Green Bay Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R1 and R2) of 4 sampled residents received the appropriate care and services to promote healing and/or prevent pressure injuries from developing. R1 was admitted to the facility with pressure injuries on the coccyx and bilateral heel deep tissue injuries (DTIs). Staff did not change R1's coccyx and heel dressings for 7 days after admission and did not initiate wound care orders until 2/4/25. In addition, R1's coccyx dressing was not changed on 2/7/25, 2/12/25, and 2/13/25. R1's heel dressings were not changed on 2/7/25 and 2/13/25. R2 had wounds on the right great toe, right heel, and coccyx. R2's wound care was not documented as completed on 7/31/25.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Hairstylist (HS)-H) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for HS-H.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 2 residents (R) (R34 and R36) in 1 of 2 medication carts were dated appropriately. In addition, the facility did not ensure two open containers of blood glucose test strips were dated appropriately in 2 of 2 medication carts. This practice had the potential to affect more than 4 of the 61 residents residing in the facility. Staff did not label or date R34 and R36's insulin pens in accordance with the facility's policy. The 400 wing medication cart contained an open and undated insulin pen for R34 and two open and undated insulin pens for R36. In addition, the medication cart contained an open and undated container of blood glucose test strips. Staff did not date a container of blood glucose strip in the 200 wing medication cart when opened.

Inspectors wroteBased on staff interview and record review, the facility did not have a Qualified Social Worker. This practice had the potential to affect more than 4 of the 61 residents residing in the facility. Social Services Director (SSD)-D and Social Services Coordinator (SSC)-C did not meet one or both requirements necessary to be considered a Qualified Social Worker in a facility licensed for 125 beds.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the right to make healthcare decisions was extended only to those delegated by the resident and in accordance with applicable law for 1 resident (R) (R24) of 19 sampled residents. R24 was admitted to the facility with a court-ordered temporary guardianship that expired on [DATE]. The facility continued to allow the temporary guardian to make healthcare decisions for R24 after [DATE].

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not report an allegation of misappropriation to the State Agency (SA) for 1 resident (R) (R31) of 19 sampled residents. On 4/28/25 at 10:46 AM, R31's guardian reported an allegation of misappropriation that involved a previous guardian who worked in the facility. The facility documented the conversation but did not report the allegation to the SA.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not thoroughly investigate an allegation of misappropriation for 1 resident (R) (R31) of 19 sampled residents. On 4/28/25, R31's guardian reported an allegation of misappropriation that involved a previous guardian who worked at the facility. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on observation, staff interview and record review, the facility did not provide appropriate catheter care and services for 1 resident (R) (R19) of 3 sampled residents. R19's uncovered catheter bag was observed in direct contact with the floor on 6/16/25, 6/17/25, and 6/18/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R40) of 2 sampled residents. The facility did not monitor R40's weight per the physician's order and in accordance with the facility's policy. In addition, the facility used R40's previous admission weight (from 1/12/24) to complete a dietary assessment and communicate with dialysis.

Inspectors wroteBased on staff interview and record review, the facility did not ensure medically-related social services were provided in order to attain or maintain the highest practicable level of well-being for 1 resident (R) (R24) of 19 sampled residents. R24 was admitted to the facility with a court-ordered temporary guardianship. The facility did not ensure permanent guardianship was completed prior to the expiration date of the temporary guardianship and completed a Power of Attorney for Health Care (POAHC) document with R24 without an assessment to ensure R24 had the cognitive ability to comprehend the document. In addition, the facility did not ensure Social Services staff, who witnessed the signature of R24's POAHC document, met the State of Wisconsin definition for Social Worker.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R) (R5) of 19 sampled residents. On 6/16/25, Surveyor observed medication on R5's bedside table hours after the AM medication pass. Staff documented the medications as administered. In addition, R5 did not have a self-administration of medication assessment or an order to self-administer medication.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure funds were safeguarded and managed appropriately for 1 resident (R) (R1) of 6 sampled residents with a Resident Fund Management Service (RFMS) account. R1 had an Irrevocable Burial Trust (IBT) account opened with the facility in March of 2021. In January of 2024, the IBT account was closed and the balance of $7,509 was withdrawn. The facility did not maintain the maximum value of $4500 allowed by Medicaid in R1's IBT account. In addition, the facility did not ensure proper notification was provided to R1's financial Power of Attorney (POA).

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures to prohibit and prevent abuse for 2 (Business Office Manager (BOM)-G and BOM-H) of 7 staff reviewed for background checks. The facility did not ensure thorough background checks were completed upon hire for BOM-G and BOM-H.

Inspectors wroteBased on staff interview and record review, the facility did not ensure neuro checks were completed post-fall in accordance with the facility's policy for 3 residents (R) (R2, R4, and R1) of 3 sampled residents. Neuro checks were not completed per the facility's policy after R2, R4, and R1 had unwitnessed falls.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. CNA-C was hired on 2/27/24 and had lived in two other states within the last three years. CNA-C's background check information did not contain out-of-state criminal or caregiver background checks.

