Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Sheboygan Senior Community Inc during CMS and state inspections, most recent first.
A resident with diabetes, peripheral artery disease, a prior BKA, and a chronic left heel ulcer received an Apligraf skin graft from podiatry with explicit orders not to disturb the graft or inner dressings until the next follow‑up. An LPN documented the "DO NOT REMOVE" instruction, but the order was not promptly entered into the TAR, and subsequent wound care orders in the record were overlapping and ambiguous. The resident later reported that a nurse removed pieces of the graft the day after application and re‑dressed the wound, and staff interviews confirmed confusion about the wound care orders and lack of a formal double‑check process for order entry. At the next wound clinic visit, the graft was found to be missing and the ulcer had worsened, and clinic and podiatry staff reported receiving no calls from the facility to clarify or report removal of the graft, demonstrating failure to provide care in accordance with physician orders.
Food was not stored and prepared in a sanitary manner. The surveyor found dried food debris inside microwaves in three household kitchens, dry storage items such as pasta, rice, and walnuts without use-by dates, and uncovered kitchen equipment including mixers and a slicer. The ADM and DM acknowledged the conditions, and the DM stated staff relied on a date sheet for discard guidance while the facility’s food dating guidance did not include dry foods.
Incomplete informed consent documentation was found for three residents receiving psychotropic medications. Residents with intact or near-intact cognition had consent forms for antidepressant and antianxiety medications that were only signed and dated on the last page, while other pages were not initialed or dated and key questions were left blank. RN and DON interviews confirmed the facility’s practice allowed forms to be treated as complete even when only the last page was signed.
The facility did not notify the State LTC Ombudsman of an emergent ED transfer for a resident with type 2 DM and PAD who had intact cognition on MDS. Survey review showed the transfer was not on the Ombudsman notification list, and the SW stated the Ombudsman was not notified because the resident returned to the facility and was not discharged. The facility’s discharge policy did not include Ombudsman notification of hospital transfers.
MDS assessments were inaccurate for three residents. One resident was coded as receiving a hypnotic medication even though the MAR/orders did not show one, another was coded as receiving parenteral feeding despite eating orally and never receiving it, and a third resident on chronic hemodialysis was not coded as receiving dialysis. The DON and MDS coordinator confirmed the coding errors.
Inadequate Pressure Injury Prevention and Wound Monitoring: Two residents had pressure injuries that were not consistently prevented, assessed, or monitored. One resident with dementia and Parkinson’s disease developed a stage 1 injury on the head that later reopened as a stage 2 wound after the head continued rubbing against the wall, while the care plan and treatment documentation were incomplete. Another resident was readmitted with a stage 2 buttock injury and later developed a second stage 2 buttock wound, but the record lacked full assessments and ongoing wound monitoring; staff and the DON confirmed the facility relied mainly on progress notes and did not have a standardized wound assessment process.
A resident with dementia, Parkinson's disease, abnormal involuntary movements, and a history of repeated falls had an unwitnessed fall and was found on the floor. The record did not include a fall report, post-fall neuro checks, or a preventative safety intervention in the care plan. The DON, Rehab Manager, and an LPN confirmed the incident report, care plan revision, and neuro checks were not completed after the fall.
Failure to Provide and Document Nebulizer Cleaning: Three residents with respiratory diagnoses and nebulizer orders had nebulizer equipment observed with residue or liquid present, and staff confirmed the records did not contain orders for nebulizer cleaning. An RN and LPN stated nebulizers should be rinsed and dried after each use, while the DON stated cleaning should be documented in the MAR or TAR.
Dialysis care was not fully documented for a resident with ESRD who received HD three times weekly. The resident’s record lacked orders and documentation for facility staff to obtain pre- and post-dialysis VS, weights, and fistula assessments for bleeding, bruit, and thrill. The resident, an RN, an LPN, and the DON all confirmed that dialysis staff obtained VS/weight and that facility documentation of these assessments was missing.
The facility did not report two incidents of resident abuse to the State Agency as required. One resident with severe cognitive impairment was involved in aggressive actions towards two other residents, including an attempted stabbing and a wheelchair altercation. Despite internal reporting, the Nursing Home Administrator decided not to report these incidents externally, violating the facility's policy and regulatory standards.
The facility failed to thoroughly investigate abuse allegations involving a resident with severe cognitive impairment who was aggressive towards two other residents. The investigations were incomplete, with missing documentation and confusion over dates and times. The facility did not document the necessary details to form a reasonable conclusion about the incidents, leading to a deficiency identified by the surveyor.
The facility did not ensure that the Dietary Manager met the minimum qualifications, affecting all 55 residents. The DM had not completed a certification course and their ServSafe certification had expired. The NHA confirmed the DM was not certified or enrolled in a training program, citing budget constraints.
