Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sheboygan Progressive Health Services during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple comorbidities had a significant change in condition after an unwitnessed fall, but staff did not complete timely nursing assessments or notify the MD and POAHC as the resident developed worsening pain, poor intake, and decreased mobility before later being hospitalized with fractures, sepsis, AKI, and malnutrition. A second resident with dementia and diabetes sustained a left great toe injury, but ordered Betadine treatment and infection monitoring were not consistently completed; the wound worsened, osteomyelitis developed, and the resident required partial amputation of the toe.
A resident with cancer, difficulty walking, and moderate cognitive impairment had a fall care plan that included transferring a chair alarm between surfaces. After staff assisted the resident from bed to wheelchair, the alarm was not moved to the wheelchair. The resident later had an unwitnessed bathroom fall while attempting to self-transfer from the toilet, was found with an abrasion and back pain, and was sent to the hospital where fractures of the lumbar spine and T12 were diagnosed.
Incomplete Background Check for RN-E: The facility did not fully implement its abuse, neglect, and exploitation screening policy for an RN. Although part of the background check was completed before hire, the DOJ and Governmental Findings reports were dated much later, and the agency that supplied the RN said the file had been deleted. The NHA stated the facility should have completed all pre-employment screening before employment and retained copies of the screening documents.
A resident with DM, neuropathy, and a chronic venous stasis wound had ongoing skin assessments that continued to note an open area, but the record lacked wound measurements, MD notification, treatment changes, and documentation of healing or infection signs. The wound was initially documented as healed, yet later was found reopened and much larger than previously recorded. The wound nurse was unaware the wound had reopened and believed staff were treating a closed wound, and EBP had not been initiated for the reopened chronic wound.
A resident with malnutrition, CHF, polyneuropathy, severe cognitive impairment, and Hospice services had multiple healed wounds, a healed stage 1 pressure injury to the coccyx, and an unhealed abrasion to the left scapula. The care plan and MD order required an air mattress setting of 75-100 pounds, but staff observed it set at 300 pounds on multiple occasions; the RCMD verified the incorrect setting and stated a Hospice CNA increased it when the resident was out of bed and did not return it to the ordered setting.
Failure to clean and maintain CPAP equipment. A resident with OSA and respiratory failure had orders for daily CPAP cleaning, monthly filter changes, and routine oxygen tubing changes, but the mask was observed oily with visible residue, the filter was black with debris, and the tubing remained dated beyond the ordered change interval. The RN confirmed the CPAP machine, mask, filter, and tubing were not maintained as ordered, and the resident reported the mask was dirty.
A cook did not follow standardized recipes when preparing pureed menu items for residents on pureed or mechanically altered diets. During meal service, the cook used unmeasured amounts of water, milk, gravy, juice, broth, breadcrumbs, seasoning, butter, and thickening agents, and could not locate recipes for the items prepared. The DM and AM verified recipes were needed to maintain appropriate consistency and nutritive value, and noted the facility did not have all pureed-item recipes after switching menu companies.
A facility failed to implement EBP for two residents who met criteria for it: one resident had an open chronic wound and another had an indwelling urinary catheter. Surveyors observed no EBP sign or PPE cart at first, and staff provided care without the required PPE, including handling a catheter bag with a bare hand during a transfer. The IP, DON, and wound nurse all stated the residents should have been on EBP.
The facility did not follow its policy to prevent abuse and neglect by failing to obtain necessary documents for a CNA with disorderly conduct convictions. Despite the requirement for full background checks, the facility did not request additional information for the CNA's convictions, leading to a noted deficiency.
A resident was observed self-administering medication without a physician's order or assessment, leading to dropped pills in bed. Despite having no cognitive impairment, the resident had a recent change in condition requiring IV fluids and oxygen. The facility's policy requires an order and assessment for self-administration, which were missing in this case.
The facility failed to ensure food safety and sanitation, affecting all 31 residents. Observations revealed improper reheating of food, incomplete cooling logs, and inadequate temperature maintenance for cold foods. Additionally, staff did not follow proper hand hygiene and glove use during meal service, leading to potential contamination.
The facility failed to transmit MDS assessments timely for three residents, resulting in a deficiency. Completed assessments were not accepted by the iQIES system due to a coding error in the EMR system. The Director of Clinical Reimbursement confirmed the oversight, noting that the assessments were marked as completed but not transmitted. The MDS nurse was still in training, and regional staff were responsible for the transmission process.
