DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Notes This report includes Provider Inspection Summaries (Facility Profiles) for Community Based Residential Facilities in Brown County. The report includes only facilities located within the City of Green Bay. Reports for facilities located in other communities are listed separately on the DQA Facility Profile webpage. The report is a PDF (Adobe Acrobat) document and includes a total of 88.00 pages. If you wish to read the profile for a particular facility without scrolling through the rest of the document, use the Search feature in the Acrobat Reader to specify part of the name of the facility you wish to review. If you wish to print the profile for a particular facility, be sure to send only the desired pages to your computer printer. Otherwise you will be printing all pages in the document. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AS (SEMIAMBULATORY) Facility Information Facility Name: ACS GREEN BAY (0011996) Address: 2670 UNIVERSITY AVE, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 08/31/2007 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111462 Type: OTHER End Date: 10/15/2012 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110485 End Date: 04/12/2012 Type: ABBREVIATED Purpose: SURVEY/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #1FGE12 Served 05/09/2012 Deficiencies Cited 83.35(1)(c) 83.45(1)(f) Subject Area LISTED AREAS FOR ASSESSMENTS FURNISHINGS CLEAN, SAFE, AND MAINTAINED Compliance Verified 10/15/2012 10/15/2012 Corrected Yes Yes This is Page 2 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (ACS GREEN BAY) Date: 05/03/2012 SOD #1FGE12 Sanctions FORFEITURE---83.35(1)(c) Appealed: No This is Page 3 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: ALLOUEZ PARKSIDE VILLAGE (0013195) Address: 1901 LIBAL ST, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 03/26/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113647 Type: OTHER End Date: 09/23/2013 Purpose: COMPLAINT/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #K04J11 Served 10/04/2013 Deficiencies Cited 83.32(3)(l) 83.59(4)(a) Survey ID: 0112408 Subject Area RIGHTS OF RESIDENTS: LEAST RESTRICTIVE DELAYED EGRESS: ONLY ONE DEVICE PERMITTED End Date: 03/14/2013 Type: STANDARD Compliance Verified Corrected Purpose: SURVEY/COMPLAINT/SELF REPORT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0109910 End Date: 01/13/2012 Type: OTHER Purpose: COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 4 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Survey ID: 0109599 End Date: 11/02/2011 Type: STANDARD Purpose: SURVEY Results: ENFORCEMENT ACTION Statement of Deficiency: #K61611 Served 11/23/2011 Deficiencies Cited 83.14(2)(a) 83.32(3)(i) 83.35(1)(c) 83.35(3)(d) 83.47(2)(d) 83.47(2)(e) 83.48(3)(a) 83.48(8)(b) 83.59(2)(a) Subject Area LICENSEE ENSURES FACILITY COMPLIES WITH LAWS RIGHTS OF RESIDENTS: PROMPT AND ADEQUATE TREA LISTED AREAS FOR ASSESSMENTS SERVICE PLANS UPDATED ANNUALLY OR ON CHANGE FIRE DRILLS OTHER EVACUATION DRILLS FIRE DETECTION SYSTEMS INSPECTED ANNUALLY SPRINKLER SYSTEM INSTALLATION AND MAINTENAN ONE-HAND, ONE-MOTION DOOR OPERATION Compliance Verified 03/12/2013 03/12/2013 03/12/2013 03/12/2013 03/12/2013 03/12/2013 03/12/2013 03/12/2013 03/12/2013 Corrected Yes Yes Yes Yes Yes Yes Yes Yes Yes This is Page 5 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (ALLOUEZ PARKSIDE VILLAGE) Date: 11/22/2011 SOD #K61611 Appealed: Yes Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION COMPLY WITH REQUIREMENT FORFEITURE---83.35(3)(d) FORFEITURE---83.14(2)(a) FORFEITURE---50.09(1)(f) FORFEITURE---83.48(8)(b) FORFEITURE---83.47(2)(e) FORFEITURE---83.48(3)(a) FORFEITURE---83.35(1)(c) FORFEITURE---83.32(3)(i) Decision: STIPULATION This is Page 6 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (ALLOUEZ PARKSIDE VILLAGE) Date Complaint Received: 08/26/2013 Date Investigation Completed: 09/11/2013 Subject Area(s) ADMINISTRATION PROGRAM SERVICES Result NOT SUBSTANTIATED NOT SUBSTANTIATED Date Complaint Received: 01/07/2013 Date Investigation Completed: 03/12/2013 Subject Area(s) RESIDENT RIGHTS STAFF ADEQUACY PROGRAM SERVICES Result NOT SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED Date Complaint Received: 12/11/2012 Date Investigation Completed: 03/13/2013 Subject Area(s) SUPERVISION Result NOT SUBSTANTIATED Date Complaint Received: 01/09/2012 Date Investigation Completed: 01/13/2012 Subject Area(s) STAFF TRAINING AND PROFICIENCY Result NOT SUBSTANTIATED SOD # SOD # SOD # SOD # This is Page 7 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: AUTUMNS PROMISE ASSISTED LIVING LLC (0014514) Address: 1700 SPARTAN RD, GREEN BAY, WI 54311 