Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Shawano Health Services during CMS and state inspections, most recent first.
Improper Wound Care During Pressure Injury Dressing Change: An RN provided wound care for a resident with a stage 2 heel pressure injury, diabetes, Alzheimer's disease, and severely impaired cognition. During the dressing change, the RN used soiled scissors to cut the clean foam dressing after cutting away the dirty outer dressing, and both the RN and DON confirmed the scissors should have been cleansed between the dirty and clean steps.
A resident with an indwelling Foley catheter, severe cognitive impairment, BPH, and a history of bladder cancer did not receive appropriate catheter care to help prevent UTI. Staff observed the catheter drainage bag hanging from a Hoyer sling behind the resident and touching the floor without a dignity bag or barrier, and an RN confirmed the improper placement. The resident’s record also showed recent antibiotic treatment for a UTI.
Medication services were not provided according to orders for three residents. An RN gave one resident the wrong calcium carbonate strength, an LPN left polyethylene glycol at another resident’s bedside without an order or assessment for self-administration, and a resident with COPD independently administered a nebulizer treatment without the required self-administration assessment or order. The DON confirmed the medication discrepancies and the lack of authorization for bedside or independent administration.
Pureed Diet Portions Did Not Match Menu Serving Sizes: The facility did not follow ordered pureed diets and menu serving sizes for 3 residents with severe cognitive impairment and nutrition-related concerns. A dietary employee served pureed egg bake with a 3 oz scoop when the menu called for 4 oz, and later portioned pureed ravioli with a 4 oz ladle when the menu called for 6 oz. The DM confirmed the wrong scoop size and wrong portion were used.
The facility did not ensure sanitary food preparation as the Dietary Manager (DM-C) was observed multiple times without a beard net, despite the facility's policy requiring it. This occurred during kitchen prep, lunch service, and cooking, even after DM-C acknowledged the policy and had access to beard nets.
A facility failed to report a suspected crime involving drug diversion and possible exploitation of a resident. The resident's prescription for 60 narcotic tablets was picked up by their spouse, but only 14 pills were returned to the facility. The resident indicated the remaining pills were owed to others. Despite being aware of the situation, the facility did not report it to authorities, as they believed they were not in possession of the missing narcotics. This failure to report was based on corporate instructions, despite staff being mandatory reporters.
The facility failed to ensure safe medication administration for three residents, leaving medications unattended in their rooms without assessing their ability to self-administer. Despite having no cognitive impairments, the residents were not evaluated for self-administration, and the facility's policy against leaving medications at the bedside was not followed. The Nursing Home Administrator and DON were unaware of this practice, which was against the facility's guidelines.
A resident with a history of kidney disease and recent surgery was given Miralax despite having diarrhea, due to a lack of documentation and communication among staff. The resident's low blood pressure and diarrhea were not recorded, leading to inappropriate medication administration and a subsequent ER visit.
Improper Wound Care During Pressure Injury Dressing Change
Penalty
Summary
Appropriate treatment to promote healing of a pressure injury was not provided for one resident with a stage 2 pressure injury on the right heel that was present upon re-admission to the facility. The resident had diagnoses including diabetes, Alzheimer's disease, and venous insufficiency, and the MDS assessment showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The resident's wound care instructions directed cleansing the wound, applying an antibacterial foam dressing, covering with an ABD pad, wrapping with Kerlix, securing with tape, and changing the dressing twice daily and as needed. During observed wound care, the RN cut the resident's soiled outer Kerlix dressing with scissors and placed the soiled scissors outside the clean field with the clean wound supplies. After removing the soiled dressing and cleansing the wound, the RN used the same scissors, without cleaning them first, to cut the clean antibacterial foam dressing to size and applied it to the wound. The RN confirmed the scissors should have been cleansed before cutting the clean dressing, and the DON also confirmed the scissors should have been cleansed between dirty and clean wound care procedures.
Improper Foley Catheter Bag Placement
Penalty
Summary
The facility did not ensure appropriate catheter care and services to prevent urinary tract infections for one resident with an indwelling Foley catheter. The resident had diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, other obstructive and reflux uropathy, and a personal history of malignant neoplasm of the bladder. The resident’s MDS assessment showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and the resident had an activated healthcare decision maker. The care plan identified the need for an indwelling Foley catheter due to bladder cancer and BPH secondary to urinary obstruction, and also noted the resident was at risk for infection due to the catheter, with a goal of being free from infection through the review date. The resident’s medical record showed treatment with Macrobid for five days for a UTI. During observation, the resident was asleep in a recliner and the catheter bag was hung from a Hoyer sling behind the resident, with the bag in contact with the floor and no barrier or dignity bag in place. A nurse verified that the catheter bag was in contact with the floor and stated the bag should be in a dignity bag and hung off the floor. The facility policy stated that residents with indwelling catheters should receive appropriate catheter care and that privacy/dignity bags should be available, with catheter drainage bags covered or shielded at all times while in use.
