Care Citations

WILLIAMS BAY HEALTH SERVICES

146 CLOVER ST, WILLIAMS BAY, WI, 53191 · 2622456400

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
1 / 5
Staffing rating
3 / 5
Certified beds
50
Ownership type
For profit - Corporation
Chain
NORTH SHORE HEALTHCARE

Inspection findings on record (35)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity J · immediate jeopardy

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Administration Deficiencies

Tag 0949 · scope/severity F · potential for more than minimal harm

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity E · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0583 · scope/severity D · potential for more than minimal harm

Keep residents' personal and medical records private and confidential.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity D · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0691 · scope/severity D · potential for more than minimal harm

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0699 · scope/severity D · potential for more than minimal harm

Provide care or services that was trauma informed and/or culturally competent.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0740 · scope/severity D · potential for more than minimal harm

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0745 · scope/severity D · potential for more than minimal harm

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Administration Deficiencies

Tag 0944 · scope/severity D · potential for more than minimal harm

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0947 · scope/severity D · potential for more than minimal harm

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0575 · scope/severity C · potential for minimal harm

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity G · actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0909 · scope/severity F · potential for more than minimal harm

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity D · potential for more than minimal harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 525346