License Status: PROBATIONARY Licensed/Certified/Registered 06/06/2013 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112913 End Date: 06/06/2013 Type: INITIAL Purpose: SURVEY Results: PROBATIONARY LICENSE ISSUED This is Page 8 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: BISHOPS COURT (410493) Address: 289 E ST JOSEPH ST, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 04/01/1998 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112182 Type: OTHER End Date: 02/11/2013 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110218 End Date: 02/16/2012 Type: STANDARD Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #YOKA13 Served 03/20/2012 Deficiencies Cited 83.32(3)(l) 83.38(1)(b) 83.38(1)(c) 83.38(1)(d) 83.59(2)(a) Subject Area RIGHTS OF RESIDENTS: LEAST RESTRICTIVE SUPERVISION LEISURE TIME ACTIVITIES COMMUNITY ACTIVITIES ONE-HAND, ONE-MOTION DOOR OPERATION Compliance Verified 02/07/2013 02/07/2013 02/07/2013 02/07/2013 02/07/2013 Corrected Yes Yes Yes Yes Yes This is Page 9 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Survey ID: 0108520 End Date: 04/19/2011 Type: OTHER Purpose: VERIFICATION VISIT Results: ENFORCEMENT ACTION Statement of Deficiency: #YOKA12 Served 05/11/2011 Deficiencies Cited 83.32(3)(i) 83.35(1)(c) 83.38(1)(b) Subject Area RIGHTS OF RESIDENTS: PROMPT AND ADEQUATE TREA LISTED AREAS FOR ASSESSMENTS SUPERVISION Compliance Verified 02/15/2012 02/15/2012 02/15/2012 Corrected Yes Yes No This is Page 10 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (BISHOPS COURT) Date: 03/19/2012 SOD #YOKA13 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION FORFEITURE---83.38(1)(c) Date: 05/10/2011 SOD #YOKA12 Sanctions FORFEITURE---83.38(1)(b) FORFEITURE---83.35(1)(c) FORFEITURE---83.32(3)(i) Appealed: No This is Page 11 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (BISHOPS COURT) Date Complaint Received: 01/09/2012 Date Investigation Completed: 02/22/2012 Subject Area(s) STAFF TRAINING AND PROFICIENCY Result NOT SUBSTANTIATED Date Complaint Received: 08/24/2011 Date Investigation Completed: 02/27/2012 Subject Area(s) RESIDENT RIGHTS Result NOT SUBSTANTIATED SOD # SOD # This is Page 12 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: BORNEMANN CBRF NORTH (0011045) Address: 1866 BROOK ST, GREEN BAY, WI 54302 License Status: REGULAR Licensed/Certified/Registered 06/01/2006 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 13 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: BORNEMANN CBRF SOUTH (0009684) Address: 1853 MILLS ST, GREEN BAY, WI 54302 License Status: REGULAR Licensed/Certified/Registered 03/01/2003 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 14 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: CARDINAL RIDGE RESIDENTIAL CARE (0010029) Address: 713 CARDINAL LANE, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 10/01/2003 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112396 Type: STANDARD End Date: 03/05/2013 Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110540 End Date: 04/03/2012 Type: OTHER Purpose: COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #BIWY12 Served 05/14/2012 Deficiencies Cited 50.09(1)(f) 83.35(1)(c) 83.37(1)(i) 83.37(3)(c) 83.59(2)(b) Subject Area PRIVACY LISTED AREAS FOR ASSESSMENTS PRN PSYCHOTROPIC MEDICATION MEDICATION STORAGE: LOCKED CABINET SOLID CORE WOOD DOORS OR EQUIVALENT Compliance Verified 03/05/2013 03/05/2013 03/05/2013 03/05/2013 03/05/2013 Corrected Yes Yes Yes Yes Yes This is Page 15 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Survey ID: 0108837 End Date: 06/09/2011 Type: STANDARD Purpose: SURVEY/COMPLAINT/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #BIWY11 Served 07/12/2011 Deficiencies Cited 83.32(3)(f) 83.35(1)(c) 83.37(1)(i) Subject Area RIGHTS OF RESIDENTS: FREE OF CHEMICAL RESTRAIN LISTED AREAS FOR ASSESSMENTS PRN PSYCHOTROPIC MEDICATION Compliance Verified 03/15/2012 03/15/2012 03/15/2012 Corrected Yes No No This is Page 16 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (CARDINAL RIDGE RESIDENTIAL CARE) Date: 05/11/2012 SOD #BIWY12 Sanctions FORFEITURE---83.35(1)(c) 2nd cite FORFEITURE---83.37(1)(I) 2nd cite Appealed: No Date: 07/11/2011 SOD #BIWY11 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION COMPLY WITH REQUIREMENT FORFEITURE---83.37(1)(i) FORFEITURE---83.35(1)(c) FORFEITURE---83.32(3)(f) This is Page 17 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (CARDINAL RIDGE RESIDENTIAL CARE) Date Complaint Received: 02/18/2013 Date Investigation Completed: 03/05/2013 Subject Area(s) RESIDENT RIGHTS Result NOT SUBSTANTIATED Date Complaint Received: 08/19/2011 Date Investigation Completed: 04/03/2012 Subject Area(s) MEDICATIONS STAFF