Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Sheboygan Health Services during CMS and state inspections, most recent first.
Food prep areas and equipment were not kept in clean, sanitary condition, with the reach-in cooler, oven doors, double door oven, nearby shelf items, and dry storage floor observed with splashes, grease, dust, and food debris. The DM confirmed the kitchen was not cleaned every 24 hours and that the identified areas were not cleaned per policy. The facility also lacked internal thermometers in the reach-in cooler and walk-in freezer, and staff relied on outside gauges instead.
Failure to Complete Required PASRR Level II Screens: The facility did not complete required PASRR follow-up for 4 residents whose Level I 30-day hospital exemptions expired. Residents had diagnoses including depression, anxiety, dementia, intellectual disability, cerebral palsy, and other mental disorders, and records showed no Level II PASRR screening after the initial Level I screens. The SSD and VPS confirmed the missing PASRR Level II screens.
Meals were not served at the posted times, with breakfast, lunch, and room trays repeatedly starting late and dinner sometimes served early. A resident reported that meal service was inconsistent, room trays were often over an hour late, and breakfast could be delayed until 9:00 AM or later; the resident had type 2 DM, CKD, intact cognition, and a noon Humalog order prior to meals. A grievance from Resident Council also stated meals were not served as scheduled and residents were not always aware when meals would be served.
A resident with schizophrenia, OCD, and anxiety who was assessed as at risk for elopement did not have the ordered WanderGuard consistently in place. The care plan and orders required an alert bracelet/WanderGuard and routine checks, but the TAR showed missed documentation, staff gave conflicting accounts about where the device was placed, and the surveyor observed the resident without the device on the walker. The DON and RN stated the resident had refused to wear it on the body and had cut it off multiple times.
A resident with dysphagia, hemiparesis, type 2 DM, and low BMI had inconsistent weights taken on both a wheelchair scale and a stand-up scale. The record showed multiple weight changes over 5 lbs, but re-weights were not obtained and the physician and POAHC were not notified. Staff interviews confirmed the discrepancies and the missing documentation.
The facility failed to serve meals at the scheduled times, with breakfast and lunch being significantly delayed, affecting residents' satisfaction. Despite the facility's policy to serve meals within designated times, ongoing issues with late meals and cold food were noted in Resident Council minutes. Interviews with residents confirmed dissatisfaction, and the Dietary Manager acknowledged communication problems regarding meal times.
A resident experienced cold conditions in their room due to a non-functional heating/air conditioning unit, which had not worked since the previous winter. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit, but the room relied on hall heat and a wall water heat register. Despite the facility's offer to relocate the resident, they chose to remain in the room, managing the cold with sweaters and blankets.
The facility failed to update PASRR Level I and conduct Level II Reevaluations for two residents with mental illness after changes in their medication. The Social Service Coordinator lacked knowledge of PASRR requirements, and the Nursing Home Administrator and President of Success were unaware of the need for updates. This oversight was due to the previous coordinator's responsibility to maintain up-to-date PASRRs.
A resident with a self-care deficit and multiple health conditions did not consistently receive oral care, as required by the facility's policy. Documentation showed multiple instances where oral hygiene was not recorded, and interviews revealed that both agency and facility staff failed to provide necessary assistance. Observations confirmed the resident's report of inadequate oral care, highlighting a systemic issue in the facility's care practices.
A resident with a history of severe sepsis due to a UTI and bilateral nephrostomy tube placement was observed with their nephrostomy tube drainage bag uncovered and on the floor, contrary to facility policy. This lapse in care was confirmed by an RN, highlighting a failure to prevent potential contamination and infection.
A resident with COPD and other respiratory conditions was observed receiving oxygen at rates higher than prescribed by their physician. The resident's order specified oxygen administration at 1-4 liters per minute to maintain saturation levels at or above 90%, but surveyors noted the resident receiving 4.5 and 5 liters per minute. An LPN confirmed the usual setting was 3 liters and adjusted it to 4 liters to achieve a 92% saturation level, highlighting a failure to follow the prescribed care plan.
A resident did not receive 16 doses of prescribed Artificial Tears due to unavailability, causing discomfort and vision issues. The facility's staff failed to administer the medication as ordered, and documentation errors were noted. The medication was later found on-site, indicating a communication lapse.