Two residents experienced issues during transfers due to improper sling sizes and inadequate staffing. One resident fell when a sling was too large, and only one staff member was present, while another resident experienced pain from a sling that was too small. Staff interviews revealed confusion about sling sizing and transfer procedures, with no clear responsibility for documenting sling sizes in care plans.
Failure to Assess Change in Condition and Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure timely assessment and notification after a resident experienced a significant change in condition following an unwitnessed fall. The resident had diagnoses including malignant lung cancer, dysphagia, anxiety, and difficulty walking, and had moderate cognitive impairment with an activated POAHC. After the fall, the resident developed increased pain, decreased appetite, reduced fluid intake, and decreased mobility. Although the resident was initially assessed for the fall and the physician and POAHC were notified, the record shows the resident then remained in bed, ate and drank poorly, and became less responsive over the next several days without a timely nursing assessment or timely provider and representative notification of the worsening condition. Documentation showed the resident’s pain continued and was treated with PRN oxycodone, but staff notes also described the resident as not eating, not taking medication, drinking very little, and being slow to respond. Staff statements indicated multiple nurses were aware of the resident’s decreased intake, increased pain, and overall change in routine and condition, but the facility did not complete a timely nursing assessment or escalate the change in condition. The resident was ultimately sent to the hospital several days after the fall and was diagnosed with minimally displaced fractures of the L2 and L3 transverse processes, a mild compression fracture of T12, sepsis secondary to UTI, toxic metabolic encephalopathy secondary to infection, concern for bilateral lobe infiltrates, acute kidney injury, cystitis, and severe protein-calorie malnutrition. The resident later died at the hospital, and the death certificate listed urosepsis and acute cystitis as the cause of death. The facility also failed to provide ordered wound treatment and monitoring for another resident after a toe injury. That resident had dementia, diabetes, chronic kidney disease, and CHF with lower extremity edema, and had severe cognitive impairment with an activated POAHC. After bumping the left great toe on a sit-to-stand lift, the resident developed a bruise and loosened toenail with bleeding. APNP-D ordered Betadine twice daily until healed and monitoring for signs and symptoms of infection, but staff did not consistently complete the treatment or monitor the wound. The wound increased in size, the toenail fell off, and the resident later went to the hospital with confusion, altered mental status, and an open wound on the left great toe. MRI showed early osteomyelitis, and the resident underwent a partial amputation of the left great toe.
Failure to Transfer Chair Alarm Before Resident Fall
Penalty
Summary
The facility did not ensure assistive devices to prevent accidents were implemented for one resident who had been assessed as at risk for falls. The resident had diagnoses including malignant lung and brain cancer and difficulty walking, and a BIMS score of 11 out of 15 indicating moderate cognitive impairment. The resident’s care plan included an intervention for a chair alarm to be changed between surfaces, but on the day of the incident the resident had an unwitnessed fall in the bathroom while attempting to self-transfer from the toilet to the wheelchair. A post-fall assessment documented that the chair alarm was not in place. After the fall, the resident was found on the floor with a right scapula abrasion and complained of back pain. The resident was assisted back to bed and later sent to the hospital after a change in condition that included altered consciousness, decreased mobility, elevated pulse, and pain. Imaging showed minimally displaced left lateral L2 and L3 transverse process fractures and a mild compression fracture of the T12 vertebral body. Staff interviews and record review showed the CNA who had assisted the resident earlier in the day did not transfer the alarm from the bed to the wheelchair, and management acknowledged the alarm had not been moved to the wheelchair when the resident fell.
Incomplete Background Check for RN-E
Penalty
Summary
The facility did not ensure its abuse policy was implemented for 1 of 9 employees reviewed for caregiver background checks. The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, states that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks will be conducted on potential employees and other applicable personnel, with documentation maintained as proof that the screening occurred. Surveyor review of background check information for RN-E, who was hired by the facility on 6/24/25, showed that part of the background check was completed on 6/6/25, but the DOJ and Governmental Findings reports were dated 6/16/26. During an interview on 6/16/26 at 3:32 PM, the NHA stated the facility contacted the agency that hired RN-E, but the agency did not have DOJ or Governmental Findings reports for RN-E and said the file had been deleted. The NHA stated the facility should have completed all background check and pre-employment screening prior to RN-E's employment and should retain copies of background check and pre-employment screening information for all employees.