ADEQUACY Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # SOD # This is Page 18 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: CARE FOR ALL AGES (0010060) Address: 1308 S NORWOOD, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 12/01/2003 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112586 End Date: 02/06/2013 Type: STANDARD Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #9YQL12 Served 04/24/2013 Deficiencies Cited 83.12(4)(c) 83.35(1)(c) 83.35(3)(d) 83.37(1)(i) Subject Area REPORTING INCIDENTS WITH SERIOUS INJURY LISTED AREAS FOR ASSESSMENTS SERVICE PLANS UPDATED ANNUALLY OR ON CHANGE PRN PSYCHOTROPIC MEDICATION Compliance Verified Corrected This is Page 19 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (CARE FOR ALL AGES) Date: 04/23/2013 SOD #9YQL12 Sanctions FORFEITURE---83.12(4)(c) FORFEITURE---83.35(3)(d) FORFEITURE---83.35(1)(c) FORFEITURE---83.37(1)(f) Appealed: No This is Page 20 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (CARE FOR ALL AGES) Date Complaint Received: 05/21/2012 Date Investigation Completed: 02/06/2013 Subject Area(s) MEDICATIONS Result SUBSTANTIATED SOD # 9YQL12 This is Page 21 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: CARRINGTON MANOR (0011878) Address: 2626 FINGER RD, GREEN BAY, WI 54302 License Status: REGULAR Licensed/Certified/Registered 11/01/2007 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113827 End Date: 09/10/2013 Type: STANDARD Purpose: SURVEY/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #4KBH11 Deficiencies Cited 83.32(3)(i) Subject Area RIGHTS OF RESIDENTS: PROMPT AND ADEQUATE TREA Compliance Verified Corrected This is Page 22 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: CENTURY RIDGE OF GREEN BAY I (0014023) Address: 2498 BLUESTONE PL, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 05/10/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112240 End Date: 02/07/2013 Type: OTHER Purpose: COMPLAINT Type: INITIAL Purpose: CHOW--LICENSURE Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110621 End Date: 05/14/2012 Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 23 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (CENTURY RIDGE OF GREEN BAY I) Date Complaint Received: 06/19/2012 Date Investigation Completed: 02/07/2013 Subject Area(s) ADMINISTRATION Result NOT SUBSTANTIATED SOD # This is Page 24 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: CENTURY RIDGE OF GREEN BAY II (0014024) Address: 2510 BLUESTONE PL, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 05/10/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112592 Type: OTHER End Date: 02/28/2013 Purpose: COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #QJ6Z11 Served 04/24/2013 Deficiencies Cited 83.12(4)(b) 83.31(4)(c) 83.32(3)(h) Survey ID: 0110622 Subject Area REPORTING WHEN LAW ENFORCEMENT IS CALLED INVOLUNTARY DISCHARGE NOTICE REQUIREMENTS RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION End Date: 05/14/2012 Type: INITIAL Compliance Verified Corrected Purpose: CHOW--LICENSURE Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 25 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (CENTURY RIDGE OF GREEN BAY II) Date: 04/23/2013 Sanctions OTHER SANCTION SOD #QJ6Z11 Appealed: No This is Page 26 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (CENTURY RIDGE OF GREEN BAY II) Date Complaint Received: 10/12/2012 Date Investigation Completed: 02/28/2013 Subject Area(s) MEDICATIONS ADMISSION, TRANSFER & DISCHARGE PROGRAM SERVICES Result SUBSTANTIATED SUBSTANTIATED NOT SUBSTANTIATED Date Complaint Received: 06/19/2012 Date Investigation Completed: 02/07/2013 Subject Area(s) ADMINISTRATION Result NOT SUBSTANTIATED SOD # QJ6Z11 QJ6Z11 SOD # This is Page 27 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: CLARITY CARE BERNARD ON HOFFMAN (0008949) Address: 898 E HOFFMAN RD, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 01/01/2001 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113429 End Date: 08/27/2013 Type: ABBREVIATED Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 28 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: CLARITY CARE SHAWANO AVENUE APARTMENTS (410443) Address: 1297 SHAWANO AVE, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 01/29/1996 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112275 Type: OTHER End Date: 02/28/2013 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110290 End Date: 03/29/2012 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #YBRW11 Served 04/04/2012 Deficiencies Cited 83.47(2)(e) 83.52(1)(d) Subject Area OTHER EVACUATION DRILLS COMMON DINING Compliance Verified 02/28/2013 02/28/2013 Corrected Yes Yes This is Page 29 