Green Bay Health Services

In the surveyor’s words

From the most serious findings on record at Green Bay Health Services, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF607Jun 18, 2025

  Based 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. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. […]

• No harm, potential for more than minimal, patternF761Jun 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF850Jun 18, 2025

  Based 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. Findings include: On 6/18/25, Surveyor reviewed the facility's employee list which indicated SSD-D's position was Social Services Qualified Director. On 6/18/25 at 8:41 AM and 9:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated SSD-D was a certified Social Worker and confirmed SSC-C was not a certified Social Worker. […]

• No harm, potential for more than minimal, patternF645May 30, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF755Apr 1, 2024

  Based 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. Findings include: The facility's Medication Administration and Controlled Substances policy, dated 1/2023, indicates: At each shift change, a physical inventory of controlled medications, as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record. […]