The facility failed to maintain sanitary food storage and preparation practices, affecting nearly all residents. Observations included incomplete cooling and temperature logs, improper hand hygiene, and lack of hair restraints in the kitchen. Staff did not consistently monitor food temperatures or follow reheating procedures, and sanitization logs were incomplete. These deficiencies indicate a failure to adhere to food safety protocols, posing a risk of foodborne illness.
The facility failed to ensure the QAA committee met the required membership and frequency. The QAPI Plan was undated and lacked specific policies. The committee did not meet in certain quarters, and some meetings lacked required members like the Medical Director and Infection Preventionist. The NHA confirmed the accuracy of the meeting records.
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete infection line lists and inadequate tracking of infections. The Director of Nursing, who was also the Infection Preventionist, confirmed these deficiencies and had only recently started infection control training.
The facility did not ensure that the designated Infection Preventionists (IPs), including the DON and an RN, completed specialized training in infection prevention and control. This oversight had the potential to affect all 55 residents. The DON had only completed two modules of the required training, and the NHA confirmed the lack of a qualified IP after the previous IP left the facility.
The facility failed to maintain resident dignity during meal times, as vital signs were taken at the dining table and medications were administered during meals. Residents experienced significant delays in meal service, with some finishing their meals while others were still waiting to be served. Staff and residents confirmed these issues, highlighting a lack of coordination in the dining service process.
The facility failed to monitor four residents for adverse reactions or side effects of psychotropic medications, despite care plans indicating the need for such monitoring. Interviews revealed that staff observed behavior but did not routinely document potential adverse drug reactions, and there was no accessible reference for medication side effects. This issue was consistent across the sampled residents, highlighting a systemic problem in medication management.
A resident with severe cognitive impairment and an activated POA was not involved in care planning at the LTC facility. Despite the need for regular care conferences, only one was held since admission, and the POA was not informed or involved in ongoing care decisions. The facility lacked a process for tracking care conferences and did not provide a care conference policy.
A resident was not provided with a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form when their Medicare Part A coverage ended, leading to a deficiency. The facility failed to inform the resident of their financial liability and appeal rights, as the social worker did not provide the ABN form due to the facility's infrequent handling of Medicare residents.
The facility failed to provide written transfer notices to three residents with severely impaired cognition when they were transferred to the hospital. The notices, which should have included transfer details and appeal rights, were not given to the residents or their POAs. Interviews revealed confusion among staff about responsibility for issuing these notices, contributing to the deficiency.
The facility failed to provide written bed-hold notices to three residents and their representatives during hospital transfers, as required by policy. Despite severe cognitive impairments and activated POAs, the residents did not receive the necessary documentation. Interviews confirmed the oversight, and the DON acknowledged the need for staff education on this requirement.
A resident with a history of heart failure, CKD, and dementia experienced a CVA and was later diagnosed with Parkinson's disease. The facility did not update the resident's care plan to reflect these new diagnoses. This deficiency was confirmed by the DON during a surveyor interview.
A resident with severe cognitive impairment and multiple health conditions experienced a significant weight loss of 12.14% over six months. The facility failed to consistently obtain and document the resident's weekly weights as ordered, and there was no evidence that the resident's Power of Attorney for Healthcare, physician, or dietitian were notified of the weight loss. The Director of Nursing acknowledged that the weight loss was missed by the team, and no re-weighing or investigation was conducted, contributing to the deficiency.
A resident prescribed clopidogrel, a high-risk anticoagulant, was not monitored for adverse reactions or side effects due to the absence of monitoring interventions in their care plan. Facility staff, including an LPN and the DON, confirmed the lack of consistent side effect monitoring for high-risk medications, with the LPN relying on external sources for information.
A facility failed to have a written contract or agreement for dialysis services for a resident with stage 5 renal disease receiving hemodialysis thrice weekly. The facility also lacked a policy or procedure for dialysis treatment. Both the Health Services Specialist and the Nursing Home Administrator confirmed the absence of necessary documentation, with the administrator unaware of the requirement due to the facility's infrequent handling of dialysis patients.
