents. The Social Services Director and Social Services Coordinator lacked degrees in social work or related fields and did not have one year of supervised social work experience in a healthcare setting. The Nursing Home Administrator confirmed the previous Social Worker left in January 2024 and was certified with the State of Wisconsin.
Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
Two residents did not receive appropriate care and services to promote healing or prevent the development of pressure injuries. One resident was admitted with pressure injuries on the coccyx and deep tissue injuries (DTIs) on both heels. Upon admission, there were no wound care orders in place, and staff did not change the resident's coccyx and heel dressings for seven days. Wound care orders were not initiated until several days after admission, and even after orders were obtained, dressing changes for the coccyx and heels were missed on multiple documented occasions. The initial skin assessment also lacked measurements of the wounds, and the care plan was not fully implemented as wound care was not consistently provided as ordered. Another resident with wounds on the right great toe, right heel, and coccyx had wound care orders in place, but documentation of wound care completion was missing for one day. The DON confirmed that wound care should have been completed and documented as ordered, but the responsible LPN stated that the care was performed but not documented at the time. The facility's policy requires a head-to-toe evaluation upon admission, prompt notification of the primary care physician, and initiation of appropriate treatment orders, which were not consistently followed for these residents.
Failure to Complete Required Background Check for Contracted Hairstylist
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not ensuring a thorough caregiver background check was completed for a contracted hairstylist. According to the facility's policy, all potential employees, contracted staff, volunteers, and consultants must undergo background, reference, and credentials checks, with documentation maintained as proof. However, when the surveyor requested background check information for a sample of staff, it was found that the hairstylist's background check was not completed prior to providing services, and the hire date was not documented. The only available documentation was a Background Information Disclosure form dated after the surveyor's request, with no evidence of a state background check conducted beforehand. Interviews with the Nursing Home Administrator (NHA) confirmed that the hairstylist was not considered an employee, and therefore, a background check was not initially completed, despite the individual being paid by the facility and providing services to residents since the previous year. The NHA acknowledged that, per facility policy, a background check should have been completed before the hairstylist began working with residents. The hairstylist also confirmed providing monthly services to residents and being compensated by the facility.
Failure to Date and Label Insulin Pens and Glucose Test Strips
Penalty
Summary
Surveyors found that staff failed to properly label and date medications and medical supplies in accordance with facility policy and professional standards. Specifically, three insulin pens used for two residents in the 400 wing medication cart were open and undated, and an open container of blood glucose test strips in the same cart was also undated. In the 200 wing medication cart, another open and undated container of blood glucose test strips was observed. Staff members, including a registered nurse and a licensed practical nurse, confirmed during the survey that these items should have been dated when opened. The facility's policy requires insulin pens to be labeled with the resident's name, physician's name, date dispensed, type of insulin, dosage, frequency, and expiration date, and to be disposed of after 28 days or per manufacturer recommendations. The Director of Nursing verified that without proper dating, staff would not be able to determine when medications or supplies expired. These lapses in labeling and dating had the potential to affect more than four residents in the facility.
Lack of Qualified Social Worker in Facility Exceeding 120 Beds
Penalty
Summary
The facility, licensed for 125 beds, failed to employ a qualified full-time social worker as required. The Social Services Director (SSD) held a master's degree in Mental Health Counseling and a bachelor's degree in Psychology, but was only licensed as an Associate Counselor in Arizona and not in Wisconsin. The SSD was in the process of obtaining a Wisconsin license but had not yet completed the necessary coursework. The Social Services Coordinator (SSC) had a degree in Health Care Administration and experience in behavioral intervention, but was not certified as a social worker in Wisconsin and did not have a year of supervised social work experience in a healthcare setting prior to employment at the facility. Interviews with facility leadership confirmed that neither the SSD nor the SSC met the qualifications outlined in the job description for a Social Services Director, which required a bachelor's degree in social work or social welfare, at least one year of experience in a healthcare setting, and a current state license as a social worker. The Nursing Home Administrator acknowledged that both staff members lacked the necessary credentials and that the facility did not have a qualified social worker on staff, potentially affecting more than 4 of the 61 residents residing in the facility.
