Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow View Health Services during CMS and state inspections, most recent first.
Unsafe food thawing, cooling, and storage practices were observed in the kitchen. A dietary manager was seen defrosting ham in a sink of water and did not know that method was unsafe, and multiple pre-made foods were found in the freezer and cooler with cooling logs showing several items were not cooled to 70 F within 2 hours. Surveyors also found dented cans in dry storage that the DM verified should not have been on the shelf for resident consumption.
Failure to Provide Daily Diabetic Foot Checks: The facility did not ensure daily foot checks and appropriate nail/foot care for multiple residents with diabetes. Records showed several residents had care plans requiring licensed nurse foot inspections and nurse-only nail care, but TARs did not include the daily foot check task, and interviews confirmed the checks were not being completed as required. Observations found one resident’s feet dry, scaly, and flaky with long, jagged, misshapen toenails, while other diabetic residents also lacked documented daily foot care.
Failure to Monitor Resident Weights and Notify Providers of Significant Weight Changes: The facility did not follow weight-monitoring orders or its own policy for four residents. One resident with CHF and other diagnoses had a large weight decline with missing required weights and no provider notification. Another resident with a stage 4 pressure ulcer and severe cognitive impairment lacked ordered re-weights and dietitian-recommended consecutive weights. Two additional residents with fractures, heart/lung conditions, and intact cognition also had significant weight loss without required re-weights, progress notes, or provider updates.
Incomplete Investigation of Alleged Misappropriation: A resident with intact cognition reported that $42 was taken from the resident’s room. The facility interviewed the resident and searched the room and belongings, but did not document staff interviews or include resident interviews about the missing money. The NHA verified the investigation was not conducted or documented in accordance with policy.
The facility failed to store and prepare food in a sanitary manner, affecting 32 residents. Unlabeled, undated, and expired food items were found in storage areas, and cooling logs showed improper cooling of food. Staff interviews revealed non-compliance with food safety policies, and falsified cooling logs were discovered.
The facility did not ensure meal preparation conserved nutritive value or adhered to planned menus and serving sizes. Observations showed staff not following recipes, leading to improper food preparation and serving. Management confirmed expectations for adherence to policies, but practices fell short, potentially affecting residents' nutritional intake.
The facility failed to provide written transfer notices to two residents who were hospitalized, as required by their Transfer and Discharge Policy. One resident, with dementia and other conditions, was transferred for abnormal vital signs without a notice given to the resident or guardian. Another resident, with renal disease and diabetes, was transferred for abnormal kidney function without receiving a notice. The DON admitted that the facility did not complete transfer notices, which was the nurses' responsibility.
The facility failed to provide written bed hold notices to two residents transferred to the hospital, as required by policy. One resident with dementia and CHF, and another with renal disease and diabetes, did not receive the notices. The DON confirmed the oversight, noting it was the nurses' responsibility to issue these notices.
The facility failed to ensure a safe environment for two residents who were known smokers. One resident, with a history of seizures, was inaccurately assessed as not requiring supervision, despite being an unsafe smoker. The other resident, with intact cognition, was observed with smoking materials on their person, contrary to policy. Staff interviews revealed inconsistencies in enforcing smoking safety protocols, leading to a hazardous environment.
A resident with intact cognition fell and fractured their hip after a CNA, who was an agency staff member, failed to follow the care plan requiring two-person assistance for transfers. The CNA transferred the resident alone without using a gait belt. The facility's investigation confirmed the lapse, and it was noted that several agency staff members had not received the required training on safe transfers.