Failure to Follow Wound Care Orders for Diabetic Heel Ulcer Skin Graft
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care was provided in accordance with a physician’s orders for a resident with a diabetic heel ulcer being treated with Apligraf skin grafts. The resident had multiple comorbidities including diabetes with polyneuropathy, peripheral artery disease, a prior right below‑knee amputation, and a chronic left posterior ankle/heel diabetic ulcer with visible tendon. Podiatry applied an Apligraf graft to the left heel on 11/3/25 with clear instructions that the graft and underlying dressings (Adaptic and Steri‑Strips) were not to be disturbed until the resident’s follow‑up the next week. A progress note by an LPN on 11/3/25 documented “Wound graft #2 placed on left foot. DO NOT REMOVE.” However, this order was not entered into the Treatment Administration Record (TAR) on the day of the visit. Subsequent wound care orders in the TAR showed overlapping and changing instructions, including orders to cleanse the wound and apply Hydrofera blue and orders specifying not to remove the skin graft or inner dressings. There were also TAR entries stating “DO NOT REMOVE DRESSING AT LEFT ANKLE UNTIL SEEN AT WOUND CLINIC. NEW GRAFT PLACED” with every‑shift frequency. Staff interviews revealed confusion about the wound care orders, with staff recalling standing instructions to change only the outer dressing and not to disturb inner dressings unless saturated, but also acknowledging that there was no consistent oversight of wound care orders and no formal double‑check process for order entry. The DON confirmed that the facility’s order entry policy did not address verification or double‑checking of newly entered orders and described the process in which LPNs entered orders from paper or faxed documents without a structured second review. The resident, who was cognitively intact and made their own healthcare decisions, reported that the day after the second Apligraf was applied, a nurse reacted to the appearance of the heel, left the room, returned with supplies, wetted the wound, and pulled pieces of the graft off. The resident stated that the same nurse later returned with another nurse and re‑did the dressing. The resident did not report this to facility staff at the time but informed the wound clinic at the next scheduled visit. At the 11/11/25 wound clinic appointment, wound care staff documented that when the dressing was removed, the Apligraf was missing and the wound contained a significant amount of boggy, non‑viable hypergranulation tissue, and the resident required surgical debridement and IV antibiotics. Wound clinic staff and podiatry office staff confirmed there were no calls from the facility to clarify orders or report removal of the graft. Facility staff interviews indicated that one nurse told the scheduler that another nurse had removed the Apligraf because the nurse did not see the new order, and that this information was not escalated to leadership. The DON stated they were not aware that the graft had been removed and acknowledged that the wound care orders were ambiguous. Additional documentation from wound care, infectious disease, vascular surgery, and podiatry after the hospitalization described the subsequent management of the resident’s heel wound, including diagnoses of calcaneal osteomyelitis and partial calcanectomy, and the use of IV and oral antibiotics. These records confirmed that the graft was no longer present at the time of the 11/11/25 visit and that the wound had worsened. The wound clinic nurse explained that the Apligraf requires at least 48 hours to adhere and that the 11/3/25 order specified no dressing changes, verifying that the graft should not have been removed. The combination of delayed and incomplete order entry, lack of a verification process for new orders, staff confusion about wound care instructions, and failure to clarify or communicate with the podiatry or wound clinic providers led to the Apligraf being removed contrary to orders and not being reported, constituting the cited deficiency in providing care according to physician orders.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored and prepared in a sanitary manner in the facility’s main kitchen and three household kitchens. During an initial tour on 1/12/26, the surveyor observed dried food debris on the interior ceiling of the microwaves in all three household kitchens. The Assistant Dietary Manager acknowledged the debris and stated microwaves should be cleaned after each use and at the end of the day. The facility’s Cleaning Instructions for Microwave Oven stated the microwave should be kept clean, sanitized, and odor free, with cleaning at least after each meal service, and the Wisconsin Food Code required microwave cavities and door seals to be cleaned at least every 24 hours. The surveyor also observed multiple dry storage items without use-by dates, including elbow macaroni noodles, rice, and halved walnuts, some with open dates from prior weeks. The Dietary Manager stated staff used a sheet with foods and use-by dates for direction on when to discard items and confirmed the observed items should have open and use-by dates. The facility’s Food Dating Policy stated opened items should be dated with a prepared date and/or use-by date, but the Produce Storage Cheat Sheet reviewed by the surveyor listed only fruits and vegetables and did not include dry foods. In addition, two mixers and a slicer in the main kitchen were observed uncovered, and the Dietary Manager stated he was not aware kitchen equipment should be covered when not in use.