Failure to Monitor and Treat Reopened Venous Stasis Wound
Penalty
Summary
The facility did not provide necessary wound monitoring and treatment for a resident with type 2 diabetes with neuropathy, chronic pain syndrome, and a left lower extremity venous stasis wound. The resident’s care plan identified impaired skin integrity and an open area on the left posterior lower leg, and the physician ordered daily wound care with normal saline or wound cleanser, Xeroform, an ABD pad, and Kerlix. The facility’s policy required weekly skin checks, assessment of current wounds at least every seven days, and notification and treatment changes when new areas were present or when wounds failed to progress. The resident’s non-pressure weekly tracker documented the wound as new on 2/22/25, healing on 2/26/25, and healed and closed on 3/5/25, but no further non-pressure weekly trackers were completed after that date. Weekly skin assessments from 3/17/25 through 8/5/25 continued to identify an open area on the left lower extremity, but they did not include measurements, physician notification, treatment changes, or documentation of healing or signs and symptoms of infection. Weekly assessments on 4/14/25 and 4/21/25 identified a skin tear without location or measurements, and the record did not show when the wound reopened. During observation and interviews, the resident stated staff cleaned and dressed the wound daily, but the wound nurse initially believed the wound was healed and said floor staff were completing weekly wound care for a closed wound. When the wound nurse later reviewed the record and removed the bandages, the left lower extremity venous stasis wound was found to be open and measured 5.8 cm x 5.2 cm with 30% skin and 70% granulation. The wound nurse stated being unaware that the wound had reopened and was not aware enhanced barrier precautions should have been initiated before the discovery. The infection preventionist confirmed that an open or reopened venous stasis wound is considered a chronic wound requiring enhanced barrier precautions, and the administrator confirmed staff did not follow the procedures in place to ensure timely treatment and communication about the resident’s wound.
Air Mattress Set Incorrectly for Resident With Skin Integrity Issues
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for R7, who had multiple healed wounds, a stage 1 pressure injury to the coccyx that had healed, and an unhealed abrasion to the left scapula. R7 was admitted with diagnoses including moderate protein calorie malnutrition, congestive heart failure, spondylosis, and polyneuropathy, had an activated POA, received Hospice services, and was dependent on staff for transfers, eating, hygiene, and toileting with a BIMS score of 3 out of 15 indicating severely impaired cognition. R7's care plan and physician order directed that the air mattress be set at 75-100 pounds and checked every shift for pressure reduction. During observations, R7 was in bed and the air mattress was set at 300 pounds on multiple occasions. The Resident Care Management Director verified the mattress was set at 300 pounds but should have been set at 75-100 pounds, and stated a Hospice CNA increases the setting when getting R7 out of bed and forgets to return it to the correct setting.
Failure to Clean and Maintain CPAP Equipment
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident with an order for continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea. The resident also had diagnoses including diffuse traumatic brain injury, acute and chronic respiratory failure with hypoxia and hypercapnia, and had been diagnosed with pneumonia in April 2025. The resident’s care plan identified CPAP use per MD order and risk for respiratory impairment related to aspiration history and sleep apnea. The resident’s orders included daily CPAP cleaning, monthly CPAP filter changes, and weekly oxygen tubing and humidifier bottle changes. On observation, the resident stated the CPAP mask was dirty and was unsure when the mask and filter were last cleaned or changed. The surveyor observed the CPAP mask appeared oily and contained white matter, and the CPAP filter was black with a ring of black particles in the filter housing. The humidifier was connected to the machine, and the oxygen concentrator tubing was dated 8/4. The resident’s TAR showed oxygen tubing changes were documented on 8/3/25 and 8/11/25, but the CPAP filter change due on 8/10/25 was not documented as completed, and there was no documentation that the filter was changed in August 2025. Later observations showed the CPAP machine remained in the same condition, with the tubing still dated 8/4 and the humidifier empty but still connected to the machine. An RN confirmed the oxygen tubing had not been changed per order and stated staff usually cleaned the CPAP machine and mask and removed the humidifier to air dry the parts. The RN also confirmed the CPAP machine was not cleaned and the filter and tubing were not changed as ordered, and was unsure when the filter was last changed or whether supplies were available. The DON stated the last time supplies were ordered would be checked and that orders for monthly filter changes and daily cleaning would be provided.
