Serenity Spring Senior Living at Green Bay

In the surveyor’s words

From the most serious findings on record at Serenity Spring Senior Living at Green Bay, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 4, 2021

  Based on Resident (R) interview, staff interviews, observation, and record review, the facility did not ensure residents were free from significant medication errors when a diuretic medication was not administered as ordered for 1 (R20) of 6 residents reviewed for unnecessary medications. The facility did not administer R20's diuretic, [MEDICATION(S)] ([MEDICATION(S)]/water pill), daily since ordered on 6/16/21 (48 doses missed) which resulted in R20 experiencing increased [CONDITION(S)] and shortness of breath and requiring the use of oxygen therapy beginning on 7/31/21. Findings include: Surveyor reviewed R20's medical record which documented R20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jan 7, 2026

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 48 residents residing in the facility.The reach-in coolers and freezers contained expired and/or undated items.During an observation of food service, [NAME] (CK)-K touched serving dishes, trays, plates, and utensils with gloved hands. CK-K then left the steam table and opened a package of cups. […]

• No harm, potential for more than minimal, widespreadF812Aug 23, 2023

  Based on staff interview and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 45 of 46 residents (one resident was fed via tube) residing in the facility. Cooling logs were not completed for leftover foods. Refrigerator temperature logs were not completed for 1 of 2 unit refrigerators and not consistently completed for the coolers and freezers in the kitchen. Findings include: On 8/21/23 at 9:06 AM, Surveyor began an initial tour of the kitchen with Cook (CK)-D who indicated the facility followed the Federal Food Code. […]

• No harm, potential for more than minimal, patternF880Jan 7, 2026

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 48 residents residing in the facility.The facility did not have an accurate flow diagram of the facility's water system that identified areas where Legionella could grow. In addition, the facility did not maintain drinking fountains on two units or post signs that residents and visitors should not use the fountains.Staff did not appropriately remove personal protective equipment (PPE) and cleanse hands during the provision of care for R4.Findings include:The facility's Legionella/Water Management… […]

• No harm, potential for more than minimal, patternF812Sep 5, 2024

  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 more than 4 of the 50 residents residing in the facility. Food items for resident consumption were not labeled with open or expiration dates and/or were beyond the labeled discard date in 3 of 3 unit refrigerators. Staff did not follow safe food cooling protocol. Findings include: On [DATE] at 1:30 PM, Surveyor interviewed Dietary Manager (DM)-C who stated the facility followed the Food and Drug Administration (FDA) Food Code. […]