Williams Bay Health Services

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R14) of 2 sampled residents with pressure injuries received the necessary care and treatment based upon standards of practice to prevent pressure injuries from developing, promote healing, and prevent new areas from developing. R14 developed an abrasion to her right buttock 13 days after admission. The abrasion deteriorated to a Stage 4 pressure injury (PI) requiring hospitalization, surgical debridement, and a wound VAC. The wound became infected requiring antibiotic treatment, 2 different times. Surveyor's observations of wound care completed by facility staff identified concerns with infection control and care plan interventions not being implemented or in place. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure 4 (R20, R34, R32 and R24) of 4 sampled residents had services that prevented accident hazards. On [DATE] R34 had an unwitnessed fall and was sent to the hospital R34. R34 sustained a left intertrochanter fracture. On [DATE] R20 had an unwitnessed fall and was sent to the hospital. R20 sustained a zygomatic arch (cheek bone) fracture. On [DATE] and [DATE] R32 was observed to be drinking with a straw in her sippy cup. R32 had been assessed and care planned they should not drink through a straw due to swallowing concerns. On [DATE], R24 was overheard by staff calling a physician office and asking for an appointment. When staff asked if R24 needed assistance and why they needed the appointment R24 replied to get an order for a gun to shoot herself with. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen. This deficient practice has the potential to affect all 33 residents who receive food from the main kitchen. *Three opened cardboard boxes containing cookie dough, turkey breast, and orange juice were observed resting directly on the floor in the walk-in freezer in the main kitchen.

Inspectors wroteBased on interview and record review, the facility did not implement policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring to develop activities to prevent adverse events potentially affecting 33 of 33 residents in the facility. The facility did not develop written documentation of performance improvement activities to facilitate the identification of facility-wide problems, devise plans to address the identified issues, and have a system to monitor the effectiveness of those plans and revise as needed.

Inspectors wroteBased on interview and record review the facility did not ensure 8 of 8 direct & non-direct staff chosen at random received behavioral health training. Licensed Practical Nurse (LPN)-OO, Housekeeper-PP, Cook-QQ, Certified Nursing Assistant (CNA)-RR, CNA-SS, CNA-TT, CNA-MM, and CNA-UU did not receive behavioral health training.

Inspectors wroteBased on interview and record review, the facility did not ensure implementation of their policies and procedures to prevent abuse. The facility failed to ensure the criminal background checks were completed prior to employment for 4 of 8 employees reviewed potentially affecting a pattern of the 33 facility residents at the time of the survey. *Registered Nurse (RN)-K was hired on 12/1/2019 and the criminal background check was completed 3/2018, 21 months prior to the hire date and not just prior to employment. A second criminal background check was completed 3/2025, 5 years after the hire date. *Life Enrichment (LE)-L was hired on 8/24/2023 and the criminal background check was completed 1/2024, 4 months after the hire date, and the out-of-state background check was completed 11/2024, 15 months after the hire date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure licensed nurses had competencies and skill sets necessary to care for diabetic residents requiring insulin was identified with 1 (R30) of 4 sampled residents. *R30 was administered insulin from an insulin pen. Registered Nurse (RN)-P did not administer the insulin as instructed by the manufacturer or to professional standards.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a sanitary environment for 3 (R4, R14, and R28) of 13 sampled residents and potentially affecting any resident eating in the dining room. *R4 was administered oral medications by Registered Nurse (RN)-P. RN-P touched every pill with bare hands before putting them in the medicine cup. *R14 had a dressing change done to a wound by RN-O where hand hygiene was not performed during the treatment and RN-P provided incontinence care to R14 without performing hand hygiene between dirty and clean areas and touched items in R14's room without performing hand hygiene. *R28 was in enhanced barrier precautions and staff did not don gowns prior to performing cares on R28 and no hand hygiene was performed after incontinence care. *An uncovered rack of unclaimed clothing was observed in the dining room throughout the survey.

Inspectors wroteBased on interview and record review, the facility did not ensure pneumonia immunizations were offered to residents affecting 4 (R4, R17, R20, And R22) of 5 sampled residents reviewed for pneumonia immunizations. *R4 was not current in their pneumococcal vaccination, and no vaccine was offered. *R17 was not current in their pneumococcal vaccination, and no vaccine was offered. *R20 was not current in their pneumococcal vaccination, and no vaccine was offered. *R22 was not current in their pneumococcal vaccination, and no vaccine was offered.