A resident was served soup that was too hot to eat because the Dietary Manager did not check the temperature after reheating it in the microwave. The facility's policy requires food to be reheated to at least 165°F, but the temperature was not recorded or verified before serving. The incident was not properly documented, leading to a deficiency noted by the surveyor.
The facility failed to maintain accurate medical records for two residents. One resident's MAR inaccurately showed administration of Artificial Tears when the medication was unavailable, while another resident received dialysis without a physician's order documented. Both residents were responsible for their healthcare decisions and not cognitively impaired.
The facility did not adhere to its policies for preventing abuse and neglect by failing to conduct timely background checks for two staff members. A CNA hired in 2017 lacked recent background check documentation, and a Maintenance Staff hired in 2023 had checks completed only after their hire date. The Business Office Manager confirmed these lapses, with the tracking spreadsheet showing incomplete records.
A resident with a history of alcoholic cirrhosis and intact cognition alleged that staff pushed them to the floor, but the facility failed to report this allegation to the State Agency and local law enforcement in a timely manner. The incident was not included in the fall investigation, and the Nursing Home Administrator and Director of Nursing were not notified promptly, leading to a breach of the facility's policy on reporting alleged violations.
A resident with intact cognition alleged that staff pushed them to the floor during an incident where they were being assisted out of other residents' rooms. The facility's investigation into the fall did not address the abuse allegation, and witness statements were destroyed after being entered into the electronic document. The DON could not recall being notified of the abuse claim, and the NHA confirmed that proper investigation procedures were not initiated due to the lack of timely notification.
A resident with multiple diagnoses, including Parkinson's disease and dementia, fell in the facility. The root cause of the fall was not identified, and the care plan was not updated with new interventions to prevent future falls, contrary to the facility's policy.
Unclean food prep areas and missing internal thermometers
Penalty
Summary
Food was not stored and prepared in a sanitary manner, and the facility did not keep food prep areas and equipment in clean condition. During an initial self-guided kitchen tour, the surveyor observed the reach-in cooler with brown and white splashes on the front of both doors, the oven doors with eggs, yellow and white splashes, and grease, and the top and side of the double door oven with dust, grease, and matter that appeared to be food particles. A shelf next to the double door oven, a vinegar bottle, and seasonings had brown/black grease, a peanut butter container had peanut butter on the sides, lid, and around the lid, and the dry storage room floor had crushed crackers, cardboard pieces, and condiments under the shelving. During a later kitchen observation, the same areas were still in the same unclean condition. The Dietary Manager stated the kitchen had an issue with cleaning, that the manager spoke to staff frequently and tried to correct the concerns, and that the manager completed most of the kitchen cleaning while working but could not keep up with the tasks. The manager confirmed the kitchen was not cleaned every 24 hours and that the identified areas were not cleaned per policy. The facility also did not have internal thermometers in the reach-in cooler and walk-in freezer; the surveyor observed outside gauges showing the reach-in cooler at 56.6 degrees F and later 46.5 degrees F, while the walk-in freezer gauge showed 0 degrees F. The Dietary Manager confirmed the internal thermometers were missing and stated staff relied on the outside temperature gauge for the reach-in cooler.
Failure to Complete Required PASRR Level II Screens
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for 4 of 5 sampled residents. The facility did not contact the state mental health authority when the residents’ PASRR Level I 30-day exemptions expired and did not pursue the required PASRR Level II screening. The facility policy stated that residents with a positive Level I screen require a Level II evaluation prior to admission, and that residents admitted under a hospital exemption who remain longer than 30 days must be screened through the state Level I process and referred for Level II evaluation. R23 was admitted with diagnoses including depression, anxiety, and dementia with agitation. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4 out of 15 and an activated decision maker for healthcare decisions. The record contained PASRR Level I screens showing a 30-day hospital exemption, but no additional PASRR screens, including the required Level II screen. R37 was admitted with major depressive disorder, anxiety disorder, and dementia with behavioral concerns and psychotic features. The resident’s MDS showed moderately impaired cognition with a BIMS score of 11 out of 15 and an activated healthcare decision maker. The record contained a PASRR Level I screen with a 30-day hospital exemption, but no other Level I or Level II screens. R1 was admitted with cerebral palsy, cognitive communication deficit, and unspecified mental disorder due to known physiological condition. The resident’s MDS showed intact cognition with a BIMS score of 14 out of 15 and an activated POAHC. The record included a PASRR Level I screen indicating intellectual disability and a 30-day hospital discharge exemption, and a county referral form noted that short-term exemptions may not be used consecutively to extend time in the facility without a PASRR Level II screen. R6 was admitted with anxiety, depression, mild cognitive impairment, and alcohol-induced dementia. The resident’s MDS showed intact cognition with a BIMS score of 14 out of 15 and an activated POAHC. The record included a PASRR Level I screen indicating a major mental disorder and a 30-day hospital discharge exemption, but no further PASRR screening was present. The Social Services Designee and the VPS confirmed that these residents should have had PASRR Level II screens, and the facility had not submitted them.