Pureed Meals Prepared Without Standardized Recipes
Penalty
Summary
The facility did not ensure pureed food was prepared in a method that conserved nutritive value for three residents with orders for pureed or mechanically altered diets. The cited residents included one resident with dysphagia, chronic respiratory failure with hypoxia, obesity, limited activity level, and a history of PEG tube feedings; a second resident with dysphagia, spastic hemiplegic cerebral palsy, and functional quadriplegia; and a third resident with a pureed diet and thin liquids after a history of TIA and cerebral infarction. The facility’s policy required food to be prepared by methods that conserve nutritive value, flavor, and appearance, and required cooks to prepare food in accordance with recipes. During lunch service, surveyors observed a cook serving pureed food and interviewed the cook about the process used to puree items. The cook stated recipes were not followed and that unmeasured amounts of liquids such as hot water, milk, gravy, juice, and broth were used as thinning agents. The cook also stated that if food was too thick, more water or another thinning liquid was added, and if too thin, unmeasured amounts of thickening agent or powder were added. The cook could not locate recipes for the pureed foods prepared that day and acknowledged guessing on the amount of food and liquid used. The cook reported using hot water and packaged breadcrumbs for a pureed dinner roll instead of pureeing actual dinner rolls, and used an unmeasured amount of water, seasoning, and butter to blend scalloped potatoes and ham before adding an unmeasured amount of potato flakes to thicken the mixture. The district manager and account manager verified staff should follow recipes to maintain appropriate consistency and nutritive value, and later stated the facility did not have all recipes for pureed items on the menu. They also verified that changing the liquid used during the puree process can alter the nutritional value and consistency of the food.
Failure to Implement EBP for Residents with Wounds and a Urinary Catheter
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infection for two residents with conditions requiring Enhanced Barrier Precautions (EBP). One resident, R27, had an open chronic wound, including a stage 3 pressure ulcer of the right heel and a stage 2 pressure ulcer of the sacral region, and had a daily wound treatment order. Surveyor observations on multiple occasions found no EBP sign or PPE cart outside the room, and review of the care plan and Kardex did not show that EBP had been initiated. The Infection Preventionist, DON, and wound nurse each stated that a resident with an open chronic wound should have been on EBP, and the wound nurse stated standard precautions were used even though EBP should have been in place. A second resident, R28, returned to the facility with an indwelling urinary catheter after a hospital stay and had diagnoses including hydronephrosis, chronic kidney disease, urinary retention, and urinary device. EBP was not initially implemented when the resident returned, and surveyor observations found no EBP sign or PPE cart near the room early that morning. The resident was observed in the dining room and in the room with an uncovered catheter bag hanging from the wheelchair or bed area, and the Infection Preventionist stated EBP should have been implemented as soon as the resident returned from the hospital. The Infection Preventionist also stated catheter bags should be covered for infection control and privacy. During a later observation, a PTA entered R28's room, removed the catheter bag from the side of the bed with a bare hand, and hung it from the resident's walker while assisting the resident to move toward the side of the bed. Another staff member verbally reminded the PTA that PPE should be used because the resident was on EBP. The PTA stated the EBP sign and PPE cart were not noticed and confirmed PPE should have been donned before touching the catheter bag or starting the transfer. The DON stated that staff should not handle a catheter bag and complete high-contact cares without wearing the appropriate PPE.