Medication Administration and Self-Administration Deficiencies
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of residents when medications were administered inconsistently with orders or left available for self-administration without authorization. R2 had an order for calcium carbonate 500 mg chewable tablets four times daily for GERD, but during the 3:00 PM medication pass an RN administered a 750 mg calcium carbonate chewable tablet instead. The DON later verified that R2 should have received the 500 mg tablet ordered by the prescriber. R42 had diagnoses including progressive multiple sclerosis, paraplegia, hypertension, and depression, and had moderately impaired cognition with a BIMS score of 12. R42’s record did not contain an order or assessment for self-administration of medication, and the care plan did not indicate that R42 could self-administer medications. Despite this, an LPN left polyethylene glycol 3350 mixed with water in a cup at R42’s bedside while continuing medication administration to other residents. The cup was later found empty on the breakfast tray, and the LPN stated uncertainty about whether the medication could be left at the bedside. The DON verified that polyethylene glycol should not have been left at the bedside without an order or assessment for self-administration. R1 had diagnoses including COPD and chronic respiratory failure with hypoxia and had intact cognition with a BIMS score of 15. R1 had an order for ipratropium-albuterol inhalation solution via nebulizer four times daily, but the order did not indicate self-administration and the record did not contain a self-administration assessment. Surveyors observed R1 independently administering the nebulizer treatment without nursing staff present. R1 stated that staff set up the nebulizer and then returned after the treatment was completed, and the DON confirmed that R1 did not have the required assessment and that nursing staff should remain with R1 during administration.
Pureed Diet Portions Did Not Match Menu Serving Sizes
Penalty
Summary
The facility did not ensure physician-ordered pureed diets and menu serving sizes were followed for 3 residents, R22, R14, and R5. The facility’s Therapeutic Diets policy stated that all residents have a diet order prescribed by the attending physician, physician extender, or credentialed practitioner and that diets are prepared according to the approved diet manual and individualized plan of care. Each of the 3 residents had orders for a pureed diet and care plans that included providing diet as ordered. All 3 residents also had severe cognitive impairment and were receiving care related to nutritional concerns, including weight loss, dysphagia, and skin issues. R22 had diagnoses including dementia and type 2 diabetes mellitus, a BIMS score of 3 out of 3, and a court-ordered guardian for healthcare decisions. R22’s care plan identified risk for nutritional status change, significant weight loss on Hospice, increased nutrient needs for wound healing, and skin conditions including an open area on the right buttock and a blister on the right lateral foot. R14 had diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, dysphagia, and severe protein-calorie malnutrition, a BIMS score of 0 out of 15, and an activated healthcare decision maker. R14’s care plan identified risk for nutrition-related decline, significant weight loss, need for pureed-texture meals and honey-thickened liquids, and skin issues including MASD on the right buttock. R5 had diagnoses including Alzheimer’s disease, dementia, and dysphagia, a BIMS score of 0 out of 15, and an activated healthcare decision maker. R5’s care plan identified risk for nutritional status change, inability to manage self-care, inadequate oral intake, and significant weight loss. During breakfast observation, the surveyor saw CK-E serve pureed egg bake to R22, R14, and R5 using a 3 oz scoop even though the menu listed a 4 oz serving size. During lunch observation, CK-E prepared pureed ravioli by placing three 4 oz scoops into a food processor, then portioned the pureed ravioli onto the residents’ plates with a 4 oz ladle even though the menu listed a 6 oz serving size. CK-E stated that three 4 oz scoops were used for each resident on a pureed diet and that the scoop was used to place an appropriate amount on each resident’s plate. The Dietary Manager confirmed CK-E served lunch with the wrong size scoop and provided the wrong portion of ravioli to R22, R14, and R5.