Incomplete Informed Consent Documentation for Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents were fully informed and understood their health status, care, and treatments because documentation was incomplete for informed consent related to psychotropic medications. For R36, who was admitted with vascular dementia with mood disturbance and anxiety disorder and had a BIMS score of 15 out of 15, the record showed duloxetine was prescribed for depression, but the Informed Consent for Medication form was not thoroughly completed: R36 only initialed and dated page 1, pages 2 and 3 were not initialed, signed, or dated, and questions 2 and 3 on page 1 were left blank. Similar incomplete documentation was found for R37 and R63. R37, who had diagnoses of anxiety disorder and depression and a BIMS score of 15 out of 15, had consent forms for lorazepam and desipramine that were only signed and dated on the last page, with pages 1 through 3 lacking initials or dates and questions 2 and 3 left blank. R63, who had anxiety and depression and a BIMS score of 13 out of 15, had consent forms for buspirone and citalopram that were also only signed and dated on the last page, with all pages lacking initials or dates and questions 2 and 3 left blank. RN-M stated not all nurses have residents initial and date every page and usually only have the resident sign and date the last page, while DON-B stated it would be nice if all pages were initialed, dated, and completed but it was fine as long as the last page was signed and dated.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility did not notify the State Long-Term Care Ombudsman of an emergent hospital transfer for one resident, R10, who was transferred to the Emergency Department on 11/25/25 for evaluation. R10 had diagnoses including type 2 diabetes mellitus and peripheral artery disease, and a 1/5/26 MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. Survey review of the Ombudsman notification list for 11/1/25 to 11/30/25 showed that R10’s ED transfer was not included. During interview, the Social Worker verified that R10 was transferred to the ED and returned to the facility, and stated that the Ombudsman was not notified because the resident was not discharged. The Social Worker also stated a belief that Ombudsman notification was only necessary when residents were discharged from the facility. The facility’s undated discharge policy did not include Ombudsman notification of hospital transfers.
MDS Assessments Were Inaccurate for Three Residents
Penalty
Summary
The facility did not ensure Minimum Data Set (MDS) assessments were accurate for three sampled residents. For one resident with vascular dementia with mood disturbance and anxiety disorder, the 1/2/26 Quarterly MDS and 12/3/25 Significant Change MDS indicated the resident received a hypnotic medication, but the physician’s orders did not include a hypnotic medication. The resident’s MDS also showed a BIMS score of 15 out of 15, indicating intact cognition, and the resident was responsible for healthcare decisions. The MDS coordinator was unsure why the assessments were coded that way and stated they may have been coded in error. For another resident with dementia, cognitive impairment, delusional disorder, and communication deficit, the 10/13/25 MDS indicated parenteral feeding even though the resident did not receive it. The resident was observed eating in the dining room, and an LPN stated the resident never received parenteral feeding. For a third resident with end stage renal disease and dependence on renal dialysis, the 11/20/25 MDS did not indicate dialysis even though the resident had been receiving hemodialysis three times weekly since admission. The MDS coordinator confirmed dialysis was missed on that assessment and stated it had also been missed on the prior year’s assessment.
Inadequate Pressure Injury Prevention and Wound Monitoring
Penalty
Summary
The facility did not ensure care and services were provided to prevent pressure injuries from developing and to promote healing for two residents. One resident, with diagnoses including dementia, Parkinson’s disease, abnormal involuntary movements, and abnormal posture, had severe cognitive impairment and an activated POAHC. The resident was noted on 11/20/25 to have a stage 1 pressure injury on the top of the head after staff found the resident sleeping with the head against the wall. The record showed the care plan was not updated after the initial injury, and later documentation showed the area reopened when the resident’s head again rubbed against the wall. A therapy screen identified foam wedges as a safety measure, but the resident’s care plan did not include those interventions, and the MAR/TAR did not include treatment orders for the later stage 2 pressure injury. The resident’s record also showed inconsistent wound monitoring and documentation. A nursing note on 12/13/25 described a small open area on the top of the head with peeled skin, and an intervention was added to place padding between the wall and bed. An admission skin assessment on 12/17/25 described a pressure wound on the scalp measuring approximately 2.5 cm x 3.0 cm with red abrased areas, shallow yellow crater areas, and dried red scabs. Staff interviews confirmed the facility did not have a standardized wound assessment tool and that nurses documented wounds only in progress notes, often documenting only if the wound worsened. A second resident was readmitted with a stage 2 pressure injury on the left buttock and later developed a stage 2 pressure injury on the right buttock. The record did not include a full nursing assessment or measurement of the left buttock wound, and there were no ongoing assessments or monitoring documented for the right buttock wound. Staff interviews confirmed that when a new wound is discovered, nurses should assess and measure it and send orders to the physician, but the facility did not have a specific procedure for ongoing wound assessments. The DON also confirmed that the only documentation of the resident’s wounds was in progress notes and that staff education had not been completed regarding wound care concerns.
Failure to Complete Post-Fall Assessment and Care Plan Update
Penalty
Summary
A resident with dementia, Parkinson's disease, abnormal involuntary movements, and a history of repeated falls had an unwitnessed fall and was found on the floor lying on the left side. The resident's MDS indicated the resident was rarely to never understood/understands, and a staff interview for mental status indicated severe cognitive impairment. The resident also had an activated POAHC to assist with healthcare decisions. The facility's record did not include a fall report, post-fall neurological checks, or a preventative safety intervention added to the care plan after the fall. The facility's Assessing Falls policy required observation for delayed complications for approximately 72 hours after a fall, completion of an incident report within 24 hours, and documentation of assessment data, vital signs, injuries, interventions, first aid, or treatment in the medical record. The Neurological Assessment procedure and Neurological Flow Sheet required routine neurological checks after a fall, including vital signs and checks at specified intervals. Interviews with the Rehab Manager, LPN, and DON confirmed the care plan was not updated, the incident report was not completed, and neurological checks were not completed following the resident's fall.
