Sturgeon Bay Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:The facility's Resident Assessment: Coordination with Pre-admission Screening and Resident Review Program policy, dated [DATE], indicates: The facility coordinates assessments with the Pre-admission Screening and Resident Review (PASRR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs .ii. A positive Level I Screen necessitates a PASRR Level II evaluation prior to admission .2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:According to the United Stated Drug Enforcement Agency (DEA), controlled medications are medications classified as Schedule I, II, III, IV, or V based on the potential of abuse or dependency. Schedule I has the highest potential and Schedule V has the least potential of abuse or dependency.The facility's Medication Ordering and Receiving From Pharmacy; Provider Ordering and Receiving Controlled Medications policy indicates: Ordering and Receiving Controlled Medications .5. Refill requests for CIII-CV (C = Schedule) and partial fill requests for CII: a. If one or more refills (CIII-Vs) or a partial fill quantity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:The facility's Enhanced Barrier Precautions Policy, revised 8/8/24, indicates: .Enhanced barrier precautions (EBP) refer to an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.R1 and R6 had ROHO cushions. R1 and R6 did not have orders to ensure the ROHO cushions were properly inflated.Findings include:The facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: State Statute Chapter 55.03(4) indicates court-ordered protective placement should be obtained for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds 90 days. On 10/28/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including Down syndrome. R15's Minimum Data Set (MDS) assessment, dated 9/12/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R15 had severely impaired cognition. R15 a had a guardianship in place at the time of admission.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: The facility's Comprehensive Care Plan policy and procedure, dated 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 10/28/24, Surveyor reviewed R5's medical record. R5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The facility's Nail Care Policy, dated 4/20/23, indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .2. Identify conditions that increase the risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. On 10/28/24, Surveyor reviewed R28's medical record. R28 had diagnoses including renal failure, arthritis, and hypertension. R28's Minimum Data Set (MDS) assessment, dated 8/2/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R28 had moderate cognitive impairment. R28's medical record indicated R28 was responsible for R28's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: The facility's Catheter Care policy and procedure, dated 3/15/23, does not address the positioning/placement of catheter tubing or drainage bags. On 10/28/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including history of diabetes, chronic kidney disease (CKD), heart failure, and urinary tract infection (UTI). R4's Minimum Data Set (MDS) assessment, dated 9/22/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R4 had moderate cognitive impairment. R4 had an activated Power of Attorney (POA) for healthcare decisions. R4's medical record indicated R4 was sent to the Emergency Department (ED) on 10/9/24 for not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 10/30/24 at 1:51 PM, [NAME] President of Success (VPS)-C indicated the facility did not have policies for nutrition or re-admission orders. Between 10/28/24 and 10/30/24, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including T11-T12 vertebra subsequent encounter for fracture with routine healing and displaced intertrochanteric fracture of the right femur. R33's Minimum Data Set (MDS) assessment, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 10/3/23, Executive Director (ED)-C verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. Cooked temperatures: The FDA Food Code 2022 indicates at section 3-401.11 Raw Animal Foods. (A) Except as specified under (B) and in (C) and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and food containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked .Internal Cooking Temperature Specifications for Raw Animal Foods .Raw eggs cooked for immediate service, fish, intact meat, except whole meat roasts and whole muscle intact beef steak at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The AIMS aids in the early detection of tardive dyskinesia as well as provides a method for ongoing surveillance.) Findings include: The National Institutes of Health (NIH) National Library of Medicine, last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.