Inspectors wroteBased on staff interview and record review, the facility did not ensure PASRR (Pre-admission Screen and Resident Review) requirements were met for 5 residents (R) (R9, R22, R15, R57, and R43) of 15 sampled residents. R9's medical record indicated R9 had a mental illness (MI) diagnosis upon admission and was prescribed psychotropic medication. R9's PASRR Level I Screen was marked no for major mental disorder, no for signs and symptoms of MI, and yes for intellectual disability (ID). The facility obtained a 30-day county exemption after R9's admission to the facility. The facility did not complete a PASRR Level II Screen when R9 remained in the facility past 30 days. R22's medical record indicated R22 had a history of ID and an MI diagnoses upon admission and was prescribed psychotropic medication. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure assistance with nail care for 1 resident (R) (R19) of 21 residents reviewed for activities of daily living (ADL) assistance. Staff did not provide routine nail care for R19.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pharmacy recommendation reports were acted on by a physician for 1 resident (R) (R5) of 9 residents reviewed for unnecessary medications. R5 had monthly pharmacy reviews that included pharmacist recommendations on 12/20/23 and 1/22/24. The facility did not ensure the recommendations were reviewed by a physician or nurse practitioner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure high-risk medications were monitored for 2 residents (R) (R18 and R15) of 5 residents reviewed for unnecessary medications. Staff did not monitor R18 for adverse reactions or potential side effects of divalproex (an anticonvulsant medication). Staff did not monitor R15 for adverse reactions or potential side effects of insulin (a medication used to control blood sugar).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 resident (R) (R1) of 2 residents observed during the provision of care. During an observation of incontinence care for R1, Certified Nursing Assistant (CNA)-F did not perform hand hygiene following glove removal on multiple occasions.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate care and treatment was provided for 1 resident (R) (R42) of 21 sampled residents. R42 stated R42 was unusually chilled on 4/1/24. The facility did not complete an appropriate assessment or notify the physician timely of R42's change in condition. In addition, R42's medical record indicated wound care was not consistently provided.

Inspectors wroteBased on staff interview and record review, the facility did not ensure adequate reconciliation of controlled medications for 4 of 4 units in the facility. This practice had the potential to affect 12 residents who were prescribed controlled medications. The nurse-to-nurse controlled substance count verification forms were not consistently filled out on 4 of 4 units.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 Resident (R) (R9) of 9 sampled residents. The facility investigated an allegation of neglect on 3/23/24 that involved Registered Nurse (RN)-C and residents on the 300 wing. The facility did not thoroughly investigate the allegation to also identify or rule out potential misappropriation of medication.

Inspectors wroteBased on staff interview and record review, the facility did not have a qualified Social Worker. This had the potential to affect all 69 residents residing in the facility. Social Services Director (SSD)-D and Social Services Coordinator (SSC)-E 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.

Inspectors wroteBased on staff interview and record review, the facility did not code the Minimum Data Set (MDS) (a comprehensive assessment of a resident completed at regular intervals or upon a significant change of condition) correctly for 2 Residents (R) (R2 and R4) of 14 residents reviewed. R2's MDS, dated [DATE], did not indicate R2 had a fall with major injury. R4's MDS, dated [DATE], did not contain accurate diagnoses and did not indicate R4 used antipsychotic medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan was developed for 1 Resident (R) (R56) of 14 sampled residents. R56 was admitted to the facility with a diagnosis of dementia. The facility did not develop a care plan to address R56's cognitive impairment. In addition, R56 was prescribed quetiapine (an antipsychotic medication) and insulin glargine (used to treat diabetes and regulate blood sugar). The facility did not develop care plans to address the use of the high risk medications.

Inspectors wrote2. R39 was admitted to the facility on [DATE] with diagnoses that included unspecified cord compression, neuromuscular dysfunction of the bladder and asthma. R39's MDS assessment, dated 3/8/23, contained a BIMS score of 15 out of 15 which indicated R39 had no cognitive impairment. R39 was their own decision maker. On 4/10/23 at 10:58 AM, Surveyor interviewed R39 who stated R39 was supposed to receive allergy eye drops for the past 6 months per R39's ophthalmologist (eye doctor). R39 stated eye drops were ordered during three visits, and more recently, R39 should be receiving eye drops for glaucoma. R39 stated R39 has not received any eye drops. R39 stated R39 mentioned the allergy eye drops to staff for a long period of time but has given up on that. [...]

Inspectors wroteBased on observation and resident and staff interview, the facility did not ensure a BiPAP (a ventilator device that helps with breathing) machine was cleaned for 1 Resident (R) (R40) of 1 resident reviewed. R40 used a BiPAP machine for a diagnosis of obstructive sleep apnea (a disorder that makes one stop breathing repeatedly during sleep, depriving the body and brain of oxygen). Staff did not clean R40's BiPAP machine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure they had an updated Hospice care plan and visit notes for 1 Resident (R7) of 1 resident reviewed for Hospice services. R7 did not have an updated Hospice care plan that depicted the type and number of visits R7 was to receive from Hospice-I. In addition, the facility was unable to provide Certified Nursing Assistant (CNA) visit notes from Hospice staff.