Failure to Adhere to Sanitary Food Preparation Standards
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as observed during multiple instances involving the Dietary Manager (DM-C). The facility's policy, revised in October 2023, requires all staff to wear appropriate attire, including hair and beard nets, while performing their duties in the kitchen. However, during several observations, DM-C was seen assisting with kitchen prep, lunch service, and cooking without wearing a beard net, despite having facial hair. This was noted during a continuous kitchen observation and during lunch service, where DM-C handled food without the required beard net. When questioned by the surveyor, DM-C initially indicated uncertainty about the facility's policy regarding beard nets and referenced the Food Code, which DM-C believed did not mandate beard nets. However, upon reviewing the facility's policy with the surveyor, DM-C confirmed that beard nets were indeed required and showed the surveyor a bag of beard nets available in the kitchen. Despite this, DM-C continued to not wear a beard net during subsequent observations, indicating a failure to adhere to the facility's sanitary standards as outlined in their policy.
Failure to Report Suspected Drug Diversion and Exploitation
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime, specifically drug diversion and possible exploitation, involving a resident. On October 19, 2024, the facility discovered missing doses of narcotic medication prescribed to a resident, which raised concerns of potential drug diversion. Despite the facility's policies requiring the reporting of such incidents, the suspected crime was not reported to the State Agency or local law enforcement. The resident, who was not cognitively impaired, had a prescription for 60 tablets of hydrocodone/acetaminophen sent to a local pharmacy. The resident's spouse picked up the medication, but only 14 pills were returned to the facility. The resident indicated that the remaining pills were owed to other people. The facility's staff, including the Director of Nursing and the Nursing Home Administrator, were aware of the situation but did not report it, as they believed the facility was not in possession of the missing narcotics. Interviews with staff and law enforcement confirmed that the situation should have been reported as a crime. The facility's failure to report the incident was based on instructions from corporate management, despite staff being mandatory reporters of suspected crimes. The lack of reporting and investigation into the missing medication and the resident's statements about owing pills to others constituted a deficiency in the facility's compliance with reporting requirements.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate and safe administration of pharmaceuticals for three residents, as observed by surveyors. On the specified date, multiple oral medications and an inhaler were left unattended in a resident's room, who was not assessed as able to self-administer medication. The resident, who had no cognitive impairment and was responsible for their healthcare decisions, was observed taking the medications without supervision. The facility's policy required that medications should not be left in a resident's room without proper orders and documentation of self-administration, which was not followed in this case. Another resident reported that nurses sometimes left Tylenol at their bedside for use during the night, despite not being assessed as able to self-administer medication. This resident also had no cognitive impairment and was responsible for their healthcare decisions. The facility's policy was not adhered to, as the practice of leaving medication at the bedside was against the facility's guidelines. The Nursing Home Administrator and Director of Nursing were unaware of this practice, which was confirmed to be against the facility's policy. A third resident was found with Tylenol capsules left unattended at their bedside, which they had not taken. This resident also had no cognitive impairment and shared a room with another resident. The facility's medication administration process required staff to ensure residents took their medication, which was not followed in this instance. The Director of Nursing confirmed that no residents were assessed as able to self-administer medication, and staff were expected to stay with residents to ensure safe medication administration.
Failure to Document and Appropriately Administer Medication
Penalty
Summary
The facility failed to ensure appropriate parameters for administering a bowel medication were met and did not document bowel movements or abnormal blood pressures for a resident. The resident, who had a history of kidney disease, type 2 diabetes, hypertension, and COPD, was admitted to the facility after a hospital stay for kidney and bladder surgery. Despite experiencing two episodes of diarrhea, the resident was administered Miralax, a laxative, which was not appropriate given the circumstances. Additionally, the resident's episodes of low blood pressure and diarrhea were not documented in the medical record. The deficiency was further compounded by communication lapses among the staff. A CNA noted the resident's low blood pressure and diarrhea but did not document these findings or effectively communicate them to the LPN. The LPN, unaware of the resident's condition, administered Miralax based on the resident's request and family input, without checking the bowel charting. Later, an RN assessed the resident and found concerning symptoms, leading to the resident being sent to the ER. The DON confirmed that the low blood pressures and dark stools required immediate documentation and notification to the medical doctor, which did not occur.
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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 Shawano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health Services | 0.3 mi | ★★★★★ | 4 | 1 |
| Birch Hill Health Services | 0.8 mi | ★★★★★ | 11 | 0 |
| The Pines Post Acute And Memory Care | 7.1 mi | ★★★★★ | 0 | 0 |
| Greentree Health And Rehabilitation Center | 11.7 mi | ★★★★★ | 2 | 0 |
| Suring Health And Rehab Center | 20.1 mi | ★★★★★ | 6 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.