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Deficiency Records for Ccc of West Green Bay
A list of the most recent deficiencies for Ccc of West Green Bay. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Ccc of West Green Bay. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-22 | 2024-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-22 | 2024-08-09 | Y |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-05-22 | 2024-08-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-22 | 2024-07-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-22 | 2024-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-22 | 2024-06-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-22 | 2024-06-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-22 | 2024-06-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-22 | 2024-06-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-22 | 2024-06-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-22 | 2024-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-22 | 2024-06-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-05-22 | 2024-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-28 | 2024-03-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-03-19 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-20 | 2023-12-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-16 | 2023-11-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-16 | 2023-11-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-05 | 2023-10-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-05 | 2023-10-29 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-05 | 2023-09-29 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-04 | 2023-05-04 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-04 | 2023-05-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-04 | 2023-05-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-04 | 2023-05-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-04 | 2023-05-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-04 | 2023-05-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-04 | 2023-05-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-04 | 2023-05-04 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-04-04 | 2023-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-04 | 2023-05-04 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-04-04 | 2023-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-04 | 2023-05-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-04 | 2023-05-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-04 | 2023-05-04 | Y |
| Post nurse staffing information every day. | Health | 2023-04-04 | 2023-05-04 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-03 | 2023-04-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-03 | 2023-04-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-03 | 2023-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-03 | 2023-04-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-31 | 2023-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-31 | 2023-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-02-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-31 | 2023-02-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-31 | 2023-02-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-31 | 2023-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-19 | 2022-11-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-19 | 2022-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-12 | 2022-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-12 | 2022-10-12 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-03-23 | 2022-04-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-23 | 2022-04-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-23 | 2022-04-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-23 | 2022-04-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-23 | 2022-04-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-23 | 2022-04-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-23 | 2022-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-23 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-23 | 2022-04-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-23 | 2022-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-23 | 2022-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-23 | 2022-04-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-23 | 2022-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-23 | 2022-04-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-23 | 2022-04-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-23 | 2022-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-23 | 2022-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-23 | 2022-04-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-22 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-22 | 2022-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-22 | 2022-04-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-22 | 2022-04-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-03 | 2022-02-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-03 | 2022-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-11 | 2021-11-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-10 | 2021-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-10 | 2021-11-10 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-10-10 | 2021-11-10 | Y |
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