Meals Served Outside Posted Times
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests. Posted meal times in the dining room and outside the activity room listed breakfast at 8:30 AM, lunch at 12:30 PM, and dinner at 5:30 PM, but surveyor observations showed lunch starting at 1:05 PM with the last resident in the dining room served at 1:26 PM, room trays leaving the dining room at 1:45 PM, and the last tray delivered at 2:00 PM. On another day, breakfast was observed beginning at 8:50 AM with room trays not starting until 9:06 AM and the last tray delivered at 9:24 AM. Lunch was also observed starting at 12:50 PM, with room trays not starting until 1:02 PM and the last tray delivered at 1:13 PM. A grievance from a Resident Council meeting stated meals were not served as scheduled, meals were early or late, and residents were not always aware when meals would be served. The Dietary Manager acknowledged meals were not served at the posted times and said kitchen staff were allowed to be 15 minutes late. A resident who ate breakfast and dinner in the dining room and lunch in the room stated meal times were not adhered to, room trays were sometimes over an hour late, dinner was served early at times, and breakfast was sometimes not served until 9:00 AM or later. The resident had type 2 diabetes and chronic kidney disease, had intact cognition on the most recent MDS, and had an order for 13 units of Humalog at noon prior to meals.
Inconsistent WanderGuard Use for a Resident at Risk for Elopement
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for one resident at risk for elopement, R19, because the WanderGuard intervention was not consistently implemented. R19 had diagnoses including schizophrenia, obsessive compulsive disorder, and anxiety, and the MDS assessment showed a BIMS score of 13 out of 15, indicating intact cognition. R19’s care plan and physician orders directed staff to use an alert bracelet/WanderGuard for elopement risk and to check its placement and function regularly. However, the treatment record showed missed documentation of WanderGuard placement on two shifts, and on 3/17/26 the surveyor observed that R19 did not have a WanderGuard in place. Staff interviews showed inconsistent implementation of the intervention. An LPN stated the WanderGuard was on R19’s walker and that staff tested and verified it once per shift, while the DON stated R19 had a history of attempting to leave the facility and that staff had tried but were unable to place the device on R19’s ankle or wrist because R19 would not allow it. After the DON stated there was a WanderGuard on the walker, the surveyor observed R19 return from an activity with the walker and no WanderGuard was observed. R19 stated the device had been removed because of the red light. The DON later documented a trial to remove the WanderGuard, but the record did not contain an order to remove it. An RN also stated the WanderGuard was placed on the walker because R19 refused to wear it on the person and verified that R19 had cut it off multiple times.
Inconsistent weight monitoring and missing notifications for significant weight changes
Penalty
Summary
The facility did not ensure consistent weight monitoring for a resident with dysphagia following an intracranial hemorrhage, hemiplegia and hemiparesis, type 2 diabetes, and a BMI of 19.9 or less. The resident had a BIMS score of 13 out of 15 and an activated POAHC. The care plan identified the resident as at risk for nutritional status changes and included interventions to review weights and notify the RD, provider, and responsible party of significant weight changes, record weights per protocol, and provide additional calories and protein. The resident’s record showed weights were taken using both a wheelchair scale and a stand-up scale, and the method was not consistent. The facility’s weight monitoring policy required use of a consistent, calibrated scale and confirmation of any weight change of 5 pounds or more. The record contained multiple weight changes of more than 5 pounds, including a 9-pound gain, a 7.2-pound gain, and a 9-pound loss, but re-weights were not obtained for these changes. The record also showed disputed weight values with no re-weigh documented. Surveyor interview confirmed the discrepancies and the lack of re-weights. An RN stated CNAs obtained weights and nurses were responsible for comparing them, and acknowledged that re-weighs were not completed and no nursing notes related to weight were found in the record. The VPS confirmed the resident’s weights were obtained with either a wheelchair or stand-up scale, that the method was inconsistent, and that the medical record did not show re-weights or notifications to the physician and POAHC for weight changes of 5 pounds or more.