Failure to Provide and Document Nebulizer Cleaning
Penalty
Summary
Safe and appropriate respiratory care was not provided for 3 residents who had nebulizer treatments ordered. R10 had diagnoses including type 2 diabetes mellitus and COPD, with a BIMS score of 15 out of 15, and had orders for budesonide nebulization once daily and ipratropium-albuterol nebulization four times daily. During observation, R10 had a nebulizer on the nightstand with a mouthpiece stained with what appeared to be red lipstick, and RN-C confirmed the mouthpiece contained red lipstick and stated it was from that day because R10 had nebulizer treatments scheduled four times daily. RN-E stated nursing staff usually rinse the nebulizer, and RN-C later stated nebulizers should be rinsed after each use, placed in the bathroom to dry, and dated and changed every 3 days. R10's record did not contain orders for nebulizer cleaning. R15 had diagnoses including shortness of breath, chronic cough, and COPD, with a BIMS score of 12 out of 15 and an activated POAHC, and had an order for budesonide nebulization twice daily. On observation, R15 had a nebulizer on the nightstand, the tubing was not dated, and the nebulizer chamber contained liquid; R15 stated the nebulizer was not cleaned that day after use. R62 had diagnoses including acute bronchospasm and influenza, with a BIMS score of 13 out of 15, and had an order for albuterol sulfate nebulization. On observation, R62 had a nebulizer on the nightstand, the tubing and equipment were not dated, and the chamber contained drops of liquid; R62 stated no one had rinsed the nebulizer chamber. RN-C and LPN-E stated nebulizer equipment should be taken apart and rinsed under tap water then dried after each use, but also confirmed R10, R15, and R62's records did not contain orders for nebulizer cleaning and that there was no documentation for cleaning. DON-B stated nebulizer chambers and parts should be rinsed with sterile water after each use and cleaning should be documented in the MAR or TAR.
Dialysis Assessments Not Documented
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease and dependence on renal dialysis who received hemodialysis three times weekly at an outside dialysis center. The facility’s dialysis policy stated that licensed nurses would communicate vital signs and weights to the dialysis facility, monitor and document the resident’s access site upon return from dialysis, and check the access site before and after dialysis for patency by auscultating for a bruit and palpating for a thrill. However, the resident’s medical record did not contain orders for facility staff to obtain vital signs, weights, or monitor the fistula site before or after dialysis. Survey review found no documentation in the resident’s record of fistula site assessment for bleeding, thrill, or bruit, and no documentation of vital signs obtained by facility staff. The only vital signs in the record were those taken by dialysis staff. The resident stated facility staff did not obtain vital signs or weight before or after dialysis, although the dialysis center obtained those measurements on arrival, and the resident said staff checked the fistula for bleeding. An RN stated the fistula was assessed and not bleeding but could not provide documentation and said some assessments might have been missed. An LPN confirmed there was no order to check for bruit and thrill and that facility staff did not obtain pre- or post-dialysis vital signs. The DON stated nurses should check the fistula for bruit and thrill, obtain vital signs pre- and post-dialysis, check for bleeding, and document these assessments in the medical record.
Failure to Report Resident Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the State Agency as required by their policy and regulatory standards. On November 22, 2024, a resident reported that another resident had been physically aggressive towards them the previous day, including an attempt to stab with a utensil. Additionally, on the same day, the aggressive resident initiated an altercation with another resident by shaking their wheelchair. Despite these incidents being reported internally to the Nursing Home Administrator, the decision was made not to report them to the State Agency. The involved residents had varying levels of cognitive impairment, with one having severe cognitive impairment and the others having moderate to no cognitive impairment. The facility's policy mandates immediate reporting of such incidents to the State Agency, but this was not adhered to. The Director of Nursing and Social Worker acknowledged that the incidents should have been reported from a regulatory standpoint, but the Nursing Home Administrator chose not to report them. The facility's failure to report these incidents represents a deficiency in adhering to abuse reporting requirements.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations involving two residents. On November 22, 2024, a resident reported that another resident had been physically aggressive towards two other residents on separate occasions. The facility's policy requires immediate and thorough investigations of such incidents, but the investigations were not adequately conducted. The Director of Nursing and Social Worker acknowledged that the investigations were incomplete, with missing documentation and confusion over dates and times. The facility did not document the necessary details to form a reasonable conclusion about the incidents. The incidents involved a resident with severe cognitive impairment who was aggressive towards two other residents, one with moderate cognitive impairment and another without cognitive impairment. The aggressive resident had a history of Alzheimer's disease and was on 1:1 supervision following the incidents. However, the documentation of the supervision was not filed in the medical record, and the grievance investigation was backdated. The facility's failure to conduct thorough investigations and maintain proper documentation led to the deficiency identified by the surveyor.