Failure to Report Alleged Misappropriation to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident to the State Agency (SA) as required by policy. The incident involved a resident with mild cognitive impairment, congestive heart failure, and type 2 diabetes, who had a guardian. The resident's current guardian reported concerns about potential financial exploitation by a previous guardian, who was also a facility staff member. Documentation showed that the facility was aware of the allegation, as evidenced by progress notes and care plan updates restricting the previous guardian's access to the resident. The facility's policy required immediate reporting of such allegations to the SA and other authorities, but no facility-reported incident was found for this case. Interviews with the resident's current guardian, facility staff, and the Nursing Home Administrator confirmed that the facility was informed of the allegation and that the previous guardian was accused of stealing money from the resident. The guardian had also reported the matter to police and Adult Protective Services (APS), and there was an active investigation. Despite this, the facility did not report the allegation to the SA within the required timeframe, resulting in a deficiency for failing to follow mandated reporting procedures for suspected misappropriation.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident with mild cognitive impairment, congestive heart failure, and type 2 diabetes. The resident's current guardian reported concerns that a previous guardian, who was also a facility staff member, may have financially exploited the resident. Although the facility's policy requires immediate investigation and reporting of such allegations, there was no evidence that an internal investigation was conducted or that the incident was reported to the State Agency. Interviews with the resident's guardian, facility staff, and the Nursing Home Administrator confirmed that the facility was aware of the allegation, and documentation showed that restrictions were placed on the previous guardian's access to the resident due to concerns about money. However, the Nursing Home Administrator stated that no investigation was initiated because they were unaware of the specific allegation, despite progress notes indicating staff awareness. Further review revealed that the Business Office Manager and former Nursing Home Administrator both acknowledged that an investigation should have occurred if misappropriation was suspected. Communications between the facility, Adult Protective Services, and the resident's guardian confirmed that the issue was discussed and that external agencies were involved. Despite this, the facility did not follow its own policy to conduct an immediate internal investigation or report the allegation, resulting in a deficiency related to the facility's response to alleged violations.
Failure to Maintain Proper Catheter Bag Position and Coverage
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed multiple times with their uncovered catheter drainage bag in direct contact with the floor. The observations occurred on three consecutive days, with the catheter bag either hanging from the bed and touching the floor or resting directly on the floor. The facility's Catheter Care Policy requires that catheter drainage bags be covered or shielded at all times and not be in contact with the floor, in order to maintain appropriate catheter care and resident dignity. The resident involved had significant medical conditions, including dementia, weakness, malignant neoplasm of the prostate, hemiplegia, urinary retention, and overactive bladder, and was assessed as being dependent for transfers, hygiene, dressing, and eating, with severe cognitive impairment. The Director of Nursing confirmed during an interview that catheter bags should not be placed on the floor and should be kept in a clean basin or have something underneath to prevent floor contact. Despite these requirements, the resident's catheter bag was repeatedly found uncovered and in contact with the floor.
Failure to Monitor and Record Resident Weight per Physician Orders and Policy
Penalty
Summary
The facility failed to monitor and record a resident's weight according to both physician orders and facility policy. Specifically, the resident, who had diagnoses including dependence on renal dialysis, critical illness myopathy, and type 2 diabetes mellitus with hypoglycemia and coma, was not weighed for eight days after admission, despite orders requiring weights on admission, daily for two days, weekly for three weeks, and then monthly. The facility's policy also required weights to be measured on admission, the next two days, and weekly for three additional weeks, with all weights recorded in the electronic health record. The nursing home administrator confirmed that these procedures were not followed for this resident. Additionally, the facility used an outdated weight from a previous admission, recorded over a year prior, to complete the resident's dietary assessment and to communicate with the dialysis provider. The resident's care plan identified them as being at risk for nutritional status changes due to infection and end stage renal disease, with interventions requiring weight monitoring and notification of significant changes. Despite this, the most recent and accurate weights were not used in clinical assessments or communications, as evidenced by the documentation reviewed by the surveyor.
