A list of the most recent deficiencies for Sturgeon Bay Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-04 | 2023-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-11-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-04 | 2023-11-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-04 | 2023-11-16 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-04 | 2023-11-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-04 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-04 | 2023-10-27 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-04 | 2023-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-17 | 2022-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-17 | 2022-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-18 | 2022-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-18 | 2022-08-19 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-08-18 | 2022-08-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-14 | 2021-08-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-14 | 2021-08-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-14 | 2021-08-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-14 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-12 | 2021-08-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-12 | 2021-08-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-12 | 2021-08-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-12 | 2021-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-12 | 2021-08-06 | N |