Unqualified Dietary Manager in LTC Facility
Penalty
Summary
The facility failed to ensure that the individual designated as the food and nutritional services director met the minimum qualifications for the role, which had the potential to affect all 55 residents residing in the facility. The Dietary Manager (DM) had not completed an approved dietary manager or food service manager certification course or other related education. During an interview, the DM indicated that they had been working in the facility for several years and had been the Dietary Manager for 3 to 4 years. Although the DM was ServSafe certified, their certification expired in August, and they had not renewed it. Furthermore, the DM was not currently enrolled in a dietary or food service manager certification course. The Nursing Home Administrator (NHA) confirmed that the DM was not certified or enrolled in a certified training program. The NHA stated that it was not in the facility's budget to get the DM certified.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, potentially affecting 54 of 55 residents. The surveyor observed that cooling temperature logs were not completed for leftover and pre-made food, and staff did not consistently monitor or document cooked food temperatures or hot/cold holding temperatures. Additionally, staff failed to test or document the parts per million (PPM) of the quaternary sanitizing solution as per the manufacturer's instructions, and did not monitor and document dishwasher and surface temperatures. Furthermore, staff did not follow procedures for reheating food in a microwave, and did not wear hair restraints when entering the kitchen where resident food was prepared. During the survey, it was noted that staff did not perform appropriate hand hygiene and safe food handling practices when serving food. For instance, a dietary aide was observed donning gloves without completing hand hygiene, touching various food items with gloved hands, and changing gloves multiple times without washing hands in between. This lack of proper hand hygiene was confirmed by the dietary aide during an interview. Additionally, the surveyor observed that staff did not check the temperature of the food prior to serving, and a hot holding cart containing food was not plugged in, leading to food being served at improper temperatures. The surveyor also noted that the facility's sanitization logs for the three-compartment sink and dishwasher were incomplete, with missing entries for several months. The dietary manager acknowledged these inconsistencies and stated that logs should be completed each time the sink is filled and that test strips should be run through the dishwasher once per day. Furthermore, staff were observed entering the kitchen without wearing hair restraints, which is against the facility's policy and the FDA Food Code. These observations indicate a failure to adhere to established food safety and hygiene protocols, posing a risk of foodborne illness to residents.
QAA Committee Membership and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required membership and frequency of meetings. The facility did not have documentation indicating that the QAA committee, which should include the Director of Nursing (DON), Medical Director or designee, Infection Preventionist, and at least three other staff members including the Nursing Home Administrator (NHA), met at least quarterly. The QAPI Plan provided was undated, appeared to be a template, and did not specify the facility's specific policy, procedure, or the required members and frequency of meetings. Upon review of the QAA committee meeting sign-in sheets, it was noted that the committee did not meet during the third quarter of 2023 and the second quarter of 2024. Additionally, the fourth quarter meeting of 2023 did not include the Medical Director or designee, the first quarter meeting of 2024 lacked sufficient staff members, and the third quarter meeting of 2024 did not include the Infection Preventionist. The NHA confirmed that the sign-in sheets accurately reflected the committee's meeting dates and attendance, indicating a failure to comply with the required structure and frequency of QAA meetings.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which is crucial for providing a safe and sanitary environment and preventing the transmission of communicable diseases and infections. The facility's policy on Surveillance for Infections, dated September 2017, outlines the responsibilities of the Infection Preventionist (IP) in conducting ongoing surveillance for healthcare-associated infections (HAIs) and other significant infections. However, the facility did not appropriately monitor residents and staff for infections and outbreaks, as evidenced by incomplete infection line lists and inadequate tracking and trending of infections. During the survey conducted from September 23 to September 25, 2024, the surveyor reviewed the facility's infection line lists for residents and staff. The line lists provided were incomplete, lacking essential details such as symptoms, laboratory results, and the dosage or duration of antibiotics used. Additionally, the line lists did not track and trend infections or contain monthly infection rates or percentages. The Director of Nursing (DON), who was also assigned the IP role, confirmed these deficiencies and indicated that they had only recently started infection control training, having completed only two modules so far.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that a designated Infection Preventionist (IP) completed specialized training in infection prevention and control, which had the potential to affect all 55 residents. The Director of Nursing (DON)-B and Registered Nurse (RN)-E were assigned as the facility's IPs but had not completed the necessary training. The facility's policy requires the IP to be qualified by education, training, experience, and/or certification, and to provide evidence of training through certificates or equivalent documentation. During an interview, DON-B stated that they started at the facility on July 8, 2024, and were assigned the IP role. However, DON-B had only completed two modules of the IP training. The Nursing Home Administrator (NHA)-A confirmed that the facility did not have a qualified IP, as the previous DON and IP had left the facility on June 30, 2024. NHA-A mentioned plans to have a consultant monitor DON-B and another nurse to maintain the infection prevention and control program.