Inconsistent Meal Service Times
Penalty
Summary
The facility failed to serve meals consistently at the scheduled times, which had the potential to affect more than four of the 36 residents. On a specific day, breakfast service began 38 minutes after the posted time, and the last breakfast tray was served 1 hour and 12 minutes late. Similarly, lunch service started 30 minutes late, with the last tray delivered 1 hour and 16 minutes after the scheduled time. The facility's policy required meals to be served within designated time frames unless there was an emergency or resident request, but this was not adhered to. Resident Council minutes from a previous meeting indicated ongoing concerns about cold food and late meals. Interviews with residents confirmed dissatisfaction with meal timeliness, with one resident stating meals arrived an hour late. The Dietary Manager acknowledged a communication problem regarding meal times and had informed the Nursing Home Administrator, but the posted meal times remained unchanged. These observations and interviews highlight the facility's failure to meet its own meal service policies, leading to resident dissatisfaction.
Non-Functional Heating Unit in Resident's Room
Penalty
Summary
The facility failed to maintain a homelike environment with a comfortable temperature for a resident, identified as R6, due to a non-functional heating/air conditioning unit in the resident's room. The facility's policy requires maintaining comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit. However, the heating/air conditioning unit in R6's room was not operational, leaving the room dependent on hall heat and a wall water heat register, which only worked when it was extremely cold. This situation resulted in R6 experiencing cold conditions in the room, especially during winter. R6, who was not cognitively impaired and responsible for their healthcare decisions, reported that the room became very cold, and the heating/air conditioning unit had not worked since the previous winter. Despite the facility's offer to move R6 to another room, R6 declined, preferring to stay in the current room and manage the cold by wearing sweaters and using blankets. The Maintenance Director confirmed the unit's malfunction and noted that the facility had plans to replace additional non-working units in the future.
Failure to Update PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to notify the state mental health authority in a timely manner following significant changes in the mental health conditions of two residents. Resident 7, who was admitted with Alzheimer's disease, dementia, and major depressive disorder, had a PASRR Level I Screen indicating a serious mental illness. Despite changes in medication, including the addition of an antipsychotic, the facility did not update the PASRR Level I or conduct a Level II Reevaluation. Similarly, Resident 22, admitted with generalized anxiety disorder, major depressive disorder, and delusional disorder, had changes in medication that were not reflected in an updated PASRR Level I or a Level II Reevaluation. The deficiency was identified during a surveyor's review of the residents' medical records and interviews with facility staff. The Social Service Coordinator, who was responsible for PASRR requirements, lacked knowledge about when updates and reevaluations were necessary. The Nursing Home Administrator and the President of Success were also unaware of the need for updated PASRR Level I Screens and Level II Reevaluations for the residents. This oversight was attributed to the previous Social Service Coordinator's responsibility to ensure PASRRs were up-to-date, which was not fulfilled.
Inconsistent Oral Care Documentation for Resident
Penalty
Summary
The facility failed to ensure consistent oral care for a resident, identified as R3, who was unable to perform activities of daily living independently. R3, who had a history of metastatic kidney cancer, schizophrenia, and diabetes, was admitted with a self-care deficit and required assistance with oral hygiene. Despite the facility's policy to provide oral care to prevent oral diseases, documentation revealed multiple instances where oral hygiene was not recorded as completed, unavailable, or refused. This lack of documentation spanned several dates across October, November, and December 2024, indicating a pattern of neglect in providing necessary oral care. Interviews with the Director of Nursing (DON) and observations by the surveyor further highlighted the deficiency. R3 reported food being stuck in their teeth and a lack of assistance from staff, which was corroborated by the surveyor's observation of a dry toothbrush and food debris in R3's teeth. The DON acknowledged that oral hygiene was not documented on several occasions and attributed some of the lapses to agency staff who did not have access to the electronic medical records. However, it was also noted that the facility's own staff failed to complete the task, indicating a systemic issue in ensuring oral care for residents.