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (CLARITY CARE SHAWANO AVENUE APARTMENTS) Date: 04/03/2012 Sanctions OTHER SANCTION SOD #YBRW11 Appealed: No This is Page 30 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (CLARITY CARE SHAWANO AVENUE APARTMENTS) Date Complaint Received: 09/21/2011 Date Investigation Completed: 03/29/2012 Subject Area(s) RESIDENT RIGHTS HOMELIKE ENVIRONMENT & CLEANLINESS NUTRITION & FOOD SERVICES Result NOT SUBSTANTIATED SUBSTANTIATED SUBSTANTIATED SOD # YBRW11 YBRW11 This is Page 31 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: COTTAGE LIVING AT MARLA VISTA GARDENS (0012183) Address: 1016 N MILITARY AVE, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 11/01/2009 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113169 Type: STANDARD End Date: 07/08/2013 Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0111668 End Date: 11/13/2012 Type: OTHER Purpose: COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #Z5VH13 Served 11/30/2012 Deficiencies Cited 83.38(1)(c) Survey ID: 0109538 End Date: 10/20/2011 Compliance Verified 07/08/2013 Subject Area LEISURE TIME ACTIVITIES Type: STANDARD Corrected Yes Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #Z5VH12 Served 11/17/2011 Deficiencies Cited 83.12(2)(a) 83.12(3)(a) 83.35(3)(c) Subject Area CAREGIVER: INVESTIGATING ABUSE AND NEGLECT INVESTIGATE INJURIES OF UNKNOWN SOURCE IMPLEMENT, FOLLOW THE INDIVIDUAL SERVICE PLAN Compliance Verified 10/24/2012 10/24/2012 10/24/2012 Corrected Yes Yes Yes This is Page 32 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Survey ID: 0107749 End Date: 12/08/2010 Type: OTHER Purpose: COMPLAINT/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #Z5VH11 Served 01/24/2011 Deficiencies Cited 83.35(3)(d) 83.38(1)(b) Subject Area SERVICE PLANS UPDATED ANNUALLY OR ON CHANGE SUPERVISION Compliance Verified 10/11/2011 10/11/2011 Corrected Yes Yes This is Page 33 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (COTTAGE LIVING AT MARLA VISTA GARDENS) Date: 11/20/2012 SOD #Z5VH13 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION FORFEITURE---83.38(1)(c) Date: 11/14/2011 SOD #Z5VH12 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION FORFEITURE---83.12(2)(a) FORFEITURE---83.12(3)(a) FORFEITURE---83.32(3)(i) Date: 01/18/2011 SOD #Z5VH11 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION COMPLY WITH REQUIREMENT FORFEITURE---83.38(1)(b) FORFEITURE---83.35(3)(d) This is Page 34 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (COTTAGE LIVING AT MARLA VISTA GARDENS) Date Complaint Received: 01/24/2013 Date Investigation Completed: 07/08/2013 Subject Area(s) RESIDENT RIGHTS RESIDENT BEHAVIOR/FACILITY PRACTICE STAFF TRAINING AND PROFICIENCY Result NOT SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED Date Complaint Received: 04/16/2012 Date Investigation Completed: 11/13/2012 Subject Area(s) RESIDENT RIGHTS Result NOT SUBSTANTIATED Date Complaint Received: 09/28/2011 Date Investigation Completed: 10/20/2011 Subject Area(s) RESIDENT RIGHTS MEDICATIONS PROGRAM SERVICES RESIDENT RIGHTS Result SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED SUBSTANTIATED SOD # SOD # SOD # Z5VH12 Z5VH12 This is Page 35 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: DURHAM (0014170) Address: 2671-2673 DURHAM RD, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 08/13/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111071 End Date: 08/13/2012 Type: INITIAL Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 36 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: GRANCARE GARDENS (0012738) Address: 1551 DOUSMAN ST, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 05/01/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0110921 Type: OTHER End Date: 07/02/2012 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110353 Type: STANDARD End Date: 03/12/2012 Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #XYT611 Served 04/12/2012 Deficiencies Cited 83.25 Survey ID: 0107420 Subject Area CONTINUING EDUCATION End Date: 11/08/2010 Type: OTHER Compliance Verified 07/02/2012 Corrected Yes Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 37 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (GRANCARE GARDENS) Date: 04/10/2012 SOD #XYT611 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION FORFEITURE---83.25 This is Page 38 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (GRANCARE GARDENS) Date Complaint Received: 01/03/2012 Date Investigation Completed: 03/13/2012 Subject Area(s) STAFF TRAINING AND PROFICIENCY Result SUBSTANTIATED SOD # XYT611 This is Page 39 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CS (SEMIAMBULATORY) Facility Information Facility Name: HAMPTON MANOR (410565) Address: 1265 ROCKWELL RD, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 05/01/1999 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112241 End Date: 02/06/2013 Type: STANDARD Purpose: SURVEY Results: STATEMENT OF DEFICIENCY ISSUED Statement of Deficiency: #BQWP11 Served 02/28/2013 Deficiencies Cited 83.48(6)(d) 83.48(6)(e) Subject Area INTEGRATED HEAT DETECTOR IN FURNACE ROOM INTEGRATED HEAT DETECTOR IN LAUNDRY ROOM Compliance Verified Corrected This is Page 40 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (HAMPTON MANOR) Date Complaint Received: 02/27/2012 Date Investigation Completed: 02/06/2013 Subject Area(s) SUPERVISION RESIDENT RIGHTS Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 41 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: HARMONY OF GREEN BAY (0008950) Address: 1450 S MILITARY AVE, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 08/01/2000 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113064 Type: OTHER End Date: 06/26/2013 Purpose: COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0112726 End Date: 03/27/2013 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT Results: ENFORCEMENT ACTION Statement of Deficiency: #E4RT11 Served 05/15/2013 Deficiencies Cited 83.06(1)(e) 83.35(1)(a) Subject Area PROGRAM STATEMENT: CLIENT GROUP SERVED PRE-ADMISSION AND ONGOING ASSESSMENTS Compliance Verified 06/19/2013 06/19/2013 Corrected Yes Yes This is Page 42 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (HARMONY OF GREEN BAY) Date: 05/13/2013 SOD #E4RT11 Appealed: No Sanctions COMPLY WITH DEPARTMENT PLAN OF CORRECTION FORFEITURE---83.35(1)(a) This is Page 43 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (HARMONY OF GREEN BAY) Date Complaint Received: 05/29/2013 Date Investigation Completed: 06/26/2013 Subject Area(s) PROGRAM SERVICES Result NOT SUBSTANTIATED Date Complaint Received: 04/26/2013 Date Investigation Completed: 04/29/2013 Subject Area(s) ADMINISTRATION Result NOT SUBSTANTIATED Date Complaint Received: 09/12/2012 Date Investigation Completed: 04/29/2013 Subject Area(s) RESIDENT RIGHTS Result SUBSTANTIATED SOD # SOD # SOD # E4RT11 This is Page 44 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HERITAGE GARDENS (0013713) Address: 1207 S JACKSON ST, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 03/12/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112568 End Date: 04/10/2013 Type: OTHER Purpose: COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110128 End Date: 03/05/2012 Type: STANDARD Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0108737 End Date: 06/13/2011 Type: INITIAL Purpose: SURVEY Results: PROBATIONARY LICENSE ISSUED This is Page 45 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (HERITAGE GARDENS) Date Complaint Received: 10/03/2012 Date Investigation Completed: 03/28/2013 Subject Area(s) PROGRAM SERVICES Result NOT SUBSTANTIATED Date Complaint Received: 09/24/2012 Date Investigation Completed: 03/28/2013 Subject Area(s) MEDICATIONS ADMINISTRATION STAFF ADEQUACY Result NOT SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # SOD # This is Page 46 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HIL BITTERWOOD (0009689) Address: 3279 BITTERS CT, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 01/01/2002 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 47 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HIL COOPERS RUN (0013270) Address: 2460 FORESTVILLE DR, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 04/12/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111397 End Date: 09/24/2012 Type: STANDARD Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 48 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HIL ORIOLE (0013593) Address: 503 PLATTEN ST, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 12/21/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0107700 End Date: 12/21/2010 Type: INITIAL Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 49 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HIL ROCKWOOD HEIGHTS (0009812) Address: 2744 ROCKWOOD HEIGHTS, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 01/01/2002 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 50 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: HIL WESTPLAIN (0014177) Address: 335-339 WESTPLAIN DR, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 06/13/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0110824 End Date: 06/12/2012 Type: INITIAL Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 51 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: INNOVATIVE SERVICES INC DIVERSION FACILITY (0013206) Address: 1311 N DANZ AVE, GREEN BAY, WI 54302 License Status: REGULAR