Sturgeon Bay Health Services

Inspectors wroteBased on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 1 resident (R) (R8) of 7 sampled residents. The facility did not contact the state mental health authority to pursue further PASRR screening for R8 when R8's 30-day exemption expired.

Inspectors wroteBased on resident and staff interview and record review, the facility did not ensure the accurate acquisition and administration of medication for 1 resident (R) (R38) of 6 sampled residents. R38 had orders for 50 milligrams of scheduled and as needed (PRN) tramadol. R38 did not receive eight doses of the medication when the medication ran out and/or was not removed from contingency stock.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R3, R4, and R5) of 3 residents observed during the provision of care. R3 was on enhanced barrier precautions (EBP). On 7/8/25, staff repositioned R3, adjusted R3's pillows and bedding, and provided incontinence care without wearing a gown and/or gloves. In addition, staff administered medication to R3, exited the room without completing hand hygiene, and retrieved supplies from the medication cart for another resident. R4 was on EBP. On 7/8/24, staff dressed and groomed R4 without wearing a gown or gloves. R5 was on EBP. On 7/8/25, staff assisted R5 with peri-care and a transfer from toilet to wheelchair without wearing a gown.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 3 residents (R) (R2, R1, and R6) of 4 sampled residents. R2 used a ROHO cushion (a type of cushion designed to prevent pressure injuries by using interconnected air cells to distribute weight and reduce pressure points) that was noted to be deflated. R2's plan of care did not indicate R2 used a ROHO cushion, did not contain an order to ensure the cushion was inflated, and was not updated with timely interventions after R2 developed what was initially thought to be a pressure injury but was later determined to be a sebaceous or pilonidal cyst. R2 was also provided a foam cushion with a cut-out but did not have an assessment for the cushion and did not use the cushion in R2's recliner. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 4 sampled residents was transferred safely with a mechanical lift. On several instances between 12/10/24 and 12/20/24, therapy and nursing staff documented R1 was unable to safely transfer with a sit-to-stand lift. On 12/18/24, therapy staff determined R1 should be transferred with a full body (Hoyer) lift for safety. R1's care plan and Certified Nursing Assistant (CNA) [NAME] (an abbreviated care plan used by nursing staff) were not updated with the changes and staff continued to transfer R1 with a sit-to-stand lift. On 12/18/24, staff observed significant bruising on R1's left upper arm, shoulder, and torso. On 12/20/24, lab results indicated R1 was experiencing severe acute anemia. R1 was hospitalized from [DATE] to 12/23/24 and required a blood transfusion.

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R15) of 1 resident with a legal guardian was obtained when the resident's nursing home stay exceeded 90 days. R15 had a legal guardian. The facility did not obtain court-ordered protective placement for R15 to ensure R15 resided in the least restrictive environment at the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R5) of 13 sampled residents. On 10/18/24, R5 was hospitalized due to not eating or drinking. R5 did not have a care plan that addressed nutrition or hydration.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R28) of 14 residents reviewed for activities of daily living (ADL) assistance. Staff did not provide routine nail care for R28.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate care and services for 1 resident (R) (R4) of 2 sampled residents with an indwelling catheter. On 10/28/24 and 10/30/24, R4's catheter drainage bag and tubing were observed in contact with the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure necessary treatment and services related to nutrition were provided for 1 resident (R) (R33) of 4 sampled residents. R33 was prescribed large portions for meals. During lunch service on 10/29/24, kitchen staff did not ensure R33 received large portions. In addition, R33 was prescribed a nutritional supplement 3 times per day for weight management. When R33 returned from the hospital on [DATE], the nutritional supplement was not provided for 11 days.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. The facility did not monitor and document food cooked temperatures and food cooling temperatures.

Inspectors wroteBased on staff interview and record review, the facility did not ensure residents were free from unnecessary psychotropic medications by monitoring for adverse reactions for 2 Residents (R) (R8 and R33) of 5 residents reviewed. R8 was prescribed lorazepam (a psychotropic medication used to treat anxiety). The facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment (used to assess tardive dyskinesia (involuntary repetitive movements) in those who are prescribed psychotropic medications) to monitor for adverse side effects of the medication. R33 was prescribed quetiapine fumarate (Seroquel) for agitation related to unspecified dementia with anxiety. The facility did not complete an AIMS assessment. (Persons taking antipsychotic medication need to be monitored for movement disorders. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the mandatory staffing data submitted from 4/1/22 through 6/30/23 was complete, accurate, and auditable. This had the ability to affect all 37 residents residing in the facility. Payroll Based Journal (PBJ) data submitted by the facility from 4/1/22 through 6/30/23 was not complete, accurate, or auditable.