Failure to Maintain Nephrostomy Bag Properly
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and services to prevent urinary tract infections (UTIs). The deficiency was identified when a surveyor observed the resident's nephrostomy tube drainage bag uncovered and placed on the floor. This observation was made on two separate occasions, indicating a lapse in maintaining the drainage bag in a proper position to prevent contamination and infection. The facility's policy requires that nephrostomy bags be kept covered and off the floor to prevent infection and maintain dignity. The resident involved had a history of severe sepsis due to a UTI and had undergone bilateral nephrostomy tube placement. The resident was not cognitively impaired and made their own healthcare decisions. Despite the resident's medical history and the facility's policy, the nephrostomy bag was not managed according to the required standards, as confirmed by a registered nurse. This oversight in care could potentially lead to further complications for the resident, given their medical condition.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, identified as R22, who was receiving oxygen therapy. R22 had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), pulmonary embolism, pulmonary hypertension, anxiety, and was dependent on supplemental oxygen. The resident's physician had ordered oxygen to be administered at a rate of 1-4 liters per minute via nasal cannula to maintain oxygen saturation levels at or above 90%. However, on two separate occasions, surveyors observed that R22 was receiving oxygen at rates higher than prescribed, specifically at 4.5 liters and 5 liters per minute. A Licensed Practical Nurse (LPN) confirmed that the usual flow rate for R22 was set at 3 liters and adjusted the oxygen flow to 4 liters to achieve an oxygen saturation level of 92%. This discrepancy between the prescribed and administered oxygen flow rates indicates a failure to adhere to the physician's orders, compromising the resident's care.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medication for a resident, identified as R16, who was prescribed Artificial Tears ophthalmic solution for dry eyes. R16, who had a BIMS score indicating no cognitive impairment, reported not receiving the prescribed eye drops for seven days due to the medication being unavailable. The resident, who suffers from spastic quadriplegic cerebral palsy, bipolar disorder, anxiety, and depression, experienced discomfort and difficulty seeing without the medication, which was confirmed by the surveyor's review of the Medication Administration Records (MARs). The MARs revealed that R16 missed 16 doses of the prescribed medication over several days, with staff documenting the medication as unavailable. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) confirmed the medication was not administered due to a delay in pharmacy shipment, and the RN admitted to erroneously documenting that the doses were given. The Vice President of Success later found a box of Artificial Tears in the facility, indicating a lack of communication or awareness among staff regarding the medication's availability.
Failure to Ensure Palatable Food Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature for a resident, identified as R18. On December 2, 2024, the Dietary Manager (DM-G) reheated a bowl of soup in the microwave for R18 but did not check the temperature before serving it. Approximately 14 minutes after being served, R18 reported that the soup was still too hot to eat. The facility's policy requires that hot food items should not fall below 135 degrees Fahrenheit after cooking and should be reheated to at least 165 degrees Fahrenheit before serving. However, DM-G did not adhere to this policy, as the temperature of the soup was not checked or recorded before it was served to R18. Further investigation revealed that DM-G did not document the temperature of the reheated soup on the facility's temperature log on the day of the incident. Although DM-G later provided a back-dated Microwave Temp Log indicating the soup reached 186 degrees Fahrenheit, the surveyor did not observe DM-G taking the temperature or stirring the soup before it was served. DM-G claimed to have taken the temperature with their back turned to the surveyor, but this was not witnessed. This oversight in following proper procedures for reheating and serving food led to the deficiency noted by the surveyor.
