Sturgeon Bay Health Services

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 22, 2025

  Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 4 sampled residents was transferred safely with a mechanical lift. On several instances between 12/10/24 and 12/20/24, therapy and nursing staff documented R1 was unable to safely transfer with a sit-to-stand lift. On 12/18/24, therapy staff determined R1 should be transferred with a full body (Hoyer) lift for safety. R1's care plan and Certified Nursing Assistant (CNA) Kardex (an abbreviated care plan used by nursing staff) were not updated with the changes and staff continued to transfer R1 with a sit-to-stand lift. On 12/18/24, staff observed significant bruising on R1's left upper arm, shoulder, and torso. […]

• No harm, potential for more than minimal, widespreadF812Oct 4, 2023

  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. […]

• No harm, potential for more than minimal, isolatedF645Mar 4, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF755Mar 4, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF880Jul 8, 2025

  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. […]