Licensed/Certified/Registered 09/22/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111489 End Date: 09/27/2012 Type: STANDARD Purpose: SURVEY Results: STATEMENT OF DEFICIENCY ISSUED Statement of Deficiency: #32D811 Served 10/23/2012 Deficiencies Cited 83.44(2)(b) 83.59(2)(b) Subject Area TOILET AND BATHING AREA SOLID CORE WOOD DOORS OR EQUIVALENT Compliance Verified Corrected This is Page 52 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: KINDREDHEARTS GREEN BAY (0010818) Address: 655 WOODSIDE RD, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 01/01/2005 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112715 End Date: 05/09/2013 Type: ABBREVIATED Purpose: SURVEY Type: ABBREVIATED Purpose: SURVEY/SELF REPORT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0109024 End Date: 07/21/2011 Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 53 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: KINDREDHEARTS GREEN BAY (0010819) Address: 653 WOODSIDE RD, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 01/01/2005 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112772 End Date: 05/06/2013 Type: ABBREVIATED Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 54 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: LAFRANK CBRF (0014492) Address: 1713 FRANK ST, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 05/13/2013 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112900 End Date: 05/14/2013 Type: INITIAL Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED This is Page 55 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: LIBAL STREET HOME (0011145) Address: 3500 LIBAL ST, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 12/16/2005 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 56 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: LSS NORTH VIEW HOUSE (410213) Address: 2517-19 N VIEW CT, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 04/08/1990 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 57 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: LSS PREBLE HOUSE (410202) Address: 830-832 EDGEWOOD DR, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 03/07/1990 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 58 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: MARLA VISTA MANOR (0011875) Address: 1006 N MILITARY AVE, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 11/01/2007 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111609 Type: STANDARD End Date: 10/31/2012 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0109677 Type: OTHER End Date: 10/24/2011 Purpose: COMPLAINT/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #EFGX11 Served 12/13/2011 Deficiencies Cited 83.32(3)(i) Survey ID: 0108265 Subject Area RIGHTS OF RESIDENTS: PROMPT AND ADEQUATE TREA End Date: 03/10/2011 Type: STANDARD Compliance Verified 10/25/2012 Corrected Yes Purpose: SURVEY/COMPLAINT/SELF REPORT Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 59 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (MARLA VISTA MANOR) Date: 12/09/2011 SOD #EFGX11 Sanctions FORFEITURE---83.32(3)(i) Appealed: No This is Page 60 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (MARLA VISTA MANOR) Date Complaint Received: 09/30/2011 Date Investigation Completed: 10/24/2011 Subject Area(s) RESIDENT RIGHTS NUTRITION & FOOD SERVICES STAFF TRAINING AND PROFICIENCY Result SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # EFGX11 This is Page 61 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: MC CORMICK MEMORIAL HOME (410199) Address: 212 IROQUOIS AVE, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 09/08/1990 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0108538 End Date: 05/03/2011 Type: OTHER Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 62 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: OAKS FAM CARE CTR CARI HOUSE (410014) Address: 1485 PLYMOUTH LN, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 05/01/1981 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113000 End Date: 06/13/2013 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110291 End Date: 03/29/2012 Type: STANDARD Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 63 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (OAKS FAM CARE CTR CARI HOUSE) Date Complaint Received: 11/26/2012 Date Investigation Completed: 06/13/2013 Subject Area(s) RESIDENT RIGHTS MEDICATIONS Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 64 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: OAKS FAM CARE CTR CHRISTIANA (410158) Address: 1643 CHRISTIANA ST, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 07/01/1986 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 