Failure to Ensure Safe Medication Administration for Resident Without Self-Administration Order
Penalty
Summary
Staff failed to ensure the accurate and safe administration of medication for one resident with moderate cognitive impairment and a history of refusing medications. On the morning of the survey, medication was observed on the resident's bedside table hours after the scheduled administration time, despite documentation indicating the medication had been given. The resident reported that staff left the medication for self-administration, but the resident forgot to take it. The resident's medical record did not contain a current physician's order or assessment authorizing self-administration of medication, and a previous assessment indicated the resident should not have medications left at bedside due to a tendency to forget or mishandle them. Interviews with staff revealed inconsistent practices regarding medication administration. The medication technician who documented administration could not explain why the medication was found in the resident's room or why the resident reported being left to self-administer. Another LPN confirmed that leaving medication at bedside was not permitted for this resident, as the resident was not assessed as capable of self-administration. The facility's policies require staff to remain with residents until medication is swallowed and prohibit leaving medication in a resident's room without proper assessment and orders, which were not followed in this instance.
Failure to Ensure Healthcare Decisions Made by Legally Authorized Representative
Penalty
Summary
The facility failed to ensure that the right to make healthcare decisions for a resident was extended only to those legally authorized, as required by state law. A resident with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15, was admitted with a court-ordered temporary guardianship that expired after a set period. Despite the expiration of the temporary guardianship and the absence of documentation for permanent guardianship, the facility continued to allow the former temporary guardian to make healthcare decisions for the resident. Medical records and social services notes confirmed that the temporary guardian was involved in signing admission agreements, vaccine consents, and making referral requests after the guardianship had lapsed. Staff interviews and record reviews revealed that the facility was aware the temporary guardianship had expired and that the resident was legally their own decision maker at that time. However, the facility did not obtain updated guardianship paperwork or ensure that only a legally authorized representative made healthcare decisions for the resident. The social services director acknowledged that the former temporary guardian continued to act as the resident's legal representative and decision maker after the expiration of the guardianship, contrary to legal requirements.
Failure to Ensure Proper Guardianship and POAHC Procedures for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services to ensure a resident achieved the highest practicable level of well-being. A resident with severe cognitive impairments, as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and multiple diagnoses including hemiplegia, schizophrenia, and cognitive communication deficit, was admitted with a court-ordered temporary guardianship. The facility did not ensure that permanent guardianship was established before the expiration of the temporary guardianship, resulting in a lapse in legal decision-making authority for the resident. Following the expiration of the temporary guardianship, facility staff determined that the resident was their own healthcare decision maker and proceeded to complete a Power of Attorney for Health Care (POAHC) document with the resident. However, there was no assessment conducted to confirm the resident's cognitive ability to comprehend and execute the POAHC document, despite the resident's documented severe cognitive impairment. Staff relied on brief interactions and the resident's momentary clarity, but did not perform or document a formal assessment of capacity. Additionally, the staff member who witnessed the resident's signature on the POAHC document was not a certified Social Worker as defined by Wisconsin State Statute, which is a requirement for employees of the facility serving as witnesses to such documents. Both the Social Services Director and Social Services Coordinator lacked the necessary certification, and this was confirmed by the Nursing Home Administrator. The facility did not have documentation to support that the witnessing staff met the legal requirements, nor that the resident's capacity to execute the POAHC was properly evaluated.
Failure to Safeguard Resident's Financial Affairs
Penalty
Summary
The facility failed to ensure the proper management and safeguarding of a resident's financial affairs, specifically concerning an Irrevocable Burial Trust (IBT) account. The resident, who had intact cognition and was assisted by a Power of Attorney (POA) for financial decisions, had an IBT account opened with the facility. However, the facility closed this account and withdrew the entire balance of $7,509, exceeding the Medicaid-allowed maximum value of $4,500 for such accounts. This action was taken without notifying the resident's POA, which is a violation of the resident's rights to manage their financial affairs. The facility's Business-Resident Trust Fund policy requires that all disbursements and withdrawals from a trust fund must be authorized in writing by the resident or their legal representative. Additionally, the policy mandates that quarterly statements be provided to residents or their legal representatives. However, the POA did not receive these statements and was not informed about the closure of the IBT account. The facility's Director of Revenue and Finance (DRF) acknowledged the oversight but was unsure why the entire amount was withdrawn instead of just the excess over $4,500. The facility also failed to pay the resident's monthly care costs to the Managed Care Organization (MCO), resulting in an overdue amount exceeding $10,000. The DRF indicated that the funds from the IBT account were transferred to the resident's trust account to cover these overdue costs. The POA was aware of the overdue payments but had instructed the MCO to contact the facility, as it was the representative payee. The lack of communication and proper financial management by the facility led to the deficiency in safeguarding the resident's financial affairs.