Failure to Implement Background Check Policy for CNA
Penalty
Summary
The facility failed to implement its written policy and procedure to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property. This deficiency was identified during a review of the background check process for a Certified Nursing Assistant (CNA-C) who was one of eight staff members reviewed. CNA-C had been convicted of disorderly conduct in 2022 and 2025, but the facility did not request the necessary criminal complaint, judgment of conviction, or relevant court and police documents as required by the Background Information Disclosure (BID) form and the Department of Health Services (DHS) memo P-00274 Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility. The facility's Caregiver Background Checks policy, revised in August 2017, mandates that any reported history of criminal activity be reviewed by the Human Resources Department for further consideration in hiring decisions. However, the Nursing Home Administrator (NHA-A) confirmed that the facility did not obtain the additional information related to CNA-C's disorderly conduct convictions. This oversight occurred despite the requirement for all staff to undergo a full background check prior to employment. The failure to adhere to these procedures resulted in a deficiency noted by the surveyor during the review conducted on February 27, 2025.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medication for one resident. The resident, identified as R4, was observed self-administering medication without a physician's order or a self-administration assessment. During the observation, R4 dropped pills in the bed and was unable to find them. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine if self-administration is safe for the resident. However, R4's medical record did not contain the necessary documentation to support self-administration of medication. R4 was admitted with diagnoses including diabetes, weakness, chronic pain, and hypertension, and had a BIMS score indicating no cognitive impairment. Despite this, R4 experienced a change in condition and was prescribed intravenous fluids and oxygen. The Director of Nursing and a Registered Nurse confirmed that R4 did not have the required order or assessment for self-administration. The RN admitted to leaving medication for R4 to self-administer, acknowledging that this was inappropriate given R4's recent change in condition.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 31 residents. During a kitchen tour, it was observed that procedures for reheating food in a microwave were not followed. A staff member heated tomato soup in the microwave without checking its temperature or ensuring it reached the required 165 degrees Fahrenheit. The staff member was unaware of the proper reheating procedures, including the need to stir, cover, and let the food stand for two minutes after reheating. Additionally, the facility did not maintain proper cooling temperature logs for leftover and pre-made food. A container of leftover ravioli was found without documentation on the cooling log, and a new cook was unaware of the documentation procedures. Similarly, a container of macaroni salad prepared the previous day was not documented on the cooling log, despite being cooled using appropriate methods. The facility's Regional Dietary Manager confirmed the need for documentation and acknowledged the oversight. The facility also failed to maintain cold food items at the proper temperature during meal service. Macaroni salad was initially found at temperatures above the safe limit and was not maintained at the correct temperature throughout the lunch service. Furthermore, staff did not complete appropriate hand hygiene during meal service. A staff member was observed donning gloves without washing hands and handling food and utensils improperly, leading to potential contamination. Despite intervention and education from the Regional Dietary Manager, the staff member continued to make errors in hand hygiene and glove use.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessments for three residents, resulting in a deficiency. The assessments for these residents were completed but not accepted by the iQIES system, indicating a failure in the transmission process. Specifically, two assessments for one resident dated January 30, 2024, two assessments for another resident dated November 29, 2023, and December 15, 2023, and two assessments for a third resident dated July 2, 2023, were not transmitted as required. This failure was identified during a survey conducted on June 17, 2024. The deficiency was attributed to a coding error within the facility's electronic medical record (EMR) system, as confirmed by the Director of Clinical Reimbursement (DCR). The DCR acknowledged that the assessments were marked as completed but were not transmitted or accepted by the iQIES system. The MDS nurse, who was still in training, and the regional staff were responsible for the transmission process. However, the DCR admitted to not checking the iQIES system for missing assessment reports, which contributed to the oversight.
Improper Sling Use and Staffing During Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R24 and R10, due to improper use of slings during transfers with a sit-to-stand (STS) lift. R24 experienced a fall when a sling that was too large was used, and only one staff member was present during the transfer, contrary to the facility's policy requiring two staff members. The CNA involved was aware of the policy but proceeded without assistance due to unavailability of a second staff member. The CNA also admitted to not knowing how to determine the correct sling size, which contributed to the incident. R10 experienced pain during transfers due to the use of a sling that was too small. The care plan for R10 specified the use of a standard size sling with two staff members, but the resident reported that the smaller sling was used multiple times per week, causing discomfort. The CNA responsible for R10's transfer confirmed that the standard size sling caused pinching and pain, indicating a need for a larger sling. However, the appropriate size sling was not readily available, and the staff were unsure of how to determine the correct size. Interviews with various staff members, including CNAs, LPNs, and RNs, revealed inconsistencies in understanding and implementing the facility's policies on sling sizing and transfer procedures. The Director of Nursing and Nursing Home Administrator were unaware of the specific incidents involving R10's pain and the improper sling size. There was no clear responsibility assigned for documenting sling sizes in residents' care plans, leading to confusion and improper handling of residents during transfers.
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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) |
|---|---|---|---|---|
| Meadow View Health Services | 0.8 mi | ★★★★★ | 8 | 0 |
| Edenbrook Sheboygan | 1.9 mi | ★★★★★ | 7 | 2 |
| Sheboygan Health Services | 2.3 mi | ★★★★★ | 7 | 0 |
| Morningside Health Services | 3.7 mi | ★★★★★ | 7 | 0 |
| Sheboygan Senior Community Inc | 4.5 mi | ★★★★★ | 16 | 0 |
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