65 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: OAKS FAM CARE CTR DAMIAN HOUSE (410097) Address: 1481 PLYMOUTH LANE, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 10/31/1980 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112999 End Date: 06/13/2013 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0110288 End Date: 03/29/2012 Type: STANDARD Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 66 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (OAKS FAM CARE CTR DAMIAN HOUSE) Date Complaint Received: 11/26/2012 Date Investigation Completed: 06/13/2013 Subject Area(s) RESIDENT RIGHTS MEDICATIONS Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 67 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: OAKS FAM CARE CTR OAKLAND HOUSE (410156) Address: 126 N OAKLAND AVE, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 01/01/1989 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 68 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: OUR PLACE (0009922) Address: 1501 N IRWIN ST, GREEN BAY, WI 54302 License Status: REGULAR Licensed/Certified/Registered 07/01/2003 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 69 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: PATIENT PINES ASSISTED LIVING INC 1715 (0013896) Address: 1715 WESTMINSTER DR, GREEN BAY, WI 543025431 License Status: REGULAR Licensed/Certified/Registered 11/01/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113404 End Date: 08/13/2013 Type: OTHER Purpose: COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0111470 End Date: 10/16/2012 Type: STANDARD Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED Survey ID: 0109534 End Date: 11/02/2011 Type: INITIAL Purpose: SURVEY Results: PROBATIONARY LICENSE ISSUED This is Page 70 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (PATIENT PINES ASSISTED LIVING INC 1715) Date Complaint Received: 04/19/2013 Date Investigation Completed: 08/13/2013 Subject Area(s) SUPERVISION MEDICATIONS OTHER Result NOT SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 71 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: PATIENT PINES ASSISTED LIVING INC 1721 (0013897) Address: 1721 WESTMINSTER DR, GREEN BAY, WI 543025431 License Status: REGULAR Licensed/Certified/Registered 11/01/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113403 End Date: 08/13/2013 Type: OTHER Purpose: COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0111464 End Date: 10/16/2012 Type: STANDARD Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED Survey ID: 0109536 End Date: 11/08/2011 Type: INITIAL Purpose: SURVEY Results: PROBATIONARY LICENSE ISSUED This is Page 72 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (PATIENT PINES ASSISTED LIVING INC 1721) Date Complaint Received: 04/19/2013 Date Investigation Completed: 08/13/2013 Subject Area(s) SUPERVISION MEDICATIONS OTHER Result NOT SUBSTANTIATED NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 73 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: RIDGE POINTE CBRF (0012658) Address: 204 S ONEIDA ST, GREEN BAY, WI 54303 License Status: REGULAR Licensed/Certified/Registered 03/25/2009 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0110893 End Date: 06/11/2012 Type: STANDARD Purpose: SURVEY/COMPLAINT Type: STANDARD Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0107354 End Date: 10/06/2010 Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 74 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CS (SEMIAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (RIDGE POINTE CBRF) Date Complaint Received: 10/31/2011 Date Investigation Completed: 06/11/2012 Subject Area(s) HOMELIKE ENVIRONMENT & CLEANLINESS MEDICATIONS Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 75 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: SCHUMACHER HOUSE (0010929) Address: 2831 FERNDALE DRIVE, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 03/31/2005 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 76 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: SERVAIS POINTE CBRF (0013912) Address: 1398 SERVAIS ST, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 10/10/2011 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111151 End Date: 07/16/2012 Type: STANDARD Purpose: SURVEY Results: LICENSE/CERT/REGISTRATION ISSUED Survey ID: 0109393 End Date: 10/10/2011 Type: INITIAL Purpose: CHOW--LICENSURE Results: PROBATIONARY LICENSE ISSUED This is Page 77 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS AA (AMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: SHERWOOD PLACE (0010552) Address: 4893 FINGER RD, GREEN BAY, WI 54311 License Status: REGULAR Licensed/Certified/Registered 06/15/2004 