Documentation Errors in Medical Records
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of two residents. For one resident, the Medication Administration Record (MAR) inaccurately indicated that six doses of Artificial Tears were administered when the medication was unavailable. The resident, who was not cognitively impaired and responsible for their healthcare decisions, did not receive the prescribed doses due to a delay in pharmacy shipment. A registered nurse admitted to documenting the administration of the medication in error, leading to inaccuracies in the MAR. Another resident, who was also not cognitively impaired and responsible for their healthcare decisions, did not have a physician's order for dialysis in their medical record, despite receiving dialysis three times a week. The Director of Nurses confirmed the absence of the necessary physician's order, acknowledging the deficiency in maintaining complete medical records. These documentation errors highlight the facility's failure to adhere to its Medication Administration policy and ensure proper medical record-keeping.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation by not conducting thorough and timely caregiver background checks for two staff members. The facility's policy, last reviewed on 7/15/22, mandates screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credentials checks. However, the facility did not provide proof of a Background Information Disclosure (BID) form, Department of Justice (DOJ) criminal background check letter, or Integrated Background Information System (IBIS) letter for a Certified Nursing Assistant (CNA) hired on 4/4/17 within the previous four years. Additionally, for a Maintenance Staff member hired on 7/5/23, the facility only provided BID, DOJ, and IBIS documents dated 2/23/24, failing to show these checks were completed prior to or on the hire date. During interviews, the Business Office Manager (BOM) indicated that caregiver background checks are typically completed before new staff are brought into the facility and should be updated every four years. However, upon reviewing the caregiver background check tracking spreadsheet, it was found that the most recent check for the CNA was recorded on 4/13/21, with no documentation available in the CNA's file. Similarly, the Maintenance Staff's name appeared on the spreadsheet without any listed dates for background checks. The Nursing Home Administrator confirmed the absence of additional documents for both staff members, highlighting a lapse in the facility's adherence to its own policies and procedures for preventing abuse and neglect through proper staff screening.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency and local law enforcement in a timely manner. The incident involved a resident who alleged that staff pushed them to the floor. The resident, who had a history of alcoholic cirrhosis of the liver and other mental and behavioral disorders, was admitted to the facility with intact cognition as indicated by a BIMS score of 15 out of 15. On the day of the incident, the resident was transferred to an emergency room after becoming aggressive with staff while searching for their spouse and subsequently falling to the floor. The resident alleged that they were pushed, but this allegation was not included in the fall investigation conducted by the facility. The Nursing Home Administrator and Director of Nursing were unable to recall being notified of the abuse allegation in a timely manner. The facility's policy requires that all alleged violations be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. However, the facility did not adhere to this policy, as the allegation of abuse was not reported to the appropriate authorities. The failure to report the incident was confirmed during interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that the allegation of abuse was not communicated to them promptly, and thus, not reported as required.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation made by a resident. The resident, who had intact cognition and was responsible for their healthcare decisions, alleged that staff pushed them to the floor. The incident occurred when the resident was being assisted out of other residents' rooms by staff and became aggressive while searching for their spouse. The resident lost balance and fell, subsequently alleging that they were pushed down. Despite the serious nature of the allegation, the facility's investigation into the fall did not address the claim of physical abuse. The facility's policy mandates immediate investigation of abuse allegations, including interviewing all involved parties and documenting the investigation thoroughly. However, the investigation lacked mention of the abuse allegation, and witness statements were not provided to the surveyor. The Director of Nursing admitted that the witness statements were destroyed after being entered into the electronic fall investigation document, and there was no recollection of being notified about the abuse allegation. The Nursing Home Administrator confirmed that if they had been informed of the allegation in a timely manner, they would have initiated the appropriate abuse investigation procedures.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for one resident reviewed for falls. The resident, who had diagnoses including Parkinson's disease, dementia, type 2 diabetes, and arthritis, fell in the facility. The root cause of the fall was not identified, and the resident's plan of care was not updated to prevent future falls. The facility's policy requires evaluation and analysis of falls to identify specific hazards and risks and to develop targeted interventions, but this was not followed in this case. The resident's medical record indicated that they were at risk for falls, with interventions such as a low bed position and non-slip footwear in place. After the fall, floor mats were added as an intervention, but this was not reflected in the resident's fall care plan. The Interdisciplinary Team reviewed the fall but did not identify a root cause or implement new interventions beyond what was already in place. The Vice President of Success confirmed that no new interventions were implemented after the fall, despite the policy requirements.
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Illustrative
What surveyors actually found near you
We read the 109 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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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) |
|---|---|---|---|---|
| Edenbrook Sheboygan | 0.4 mi | ★★★★★ | 7 | 1 |
| Morningside Health Services | 2 mi | ★★★★★ | 7 | 0 |
| Sheboygan Senior Community Inc | 2.3 mi | ★★★★★ | 16 | 0 |
| Sheboygan Progressive Health Services | 2.3 mi | ★★★★★ | 12 | 0 |
| Meadow View Health Services | 3.1 mi | ★★★★★ | 8 | 0 |
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