Unsafe Food Thawing, Cooling, and Storage Practices
Penalty
Summary
Food was not stored and prepared in a sanitary manner during kitchen observations and record review. During an initial kitchen tour, surveyors observed a plastic bag of ham soaking in water in the sink. On a later kitchen observation, the dietary manager stated the ham was being defrosted in the sink and identified safe thawing methods as in the sink in water, in the sink under running water, and in the refrigerator, but was not aware that thawing meat in water in the sink was not a safe defrosting method. The facility indicated it followed the FDA Food Code, but the observed thawing practice did not match the safe thawing requirements cited in the report. Surveyors also observed multiple pre-made foods stored in the reach-in freezer and walk-in cooler, including sausage links, pumpkin, BBQ, beef tips, pork, and grilled chicken. Review of the cooling logs showed the sausage links and pumpkin were not documented on the cooling log, and the BBQ did not reach 70 degrees F within the required two-hour time frame. Surveyors reviewed cooling logs from 10/27/25 to 12/16/25 and found 50 documented foods were cooked, cooled, and saved for resident consumption but did not reach 70 degrees within two hours. In addition, surveyors observed dented cans of pumpkin, chili sauce, and three bean salad in dry storage, and the dietary manager verified the dented cans should not have been on the shelf for resident consumption.
Failure to Provide Daily Diabetic Foot Checks
Penalty
Summary
The facility did not ensure proper foot and nail care for 8 residents with diabetes, and daily diabetic foot checks were not provided in accordance with professional standards of practice, resident care plans, or the facility’s Skin Integrity-Foot Care policy. The policy stated that daily foot checks would be performed by the licensed nurse for all diabetic residents and that care should include checking for dryness, scaling, cracking, calluses, broken skin between the toes, and ulcers, with abnormal findings reported to the physician and responsible party. For R21, the record showed diagnoses including dementia, communication disorder, type 2 diabetes, and chronic kidney disease, with severe cognitive impairment and dependence on staff for foot and nail care. The care plan directed that nail care be completed by a nurse only and that feet be inspected daily for open areas, sores, pressure areas, blisters, edema, or redness. Survey observations found R21’s feet exposed, dry, and covered with thick scaly and flaky areas, and the toenails were long, jagged, and misshapen. RN and DON interviews confirmed that diabetic residents should have daily foot checks by licensed nursing staff, but R21’s TAR did not contain daily foot check orders and the record did not show the checks were being completed. Similar findings were identified for R5, R9, R10, R6, R27, R29, and R30. These residents had diabetes and varying levels of cognitive impairment and dependence for ADLs, and their care plans included daily foot inspection interventions, with nail care limited to nurses only. The DON confirmed that R5, R10, R6, R27, R29, and R30 had care plan interventions for daily foot checks but their TARs did not include instructions for nurses to complete them, and that R9’s care plan incorrectly stated the resident was non-diabetic despite a diabetes diagnosis. The DON also verified that the records did not indicate daily foot checks were being completed for these residents.
Failure to Monitor Resident Weights and Notify Providers of Significant Weight Changes
Penalty
Summary
The facility did not ensure weights were monitored for four residents and did not obtain weights or re-weights in accordance with physician orders and facility policy. The facility’s Weight Monitoring policy stated that any weight change of 5 pounds or more since the last weight assessment would be retaken for confirmation and that nursing staff would notify the physician and dietary staff of unintended significant weight changes. The Director of Nursing confirmed residents should be weighed on admission, daily for 2 days, weekly for 3 weeks, and then monthly if there were no significant weight changes, and that re-weights and provider notification were expected when weight changes occurred. One resident had diagnoses including surgical aftercare following digestive surgery, chronic systolic CHF, sarcopenia, and localized edema, and had an order for daily weights and re-weighting if there was a 5-pound change. The resident’s record showed multiple daily weights with a decline from 164.0 pounds to 140.0 pounds, but there was no documented weight on one required day and no re-weights on two dates when the weight change met the threshold. The record also did not contain progress notes about the missing weights or indicate the provider was updated. A second resident with osteomyelitis of the vertebra, stage 4 sacral pressure ulcer, diabetes, and severely impaired cognition had weight orders and a dietitian note recommending re-weighing for 3 consecutive days after a weight warning. The record did not contain the ordered re-weights or the recommended consecutive weights, and there were no progress notes or provider updates. A third resident with sacral fracture, atrial fibrillation, heart failure, and intact cognition had an order for daily weights and re-weighting if there was a 5-pound change; the record showed an 8-pound loss but no documented re-weight, progress note, or provider update. A fourth resident with bilateral femur fractures, pneumonia, and acute respiratory failure with hypoxia had weight orders and showed a 13-pound loss, but the record did not contain a required weight or re-weight, progress notes, or evidence that the provider was notified.