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0110873 End Date: 06/25/2012 Type: ABBREVIATED Purpose: SURVEY Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 78 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: TENDER HEARTS ASSISTED LIVING LLC BLG NO 1 (0012910) Address: 300 CARDINAL LN, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 09/01/2010 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0113357 End Date: 08/05/2013 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED This is Page 79 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (TENDER HEARTS ASSISTED LIVING LLC BLG NO 1) Date Complaint Received: 05/15/2013 Date Investigation Completed: 08/05/2013 Subject Area(s) PROGRAM SERVICES Result NOT SUBSTANTIATED Date Complaint Received: 02/18/2013 Date Investigation Completed: 08/05/2013 Subject Area(s) RESIDENT RIGHTS Result NOT SUBSTANTIATED SOD # SOD # This is Page 80 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: TENDER HEARTS ASSISTED LIVING LLC BLG NO 2 (0013822) Address: 320 CARDINAL LN, GREEN BAY, WI 54313 License Status: REGULAR Licensed/Certified/Registered 10/01/2012 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0111051 End Date: 06/08/2012 Type: STANDARD Purpose: SURVEY/COMPLAINT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0109309 End Date: 09/21/2011 Type: INITIAL Purpose: SURVEY Results: PROBATIONARY LICENSE ISSUED This is Page 81 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (TENDER HEARTS ASSISTED LIVING LLC BLG NO 2) Date Complaint Received: 05/03/2012 Date Investigation Completed: 06/08/2012 Subject Area(s) MEDICATIONS ADMINISTRATION Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 82 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: WOODSIDE MANOR I II III (410168) Address: 1060 PILGRIM WAY, GREEN BAY, WI 54304 License Status: REGULAR Licensed/Certified/Registered 01/01/1989 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 83 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Facility Information Facility Name: WYNDEMERE EAST (410518) Address: 2999 RIVERSIDE DR, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 03/01/1998 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History No survey activity during the period 10/01/2010 through 09/30/2013. This is Page 84 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: WYNDEMERE ESTATE (410314) Address: 3001 RIVERSIDE DR, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 10/01/1993 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0110178 End Date: 03/08/2012 Type: ABBREVIATED Purpose: SURVEY/COMPLAINT/SELF REPORT Results: STATEMENT OF DEFICIENCY ISSUED Statement of Deficiency: #RMSF11 Served 03/14/2012 Deficiencies Cited 83.47(2)(e) Subject Area OTHER EVACUATION DRILLS Compliance Verified Corrected This is Page 85 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Complaint History (WYNDEMERE ESTATE) Date Complaint Received: 06/16/2011 Date Investigation Completed: 03/08/2012 Subject Area(s) RESIDENT RIGHTS PHYSICAL PLANTS & SAFETY HAZARDS Result NOT SUBSTANTIATED NOT SUBSTANTIATED SOD # This is Page 86 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. Provider Inspection Summary DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) Facility Information Facility Name: WYNDEMERE NORTH (410408) Address: 2995 RIVERSIDE DR, GREEN BAY, WI 54301 License Status: REGULAR Licensed/Certified/Registered 03/16/1996 Regional Office: NORTHEASTERN REGION (GREEN BAY), (920) 448-5252 Survey History Survey ID: 0112975 Type: OTHER End Date: 06/04/2013 Purpose: VERIFICATION VISIT Results: NO STATEMENT OF DEFICIENCY ISSUED Survey ID: 0112603 End Date: 03/04/2013 Type: ABBREVIATED Purpose: SURVEY/SELF REPORT Results: ENFORCEMENT ACTION Statement of Deficiency: #SI6Q11 Served 04/30/2013 Deficiencies Cited 83.32(3)(n) Subject Area RIGHTS OF RESIDENTS: SAFE ENVIRONMENT Compliance Verified 05/01/2013 Corrected Yes This is Page 87 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance Printed 10/29/2013 Provider Inspection Summary For the period 10/01/2010 to 09/30/2013 Community Based Residential Facility--CLASS CNA (NONAMBULATORY) STATE OF WISCONSIN Bureau of Assisted Living P.O. Box 7940 Madison WI 53707-7940 Enforcement History (WYNDEMERE NORTH) Date: 04/29/2013 SOD #SI6Q11 Sanctions FORFEITURE---83.32(3)(n) Appealed: No This is Page 88 of 88 total pages. If printing this report ensure that your printer is set to print only the desired pages. Disclaimer: This information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that this information is accurate, up-to-date, or complete. This information, which should not be used as a sole source in selecting a facility, does not replace official information sources.