Failure to Conduct Thorough Background Checks for Staff
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not conducting thorough background checks for two Business Office Managers (BOM-G and BOM-H) out of seven staff reviewed. According to the facility's policy dated 7/15/22, potential employees must be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, which includes conducting background, reference, and credentials checks. However, upon review on 2/20/25, it was found that BOM-G, hired on 8/10/23, did not have a Department of Justice (DOJ) letter, and BOM-H, hired on 10/20/23, lacked both DOJ and Integrated Background Information System (IBIS) letters. The Nursing Home Administrator (NHA-A) confirmed the absence of these documents, which are expected to be obtained for all staff before their first day of work.
Failure to Complete Neuro Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neuro checks were completed post-fall in accordance with its policy for three residents who experienced unwitnessed falls. The facility's policy required neuro checks to be conducted initially, then every hour for three hours, every four hours for six checks, and every eight hours for six checks, with any abnormal findings reported to the Medical Doctor immediately. However, the surveyor found that neuro checks were not completed as required for residents R2, R4, and R1, leading to a deficiency in the facility's fall prevention and management practices. Resident R2, who had a history of mild cognitive impairment and was at risk for falls, experienced multiple unwitnessed falls. The surveyor noted several instances where neuro checks were either missing or not completed in a timely manner according to the facility's policy. For example, after a fall on 11/10/24, the first neuro check was not documented until the following day, and several other falls also had missing or delayed neuro checks. Similarly, Resident R4, who was severely cognitively impaired and at risk for falls, had unwitnessed falls with incomplete neuro checks. For instance, after a fall on 1/18/25, the first neuro check was not completed until two days later. Resident R1, who had intact cognition but was at risk for falls, also had unwitnessed falls with missing neuro checks. The surveyor's interviews with staff revealed that neuro checks were not always completed, and there was confusion among staff about the timing and completion of these checks, particularly with agency staff.
Failure to Conduct Comprehensive Background Checks for CNA
Penalty
Summary
The facility failed to implement its abuse policy by not conducting comprehensive background checks for a Certified Nursing Assistant (CNA-C) who was hired on February 27, 2024. The facility's policy, revised on July 15, 2022, mandates that potential employees be screened for any history of abuse, neglect, exploitation, or misappropriation of resident property, including conducting background checks consistent with state laws and regulations. However, the background check for CNA-C did not include out-of-state criminal or caregiver background checks, despite CNA-C having lived in two other states within the last three years. During a survey conducted on November 11, 2024, the surveyor reviewed CNA-C's background check information and noted the absence of out-of-state checks. Upon inquiry, the Nursing Home Administrator (NHA-A) confirmed that the facility had not completed these checks for CNA-C and had no additional information to provide. Although an audit and process improvement plan were conducted to ensure employee files were complete, the out-of-state background checks for CNA-C remained missing as of October 31, 2024.
Failure to Complete PASRR Level II Screens for Residents
Penalty
Summary
The facility failed to ensure that PASRR (Pre-Admission Screening and Resident Review) requirements were met for five residents, leading to deficiencies in the assessment and care planning for individuals with mental disorders or intellectual disabilities. The PASRR process involves a Level I Screen to identify potential mental illness (MI) or intellectual disability (ID), followed by a Level II Screen for those who test positive, to determine the need for specialized services. However, the facility did not complete the necessary Level II Screens for residents who remained in the facility beyond the initial 30-day county exemption period. Resident 9 was admitted with diagnoses including epilepsy, unspecified intellectual disabilities, anxiety disorder, and depression, and was prescribed psychotropic medication. Despite these indicators, the PASRR Level I Screen incorrectly marked no for major mental disorder and no for signs and symptoms of MI, and the facility failed to complete a Level II Screen after the 30-day exemption expired. Similarly, Resident 22, with a history of ID and MI, was admitted with a Level I Screen that inaccurately marked no for major mental disorder and psychotropic medication, and no Level II Screen was conducted after the exemption period. Other residents, such as Resident 15, who had a serious mental illness and was on multiple psychotropic medications, did not receive a Level II Screen despite the Level I Screen indicating the need for one. Resident 57's Level I Screen was completed incorrectly, failing to acknowledge a major mental disorder despite the resident receiving medication for such conditions. Lastly, Resident 43, with diagnoses including vascular dementia and PTSD, was not provided a Level II Screen despite the Level I Screen indicating the necessity. These oversights highlight a systemic issue in the facility's PASRR process, affecting the care and services provided to residents with mental health needs.