Inspectors wroteBased on interview and record review the facility did not ensure a resident's physician was consulted with for 1 (R28) of 13 residents reviewed. *The Facility did not ensure the physician was notified/consulted after R28 reported mild knee pain to Physical Therapy on 1/29/2026. R28 continued to experience left knee swelling and the physician was not notified until 2/12/2026.

Inspectors wroteBased on observation and record review the facility did not ensure 1 (R14) of 15 sampled residents were provided with privacy during treatments/cares. On 5/20/26 at 10:25 a.m. Surveyor observed R14 receive wound treatment to the right buttock. During the treatment, R14's window blinds were not closed and the window faced the outside where people could possibly walk by and observe R14 receiving care.

Inspectors wroteBased on observation and interview, the facility did not ensure a safe, clean, comfortable, and homelike environment for 2 (R4, and R30) of 13 sampled residents. *R4 had a large hole in R4's wall in R4's room on the right side.*R30 had a large amount of paint missing on R30's wall on the right side.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R32) of 3 sampled residents reviewed for potential abuse concerns had their allegations reported to the state agency. On 5/1/26 a bump with bruising was discovered on R32's right forehead. The area measured 1.9 centimeters (cm) by 4.0 cm. R32 was unable to state what happened so an investigation was initiated. This potential allegation was not reported to the state agency.

Inspectors wroteBased on interview and record review, the facility did not ensure written notice of the facility bed hold policy was provided to the resident and/or the resident's representative. Proper transfer/discharge information was also not sent to the State Long-Term Care Ombudsman for 3 (R7, R8, & R22) of 7 residents reviewed for transfers or discharges. *R7 was hospitalized on [DATE]. A written copy of R7's bed hold notice was not sent to R7's representative, and the facility did not notify the State Long-Term Care Ombudsman of R7's transfer to the hospital. *R8 was hospitalized on [DATE] and 3/21/26. A written copy of R8's bed hold notice was not sent to R8's representative, and the facility did not notify the State Long-Term Care Ombudsman of R8's transfer to the hospital on 3/21/26.*R22 was hospitalized on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive care plan based upon an assessment for 1 (R14) of 15 sampled residents.*R14's was assessed as needing side rails on their bed. R14's care plan did not include R14's use of side rails as part of their care plan.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided for 1 (R37) of 13 residents observed for call light wait times in order to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. *On 5/20/26, Surveyor observed R37's call light go unanswered for 35 minutes when R37 needed assistance with toileting.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R28) of 13 residents (R) received necessary care and treatment.* R28 experienced changes in their left lower extremity that included, swelling, pain, and decrease in strength. The facility staff documented about R28 having increased swelling but a thorough assessment was not completed. Consistent monitoring did not occur. On 2/12/26 a doppler ultrasound was ordered which ruled out a possible blood clot. An x-ray of the knee was not ordered until 2/20/26 which indicated a possible fracture of the knee. This was confirmed by a second x-ray.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 (R28) of 2 residents with a urostomy received appropriate treatment & care.*R28 was admitted to the Facility with a urostomy (a surgical procedure that creates an alternate route for urine to leave your body when the bladder is removed or malfunctioning). The Facility did not have the proper supplies to care for R28's urostomy needs.

Inspectors wroteBased on interview and record review the Facility did not comprehensively assess 3 (R22, R24, and R30) of 3 sampled Residents for traumas and develop care plan approaches ensure provision of trauma informed care to mitigate any triggers to prevent re-traumatization.* R22's psychology progress note dated [DATE] identify' s R22 as having military service with deployment. The facility did not complete a comprehensive trauma assessment to develop and implement an individualized trauma informed plan of care.*R24's trauma informed care assessment dated [DATE] was incomplete with 8 questions not answered. The facility did not complete a comprehensive trauma assessment to develop and implement an individualized trauma informed plan of care.*R30 was admitted on [DATE] with a diagnosis of Post Traumatic Stress Disorder (PTSD). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure Residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 3 (R2, R24, and R30) of 5 sampled Residents reviewed for mood concerns.*R2 expressed the need to receive in-person psychotherapy and psychotherapy was not initiated by the facility.*R24 expressed suicidal ideation on 2/2/26. No documentation was found that a suicidal evaluation was completed. The physician was not notified, or a Care Plan was not developed to address R24's suicidal ideation.*R30 expressed the need to receive in-person psychotherapy and psychotherapy was not initiated by the facility.