Incomplete Investigation of Alleged Misappropriation
Penalty
Summary
The facility did not ensure an allegation of misappropriation was thoroughly investigated for one resident who reported that $42 was taken from the resident’s room. The resident had diagnoses including Prader-Willi syndrome, anxiety, and major depressive disorder, and the MDS assessment dated 9/10/25 showed a BIMS score of 15 out of 15, indicating intact cognition. The resident was their own decision maker. The facility-reported incident showed the allegation was brought to the facility on 9/29/25 and that the resident was interviewed, the resident’s room and personal belongings were searched, and the resident was offered a safe or storage of money in the business office, which the resident declined. The police and Ombudsman were notified, and staff education on misappropriation was completed. However, the investigation did not include staff or resident interviews about the missing money. The NHA stated staff were interviewed but the interviews were not documented, names of interviewed staff were written down, and other residents were not recalled as being interviewed; the NHA verified the investigation was not conducted or documented in accordance with facility policy.
Deficiencies in Food Storage and Cooling Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect 32 of the 33 residents residing in the facility. During an initial kitchen tour, surveyors observed multiple food items in the coolers, freezers, and dry storage areas that were unlabeled, undated, or past their use-by dates. These included cups of Jell-O, applesauce, pudding, cooked pasta, and various meats and produce. Additionally, dented cans and outdated emergency food supplies were found in the dry storage area. Staff interviews revealed that the facility's policies for labeling, dating, and disposing of food were not consistently followed, and kitchen staff were aware of the requirements but failed to implement them. The facility also did not adhere to safe food cooling protocols. The cooling logs for July and August 2024 showed that many food items were not cooled to the required 41 degrees Fahrenheit or less, and several cooked and dated food items in the cooler and freezer were not documented on the cooling logs. The logs indicated that food was not cooled within the time and temperature criteria specified by the FDA Food Code. Interviews with the Dietary Manager and other staff confirmed that the cooling logs were not used correctly, and staff failed to document all cooked and cooled food as required by the facility's policy. Interviews with the Nursing Home Administrator and Regional Managers revealed that there was an expectation for kitchen staff to follow the facility's food preparation, labeling, storage, and cooling policies to ensure food safety. However, it was discovered that staff had falsified entries on the cooling logs, which was acknowledged by the Regional Manager. The deficiencies in food storage, labeling, and cooling practices were attributed to a lack of adherence to established policies and insufficient oversight by kitchen management.
Failure to Follow Nutritional Guidelines and Menus
Penalty
Summary
The facility failed to ensure that meal items were prepared in a manner that conserved their nutritive value and did not adhere to the planned menus and serving sizes. This deficiency was observed during a kitchen inspection where a cook was seen free-pouring ingredients for rice pilaf without following a recipe, which is necessary to maintain nutritional content. The cook admitted to guesstimating ingredient amounts and was unsure of the serving sizes, indicating a lack of adherence to the facility's policy requiring the use of standardized recipes. Further observations revealed that the Dietary Manager prepared instant mashed potatoes without measuring the ingredients or following a recipe, resulting in improperly mixed potatoes with dry flakes at the bottom of the container. The Dietary Manager served these potatoes to residents on pureed diets without ensuring the correct serving size, which deviated from the facility's menu that specified pureed noodles and banana cake. Instead, applesauce was served without resident requests for these changes, highlighting a disregard for the planned menu. Interviews with facility management, including the District Manager, Nursing Home Administrator, and Regional Managers, confirmed that there was an expectation for kitchen staff to follow recipes and the facility's food preparation policies. However, the observed practices demonstrated a failure to meet these expectations, potentially affecting the nutritional intake of more than four residents, including those on specialized diets.