Failure to Provide Timely Assessment and Consistent Wound Care
Penalty
Summary
The facility failed to ensure appropriate care and treatment for a resident (R42) who experienced a significant change in condition. On 4/1/24, R42 reported feeling unusually chilled, but the facility did not complete an appropriate assessment or notify the physician in a timely manner. It was only after R42's condition worsened, showing symptoms such as a high temperature, elevated pulse, and respiratory issues, that the physician was notified, and R42 was sent to the emergency room. The delay in assessment and notification contributed to R42 being diagnosed with sepsis at the hospital. Additionally, the facility did not consistently provide wound care as ordered for R42. The treatment administration records (TARs) indicated multiple instances where wound care was not documented as completed on the scheduled dates. Specifically, wound care for R42's left lower leg and right heel was missed on several occasions in March, April, and May 2024. There was no documentation in R42's medical record explaining why the wound care was not completed on these dates. Interviews with staff revealed a lack of communication and proper procedure when R42 reported feeling chilled. Certified Nursing Assistants (CNAs) did not report the change in condition to the Licensed Practical Nurse (LPN) on duty, and the LPN did not notice any unusual symptoms during the shift. The Director of Nursing (DON) confirmed that staff should document reasons for missed wound care and that feeling chilled should prompt a temperature check and notification of the provider. The failure to follow these protocols resulted in inadequate care for R42.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident, identified as R19, who was dependent on staff for all activities of daily living. R19 had a medical history including diabetes, encephalopathy, and stroke, and had severely impaired cognition. The facility's Nail Care Policy required regular nail care, especially for residents with conditions like diabetes. However, observations by the surveyor on two consecutive days revealed that R19's fingernails were approximately a half inch long with a brown substance underneath, indicating neglect in nail care. Interviews with facility staff, including a CNA, an LPN, and the Director of Nursing, confirmed that nail care was not performed as per the facility's policy. The CNA mentioned that nail care should be provided during weekly showers, and the LPN confirmed that nurses are responsible for nail care for diabetic residents. The Director of Nursing acknowledged that it appeared to have been a few weeks since R19's nails were last cared for, further verifying the deficiency in adhering to the facility's nail care policy.
Failure to Act on Pharmacy Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acted upon by a physician for a resident reviewed for unnecessary medications. The resident, who had diagnoses including cerebral palsy, epilepsy, and anxiety, was subject to monthly pharmacy reviews. On two occasions, dated 12/20/23 and 1/22/24, the consultant pharmacist made recommendations regarding the resident's medication regimen, specifically concerning the prescription of diazepam without a stop date. However, these recommendations were not reviewed or acted upon by a physician or nurse practitioner. The facility's policy required that recommendations from the consultant pharmacist be made available to the care team and acted upon within 30 days. Despite this, the surveyor found that the physician/prescriber response was not documented for the review dated 12/20/23, and there was no clinical pharmacy report or physician response for the review dated 1/22/24. The Nursing Home Administrator confirmed these findings, acknowledging that the recommendations were not addressed, and the necessary documentation was missing from the resident's medical record.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring of high-risk medications for two residents, leading to a deficiency in medication management. Resident 18 was prescribed divalproex sodium for epilepsy, but the plan of care did not include monitoring for adverse reactions or potential side effects, despite the resident being at risk for such effects. The Director of Nursing confirmed the absence of monitoring interventions in the resident's care plan, which is contrary to the facility's Medication Management Policy that requires monitoring for unnecessary drugs. Similarly, Resident 15 was prescribed insulin glargine for type 2 diabetes, but their plan of care also lacked monitoring for adverse reactions or potential side effects. The Director of Nursing verified the insulin order and acknowledged the omission of monitoring interventions in the care plan. This oversight in monitoring high-risk medications for both residents indicates a failure to adhere to the facility's policy, which emphasizes the evaluation of residents for adverse consequences of medications.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the provision of care to a resident. The CNA did not perform hand hygiene after removing gloves on multiple occasions while providing incontinence care. This included handling soiled items and moving from contaminated to clean tasks without washing hands or using an antiseptic hand rub, contrary to the facility's Hand Hygiene policy. During the observation, the CNA was seen providing pericare, removing a stool-soiled dressing, and handling various items in the resident's environment without performing hand hygiene between glove changes. The Assistant Director of Nursing (ADON) confirmed that the CNA should have completed hand hygiene after removing soiled gloves and before donning clean ones. This lapse in protocol was observed during care for a resident who required assistance with incontinence and had a stool-soiled dressing on the right buttock.