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 1 (R2) of 13 sampled residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.*Therapy assessed R2 as needing a bigger wheelchair 10/24/25. R2 attends dialysis 3 times a week and the transportation company stated they would no longer be able to transport R2 to and from dialysis with a bigger wheelchair. R2 has not received the replacement wheelchair and continues to use a wheelchair that is too small and is broken because the facility informed R2 that R2 would need to seek alternative placement to get a bigger chair and continue dialysis. R2 does not want to leave the facility. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain procedures for acting upon the monthly drug regimen review recommendations for 1 (R7) of 5 residents reviewed. R7's Pharmacy Medication Regimen Review, dated 1/21/26, recommended discontinuing scheduled Benzonatate 100 milligrams (mg) daily and changing it to PRN (as needed). R7's physician approved this recommendation on 2/11/26. R7 continued to receive scheduled Benzonatate 100 mg daily until it was discontinued on 3/4/26.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 (R7) of 5 residents reviewed. R7's pharmacy medication regimen review dated 1/21/26 recommended R7's order for Benzonatate 100 milligrams (mg) daily be discontinued or changed to as needed (PRN). R7's ordering practitioner response documented OK PRN dated 2/11/26, but R7 continued to receive Benzonatate 100 mg daily until 3/1/26.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R34) of 6 residents reviewed for medications were free from significant medication errors. On 3/17/26 between 7:50 p.m. and 10:00 p.m., R34 received a combination of narcotics, benzodiazepine and muscle relaxers in a short time span and not according to physician orders for the amount and frequency.

Inspectors wroteBased on interview and record review the facility did not ensure 2 of 2 non-direct staff chosen at random received QAPI (Quality Assurance Performance Improvement) training on the elements and goals of the facility's QAPI program. Housekeeper-PP and Cook-QQ did not receive QAPI training.

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 5 randomly sampled Certified Nursing Assistant (CNA) had a current CNA Skills Competency Checklist completed to address areas of weakness. CNA-TT's last CNA Skills Competency Checklist was completed on 1/1/24.

Inspectors wroteBased on observation, staff interview, and record review the facility did not ensure contact information for all pertinent State agencies and advocacy groups, was posted. Further, a statement that the Resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to Resident abuse or neglect, and non-compliance with the advanced directives requirements, Medicaid Fraud Control Unit and requests for information regarding returning to the community was not posted. This practice had the potential to affect all 33 residents of the facility at the time of the survey. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide left arm support at the toilet to assist in transfers for one resident (Resident) 1) in a total sample of 3. This failure placed the resident at higher risk for falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 (R26 and R29) of 2 residents reviewed received adequate supervision, interventions to prevent accidents. * On 02/12/2025, R26 sustained an injury during a transfer resulting in a skin tear to left lower leg requiring R26 to go to the emergency room where Steri-Strips were applied to R26's wound. On 03/03/2025, R26 reinjured R26's left lower leg during a transfer which caused bleeding and R26 was prescribed an antibiotic for Cellulitis. On 03/26/2025, Surveyor observed staff improperly transfer R26. *There was no quarterly smoking assessment for R29 on a quarterly basis. Findings Include: The facility's policy, titled NSG-Safe Resident Handling and transfers, with a last reviewed date of 05/05/2022, documents: Policy: [...]

Inspectors wroteBased on record review and staff interview, the facility did not maintain an effective infection control program under which it investigates, controls, and prevents infections in the facility. * Total infection rates were not calculated accurately and rates of infection for individual infection types were not calculated. Since infection rates were not calculated it was not possible to analyze the data to determine if there was a rise in the prevalence of infections from month to month with a potential to affect 32 of 32 residents. * R33 was observed to receive treatment to her pressure injuries and proper hand hygiene was not used in accordance to the facilities policies and procedures.

Inspectors wroteBased on observation, interview and record review, the Facility did not ensure proper inspection of resident beds. *On 02/12/2025 and 03/03/2025, R26 was injured during a transfer. The metal pieces of R26's bed did not have plastic caps to protect R26's shins and legs from the bed's sharp metal edges.

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 (R26) of 2 residents reviewed for pain management received pain management consistent with professional standards of practice and Resident choice related to pain management. * The facility did not provide as needed pain medication or offer non-pharmacological interventions on 03/07/2025 for R26. The facility did not confer with R26's healthcare team regarding documented ineffective pain medication and did not offer non-pharmacological pain interventions for R26 on 03/08/2025, 03/21/2025, and 03/25/2025.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect by staff for one of three residents (Resident (R) 1) reviewed for neglect in a total sample of eight residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of neglect by staff for one of three residents (Resident (R) 1) reviewed for neglect in a total sample of eight residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to investigate an allegation of neglect by staff for one of three residents (Resident (R) 1) reviewed for neglect in a total sample of eight residents.