Dignity and Meal Service Deficiency
Penalty
Summary
The facility failed to maintain the dignity of residents during meal times, as observed by surveyors. In the Oak dining room, a resident's vital signs were taken at the dining table while other residents were present, and medications were administered to residents during their meals. Additionally, residents at the same table were not served their meals simultaneously, leading to some residents finishing their meals while others were still waiting to be served. This was observed on multiple occasions, with significant delays in meal service, causing discomfort and dissatisfaction among the residents. Interviews with staff and residents confirmed these observations. A Dietary Aide admitted to cooking and serving meals one by one, which often took an hour, while a Licensed Practical Nurse acknowledged that vital signs should not be taken at the dining table unless a resident is in distress. Residents expressed feelings of awkwardness and dissatisfaction with the meal service, noting that it felt more like a hospital environment. Staff members also reported that residents became anxious and complained about the delays in receiving their meals, indicating a lack of coordination and efficiency in the dining service process.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that four residents who were prescribed psychotropic medications were adequately monitored for adverse reactions or side effects. These residents included individuals with severe cognitive impairments and various diagnoses such as Alzheimer's disease, depression, and anxiety. Despite having care plans that required monitoring for the effectiveness and adverse effects of these medications, the facility did not implement specific monitoring interventions or conduct baseline and ongoing assessments for these residents. For instance, one resident was prescribed lorazepam, sertraline, and quetiapine, yet their medical record lacked documentation of monitoring for adverse reactions or side effects. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that while staff observed residents' behavior and monitored for sleepiness, there was no routine documentation of potential adverse drug reactions. Additionally, there was no accessible reference for nursing staff to identify potential medication side effects, leading them to rely on external sources like the internet or reference books. Another resident, who had intact cognition, was prescribed Seroquel for visual hallucinations, but their medical record did not include any monitoring interventions for adverse reactions or side effects. The Director of Nursing confirmed the absence of such monitoring in the resident's medical record, acknowledging that it should have contained interventions for staff to be aware of potential adverse reactions. This lack of documentation and monitoring was consistent across the sampled residents, indicating a systemic issue within the facility's medication management practices.
Failure to Involve POA in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their activated Power of Attorney (POA) were involved in the development and implementation of the resident's person-centered plan of care. The resident, who was admitted with diagnoses including cerebral infarction, epilepsy, and cognitive communication deficit, had severely impaired cognition and an activated POA. Despite these conditions, the facility only conducted one care conference since the resident's admission, which occurred on 9/17/21. The facility did not offer or document any additional care conferences, nor did they involve the POA in ongoing care planning. Interviews with the POA and the Social Worker (SW) revealed that the POA was not involved in the resident's care planning and had not attended any care conferences since the resident's admission. The POA expressed a desire to participate in care conferences and decision-making but was not aware of any being scheduled. The SW confirmed the lack of care conferences and acknowledged that the facility did not have a process for tracking them, relying instead on annual scheduling. The facility failed to provide a care conference policy, and there was no documentation indicating that care conferences were offered or declined.