Inadequate Reconciliation of Controlled Medications
Penalty
Summary
The facility did not ensure adequate reconciliation of controlled medications for all four units, potentially affecting 12 residents who were prescribed controlled medications. The nurse-to-nurse controlled substance count verification forms were not consistently filled out, as required by the facility's Medication Administration and Controlled Substances policy dated January 2023. This policy mandates that at each shift change, a physical inventory of controlled medications is conducted by two licensed clinicians and documented on an audit record. However, the surveyor observed multiple instances across all units where these forms were missing signatures, indicating that the required counts were not performed or documented properly. Specifically, the surveyor noted missing signatures on various dates and shifts for the 100, 200, 300, and 400 units. For example, on the 100 unit, signatures were missing for three consecutive shifts on March 25. Similar patterns of missing signatures were observed on the other units, with the 200 unit having the most frequent occurrences. During an interview, the Nursing Home Administrator confirmed that two nurses should count and sign the verification forms between each shift, verifying the deficiency in the facility's practice of controlled substance reconciliation.
Incomplete Investigation of Neglect and Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a registered nurse (RN) and residents on the 300 wing. The incident occurred when staff observed the RN sleeping in their car during their shift and appearing to be under the influence of a substance. The RN refused a drug test and was subsequently terminated. During the investigation, it was discovered that the RN did not sign out morning medications for residents on the 300 wing on the day of the incident. However, the controlled drug logs showed that the RN had signed out scheduled and as-needed medications for one resident, but these were not documented as administered in the Medication Administration Record (MAR). The facility's investigation did not identify or rule out potential misappropriation of medication, as required by their policy on abuse, neglect, and exploitation. The Nursing Home Administrator (NHA) admitted that the controlled drug logs were reviewed during the investigation but was unaware that the RN had signed out controlled medications until informed by the surveyor. This oversight indicates that the facility did not conduct a thorough investigation to determine if misappropriation of medication had occurred. The failure to follow the facility's policy on investigating allegations of neglect and potential misappropriation of medication resulted in an incomplete investigation and a deficiency in ensuring resident safety and proper medication administration.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility did not have a qualified Social Worker, which had the potential to affect all 69 residents residing in the facility. The Social Services Director (SSD) and Social Services Coordinator (SSC) did not have degrees in social work or a related human services field and did not have one year of supervised social work experience in a health care setting. The Facility Assessment indicated the facility is licensed for 125 beds with an average daily census between 50-65 residents over the last 6 months and stated the facility provides a social worker, mental health social worker/counseling services to its residents. The SSD was hired on 2/14/24 as a full-time employee with a degree in Health Care Administration and previous work experience in behavioral intervention and working with adolescents with autism. The SSD confirmed they were not certified as a Social Worker in the State of Wisconsin and did not have one year of supervised social work experience in a health care setting. The SSC was hired in August of 2023 as a Certified Nursing Assistant (CNA) and started in the Social Services Department in December of 2023 while pursuing a biomedical degree. The SSC confirmed they were not certified as a Social Worker in the State of Wisconsin, did not have a degree in social work or human services, and did not have one year of supervised social work experience in a health care setting. The Nursing Home Administrator confirmed the facility's previous Social Worker left in January of 2024 and was certified with the State of Wisconsin.
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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) |
|---|---|---|---|---|
| Ccc Of West Green Bay | 0.3 mi | — | 0 | 0 |
| Grancare Nursing Center | 0.4 mi | ★★★★★ | 6 | 0 |
| Woodside Lutheran Home | 3.2 mi | ★★★★★ | 13 | 0 |
| Odd Fellow Home | 3.3 mi | ★★★★★ | 5 | 0 |
| Rennes Health And Rehab Center-de Pere | 5.8 mi | ★★★★★ | 9 | 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 July 2026) and official state health department websites.