Williams Bay Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Jun 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure 1 (R14) of 2 sampled residents with pressure injuries received the necessary care and treatment based upon standards of practice to prevent pressure injuries from developing, promote healing, and prevent new areas from developing.R14 developed an abrasion to her right buttock 13 days after admission. The abrasion deteriorated to a Stage 4 pressure injury (PI) requiring hospitalization, surgical debridement, and a wound VAC. The wound became infected requiring antibiotic treatment, 2 different times. […]

• Immediate jeopardy, isolatedF600Jul 20, 2022

  Based on interview, observation and record review, the facility did not ensure 1 of 1 resident was free from sexual abuse. On 7/4/22, R1 was allegedly sexually assaulted by R2. Although staff were surprised that R2 did what he did and although R2 rarely left his room, less than 24 hours earlier, R2 acted out sexually with a certified nursing assistant (CNA) which was a new behavior for R2. Licensed Practical Nurse (LPN)-H put a verbal plan in place to protect CNAs by encouraging the use of two CNAs in R2's room to provide cares but did not put a plan in place to protect residents. On 7/3/22, LPN-H said to CNA-F that (R2) should get tested for a urinary tract infection ([CONDITION(S)]), however a urinalysis was not done until 7/5/22, the day following the assault of R1. […]

• Actual harm, isolatedF689Jun 3, 2026

  Based on observation, interview and record review the facility did not ensure 4 (R20, R34, R32 and R24) of 4 sampled residents had services that prevented accident hazards. On [DATE] R34 had an unwitnessed fall and was sent to the hospital R34. R34 sustained a left intertrochanter fracture. On [DATE] R20 had an unwitnessed fall and was sent to the hospital. R20 sustained a zygomatic arch (cheek bone) fracture. On [DATE] and [DATE] R32 was observed to be drinking with a straw in her sippy cup. R32 had been assessed and care planned they should not drink through a straw due to swallowing concerns. On [DATE], R24 was overheard by staff calling a physician office and asking for an appointment. […]

• Actual harm, isolatedF689Mar 27, 2025

  Based on observation, interview and record review, the facility did not ensure 2 (R26 and R29) of 2 residents reviewed received adequate supervision, interventions to prevent accidents. * On 02/12/2025, R26 sustained an injury during a transfer resulting in a skin tear to left lower leg requiring R26 to go to the emergency room where Steri-Strips were applied to R26's wound. On 03/03/2025, R26 reinjured R26's left lower leg during a transfer which caused bleeding and R26 was prescribed an antibiotic for Cellulitis. On 03/26/2025, Surveyor observed staff improperly transfer R26. *There was no quarterly smoking assessment for R29 on a quarterly basis. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2026

  Based on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety (Wisconsin Food Code) in the main kitchen. This deficient practice has the potential to affect all 33 residents who receive food from the main kitchen. *Three opened cardboard boxes containing cookie dough, turkey breast, and orange juice were observed resting directly on the floor in the walk-in freezer in the main kitchen. […]