Failure to Provide ABN Form to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R109, received and signed a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form. This form is crucial for informing residents about the end of their Medicare Part A coverage, their potential financial liability for continued services, and their rights to appeal claims. The deficiency was identified during a survey conducted from September 23 to September 25, 2024, where it was found that R109 was not provided with the ABN form when their Medicare benefits ended on May 16, 2024, despite remaining in the facility. The surveyor's review of R109's medical records revealed that the resident was given a Notice of Medicare Non-Coverage (NOMNC) form, indicating the end of services on May 16, 2024. However, the facility only provided a generated form that stated the last day of Medicare coverage and the start of private pay without including necessary information such as standard claim appeals rights. An interview with the social worker, SW-C, revealed that the facility rarely had Medicare residents, leading to the omission of providing the Medicare ABN form to residents who continued to stay in the facility.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to three residents, R1, R19, and R32, when they were transferred to the hospital. These notices should have included the date of transfer, reason for transfer, location of transfer, and appeal rights. R1 was transferred due to abdominal pain, R19 due to a fall, and R32 due to a change in condition. All three residents had severely impaired cognition and activated Powers of Attorney (POA), yet neither the residents nor their POAs received the required written notices. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing transfer notices. The Social Worker indicated that nursing staff were responsible for providing these notices, while the Director of Nursing was unaware that a written notice should be given each time a resident is transferred. This confusion led to the failure to provide the necessary documentation to the residents and their representatives, as confirmed by the Director of Nursing during the survey.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed-hold notices to three residents (R1, R19, and R32) and their representatives upon their transfer to a hospital, as required by the facility's policy. The policy mandates that residents and their representatives receive written information about the bed-hold policy, reserve bed payment policy, and the right to return to the facility at the time of transfer. However, the medical records for R1, R19, and R32 did not indicate that such notices were provided. Interviews with the residents' representatives and facility staff confirmed the absence of these notices. R1, who had severe cognitive impairment and an activated Power of Attorney (POA), was transferred to the hospital for abdominal pain, while R19, also with severe cognitive impairment and an activated POA, was transferred due to a fall. R32, with similar cognitive challenges, was transferred due to a change in condition. Despite the facility's policy, the Director of Nursing (DON) and other staff members were unaware that a written notice should accompany each transfer, leading to a failure in communication and documentation. The DON confirmed that the nursing staff needed education on this requirement.
Failure to Update Care Plan for New Diagnoses
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as R32, was reviewed and revised to address new medical diagnoses. R32, who had a history of heart failure, chronic kidney disease, and dementia, was admitted to the hospital for a cerebrovascular accident (CVA) and later diagnosed with Parkinson's disease. Despite these significant changes in R32's medical condition, the care plan was not updated to reflect the new diagnoses. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the care plan should have been updated following the new diagnoses.
Failure to Monitor and Address Resident's Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R19, received the necessary care and services to prevent or monitor weight loss. R19, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia, congestive heart failure, chronic kidney disease, and peripheral vascular disease, was supposed to have weekly weights recorded as per physician's orders. However, the facility did not consistently obtain and document these weights. The resident experienced a severe weight loss of 12.14% over six months, with significant weight loss noted between 8/28/24 and 9/11/24. Despite the facility's policy requiring significant weight changes to be reported and addressed, there was no documentation indicating that R19's Power of Attorney for Healthcare, physician, or dietitian were notified of the weight loss. The Director of Nursing (DON) acknowledged that weights should be completed as ordered and that the facility's system used red flags to indicate significant weight differences. However, the DON admitted that the red-flagged weight loss for R19 on 9/11/24 was missed by the team, and no re-weighing or investigation was conducted. Additionally, weights were missing on several dates, including 9/18/24, which was supposed to be a scheduled weigh day. The lack of follow-up and documentation regarding the resident's weight loss and the failure to adhere to the facility's policy contributed to the deficiency identified by the surveyor.
Failure to Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse reactions or side effects of a high-risk medication. The resident, identified as R208, was prescribed clopidogrel, an anticoagulant medication, but their care plan did not include monitoring interventions for potential adverse reactions or side effects. The resident's medical record, including the Medication Administration Record (MAR), lacked any orders for monitoring these side effects, despite the known risks associated with clopidogrel. Interviews with facility staff revealed a lack of awareness and documentation regarding the monitoring of medication side effects. A Licensed Practical Nurse (LPN) stated that there was no designated place in the resident's medical record for documenting or monitoring medication side effects and that they relied on external sources to understand potential side effects. The Director of Nursing (DON) confirmed that side effect monitoring was not consistently implemented for residents receiving high-risk medications, acknowledging that such interventions should be documented in the resident's medical record.
Lack of Contract and Policy for Dialysis Services
Penalty
Summary
The facility failed to acquire a current contract or agreement in writing for outside dialysis services for a resident who required dialysis treatment. The resident, identified as R360, was admitted with diagnoses including hypertensive chronic heart and kidney disease with stage 5 renal disease and received hemodialysis three times weekly. Upon review, the surveyor found that the facility did not have a contract with the dialysis provider, nor did it have a policy or procedure related to dialysis treatment. Both the Health Services Specialist and the Nursing Home Administrator confirmed the absence of a contract and policy, with the administrator unaware that such documentation was required, as the facility did not typically have dialysis patients.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 120 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Health Services | 2.3 mi | ★★★★★ | 7 | 0 |
| Edenbrook Sheboygan | 2.6 mi | ★★★★★ | 7 | 1 |
| Morningside Health Services | 2.9 mi | ★★★★★ | 7 | 0 |
| Sheboygan Progressive Health Services | 4.5 mi | ★★★★★ | 12 | 0 |
| Meadow View Health Services | 5.3 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.