Failure to Provide Transfer Notices to Hospitalized Residents
Penalty
Summary
The facility failed to provide timely and appropriate transfer notices to two residents, R18 and R23, who were transferred to the hospital. R18, who had diagnoses including dementia, COPD, CHF, and was on hospice care with a guardian, was transferred on 6/14/24 due to abnormal vital signs. Despite the transfer, neither R18 nor the guardian received a written transfer notice. The Director of Nursing (DON) provided an eINTERACT form with basic information but did not supply the required transfer notice. Similarly, R23, with diagnoses of renal disease, diabetes, and CHF, was transferred on 7/19/24 for abnormal kidney function. R23 did not have a guardian or activated POAHC and did not receive a written transfer notice. The DON acknowledged that the facility did not complete transfer notices for residents and stated it was the nurses' responsibility to do so. This lack of compliance with the facility's Transfer and Discharge Policy resulted in a deficiency noted by the surveyor.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide written bed hold notices to two residents, R18 and R23, upon their transfer to the hospital, as required by the facility's Transfer and Discharge Policy. This policy mandates that a notice of the facility's bed hold policy be given to the resident and their representative at the time of transfer, or within 24 hours. R18, who had diagnoses including dementia and congestive heart failure, was transferred to the hospital for abnormal vital signs but did not receive a written bed hold notice. Similarly, R23, with conditions such as renal disease and diabetes, was transferred due to abnormal kidney function and also did not receive the required notice. During the survey conducted from August 26 to August 28, 2024, the surveyor reviewed the medical records of both residents and found no documentation of the bed hold notices. The Director of Nursing (DON-B) confirmed that the facility was not providing these notices and acknowledged that it was the nurses' responsibility to complete them. The surveyor was only provided with eINTERACT forms containing basic information about the residents, which did not fulfill the requirement for a bed hold notice.
Deficiencies in Smoking Safety Management for Two Residents
Penalty
Summary
The facility failed to ensure a safe environment for two residents who were known smokers, leading to deficiencies in their care. Resident R6, who had a history of seizures, vertigo, and unresponsive episodes, was not accurately assessed or reassessed for smoking safety. Despite being deemed an unsafe smoker and having smoking privileges revoked, R6 continued to smoke in non-designated areas and concealed smoking materials. The facility's staff did not consistently enforce the smoking policy, and R6's most recent Nicotine Assessment inaccurately indicated that R6 did not require supervision, contradicting staff observations and previous assessments. Resident R12, who had intact cognition, also experienced deficiencies in smoking safety management. Although R12 was assessed as an independent smoker, the assessment required that smoking materials be maintained by staff. However, R12 was observed multiple times with cigarettes and a lighter on their person inside the facility, indicating a lack of adherence to the policy. Interviews with staff revealed inconsistencies in enforcing the policy, as R12 often forgot to return smoking materials to the nurses' station, and staff did not consistently secure them. The facility's failure to accurately assess and manage the smoking safety of these residents resulted in a hazardous environment. The staff interviews highlighted discrepancies between the facility's smoking policy and its implementation, as well as inaccuracies in the residents' Nicotine Assessments. These deficiencies indicate a lack of adequate supervision and enforcement of smoking safety protocols, compromising the safety of the residents involved.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that interventions were followed to prevent a fall for one resident. On June 1, 2024, a Certified Nursing Assistant (CNA) did not transfer the resident according to their plan of care, which required the assistance of two staff members for transfers. This resulted in the resident falling and sustaining a left hip fracture. The resident, who had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was found on the floor with a skin tear and complained of excruciating pain. The resident was subsequently sent to the emergency room for evaluation and treatment. The facility's investigation revealed that the CNA, who was an agency staff member, transferred the resident alone and did not use a gait belt during the transfer, contrary to the care plan. The facility initiated staff education on safe resident handling and transfers, emphasizing the use of a gait belt and referencing the resident's Kardex for transfer status. However, the surveyor noted that several agency staff members who worked between June 1 and July 2, 2024, had not signed the education sheets, indicating they had not received the necessary training.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sheboygan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sheboygan Progressive Health Services | 0.8 mi | ★★★★★ | 12 | 0 |
| Edenbrook Sheboygan | 2.7 mi | ★★★★★ | 7 | 1 |
| Sheboygan Health Services | 3.1 mi | ★★★★★ | 7 | 0 |
| Morningside Health Services | 4.4 mi | ★★★★★ | 7 | 0 |
| Sheboygan Senior Community Inc | 5.3 mi | ★★★★★ | 16 | 0 |
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