Brown County Health and Living Community

In the surveyor’s words

From the most serious findings on record at Brown County Health and Living Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were transferred per plan of care with the right amount of assistance for 2 of 6 residents reviewed for accidents. One resident sustained a fractured right shoulder (Resident 98) and another resident sustained injury to an existing wound requiring invasive wound vacuum therapy. (Resident 26) The Immediate Jeopardy began on 6/7/22 when the facility failed to ensure a resident was safely transferred by qualified staff which resulted in the resident experiencing immediate pain and was sent to the hospital where it was discovered the resident sustained right shoulder fracture (Resident 98). On 7/17/22 a resident sustained a fall which resulted in profuse bleeding from an existing wound. […]

• Actual harm, isolatedF740Dec 20, 2022

  Based on interview and record review, the facility failed to provide supervision to prevent resident to resident behaviors for 1 of 3 residents reviewed. This resulted in a resident sustaining a fracture following a resident to resident altercation. (Resident B, Resident C) Findings include: On 12/21/22 at 11:00 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder, Alzheimer's disease, and restlessness and agitation. The Quarterly MDS (Minimum Data Set) assessment, dated 11/22/22, indicated the resident was not cognitively intact. The resident's care plan indicated, PROBLEM: Problem Start Date: 10/13/22 .edited 12/20/22 . […]

• No harm, potential for more than minimal, isolatedF698Aug 15, 2025

  Based on interview and record review, the facility failed to ensure the dialysis center provided a report or communication form after dialysis treatment and the Pre-Dialysis and Post-Dialysis Assessment Observation were completed after Resident 7's dialysis treatment and for 1 of 1 resident reviewed for dialysis. (Resident 7)Findings include:On 8/11/25 at 2:40 p.m., Resident 7 indicated he received dialysis early in the mornings on Monday, Wednesday, and Friday.On 8/13/25 at 10:28 a.m., Resident 7's clinical record was reviewed. […]

• No harm, potential for more than minimal, isolatedF657Sep 5, 2023

  Based on interview and record review, the facility failed to revise a care plan for a resident who fell and sustained an injury for 1 of 1 residents reviewed for accidents. (Resident 8) Findings include: During an interview on 8/30/23 at 10:30 A.M., Resident 8 indicated she had fallen in June while she was reaching for a snack. She was sent to the hospital where it was determined that she had broken her left hip. She did not recall meeting with staff regarding new interventions to her fall care plan. On 8/30/23 at 10:45 A.M., Resident 8's clinical record was reviewed. […]

• No harm, potential for more than minimal, isolatedF602Aug 1, 2023

  Based on interview and record review, the facility failed to protect the residents right to be free from misappropriation of property for 1 of 1 residents reviewed. A resident's narcotic pain medication and count sheet were unaccounted for. (Resident C, RN 1) Findings include: During an interview on 8/1/23 at 9:50 a.m., the Director of Nursing (DON) and Administrator (ADM) indicated the on 7/23/23, LPN 1 discovered a bottle of Resident C's liquid Dilaudid (a narcotic medication used for pain control) was missing from the medication cart along with the narcotic count sheet. Their investigation discovered RN 1 was working around that time who was administering a significant amount of as needed medication (PRN) and her statements were incriminating. […]